Dynamics of Care, Situations of Choice: HIV Tests in Times of ART

Abstract

In the 1990s, African AIDS programs followed a voluntary counseling and testing (VCT) approach to HIV testing. In the wake of large scale AIDS treatment programs, policymakers opted for routine provider-initiated testing (PITC) with less emphasis on counseling, which led to concerns about the ethical conduct of HIV testing. Inspired by Annemarie Mol, we ask if PITC can be framed as good care, rather than as medical domination that threatens to violate patients' rights. Based on fieldwork in Ugandan and Kenyan health facilities, we reveal that situations of choice vary: patients in hospital wards, are given time to decide whether they want a test, while in antenatal care testing women find it very hard to opt-out. We argue that the medical context inherent in PITC provides an attractive moral space for people to undergo HIV tests.

Key Words:

• choice
• health policy
• hospital ethnography
• human rights
• logic of care
• medical technology

ACKNOWLEDGMENTS

This project was supported by a grant from the National Institutes of Health (5 R01HD053268-05, PI Carla Obermeyer). This support is gratefully acknowledged. The results presented here do not represent the official views of the World Health Organization. We thank all our informants in Uganda and Kenya for frankly discussing their experiences and views with us, Clare Spronk for assisting in the analysis of the qualitative data, and the anonymous reviewers for their very constructive and thought-provoking comments on an earlier version of this article.

Notes

The term “situations of choice” is used by Mol (2008). Analyzing the way HIV tests and counseling are conducted in the prevention of mother-to-child transmission programs in Vietnam and Indonesia, Hardon and colleagues refer to “dynamics of care” to describe the processes at stake and the interactions between the people involved in the programs (Hardon et al. 2009).

The PITC guidance acknowledges that in some circumstances, such as in health facilities that serve highly vulnerable populations, opt-in approaches merit consideration, and stresses: “whether patients ‘opt-in’ or ‘opt-out’, the end result should be the same: an informed decision by the patient to accept or decline the health care provider's recommendation of an HIV test” (WHO/UNAIDS 2007:20).

At the time of our study, however, the above mentioned above mentioned PITC programs mentioned were underway, which contributed to a policy review in late 2009 after our field study was completed.

Specifically, we conducted: observations in three faith-based, eight public, and one nongovernmental health facility in Kenya (Nairobi and Central Province), and five public health facilities in Uganda (Kampala, Soroti, and Mpigi districts); 58 in-depth interviews with clients in Kenya and 19 such interviews in Uganda; 6 single-sex focus group discussions recruited through support groups in Uganda, and two recruited through HIV Comprehensive Care Centers in Kenya; and interviews with health workers, mainly nurses and counselors (28 in Kenya, 21 in Uganda). The MATCH study also involved client and provider surveys, the results of which we are still analyzing.

One could argue that in this sense VCT has contributed to “therapeutic citizenship”, defined by Nguyen as a “system of claims and ethical projects that arise out of the conjugation of techniques used to govern populations and manage individual bodies” (2005:126).

See also Mol and colleagues (2010), who encourage us to conduct detailed ethnographic studies of the “goods” and “bads” at stake in situated care practices.

Additional information

Notes on contributors

Anita Hardon

ANITA HARDON, PhD, is Professor in Anthropology of Care and Health at the University of Amsterdam, Amsterdam, The Netherlands. She conducts comparative studies of health care arrangements, including research on the global diffusion of contraceptive technologies and modern pharmaceutical medicines, and on the scaling-up of HIV/AIDS treatment programs, and undertook the comparative analysis of counseling practices presented in the current article.

Emmy Kageha

EMMY KAGEHA, MSc, is a PhD candidate at the Amsterdam Institute for Social Science Research at the University of Amsterdam, Amsterdam, The Netherlands. She conducted the fieldwork on HIV testing practices in Kenya and was involved in the analysis of the Kenya data.

John Kinsman

JOHN KINSMAN, PhD, is a social scientist attached to the Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands. His research focuses on AIDS, primarily in sub-Saharan Africa. John Kinsman conducted the policy analysis on HIV testing.

David Kyaddondo

DAVID KYADDONDO is a medical anthropologist who works at the Child Health and Development Centre of Makerere University, Kampala, Uganda. He conducted the multi-sited ethnographic fieldwork on HIV testing practices in Uganda.

Rhoda Wanyenze

RHODA WANYENZE, MD/MPH, conducts research on HIV/AIDS care at the Makerere University School for Public Health, Kampala, Uganda. She was involved in the multi-sited fieldwork in Uganda and in the analysis of the Uganda data.

Carla Makhlouf Obermeyer

CARLA MAKHLOUF OBERMEYER, DSc, is a scientist in the Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.