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testing and counselling are not time-consuming and are part perspectives on HCT services, whereas given the patient
of routine clinical care in the ED might address the barrier of volumes, high turnover and the lack of any coordinated
having to seek out testing as a discrete task in itself. processes in our study setting, it is possible that patients were
less likely to report stigma as a reason for declining testing.
Acceptance, however, was not universal. In our study
population, women were significantly more likely to decline to Pain was a notable justification for declining testing in this
test, whereas men were more likely to accept. Similar findings context and showed significant correlation through bivariate
were observed in other studies examining the acceptability of and multivariate analysis. The second most common reported
testing in EDs, in both high- and low-resource settings. 20,25 This reason, ‘in too much pain’, was not surprising, as a high
might be because women are aware of having access to testing proportion of cases presented with acute traumatic injuries. In
services during antenatal visits, through preventing mother- addition, traumatic injuries and arriving at the ED in an
to-child transmission (PMTCT) programmes or through family ambulance, which are critical proxies to pain and the
1
planning services, and hence do not need to test in the ED. seriousness of a patient’s condition, were positively correlated
This is supported by the finding that more women were with declining testing. This finding is specific to declining
already aware of their HIV status; 71.6% of the patients with a HCT in the ED and has not been previously reported as a
known HIV-positive diagnosis were women. In addition, a barrier in other testing venues. To address this barrier, the
significant proportion of women presenting to the ED in our integration of pain management before HCT is recommended.
context were diagnosed with pregnancy complications or If a patient’s presenting complaint has been addressed by
injury wounds, likely justifying ‘in too much pain’ as the providers, and appropriate action taken, patients might be
primary reason reported for women to decline HCT. On the more likely to accept testing.
contrary, though women were more likely to decline HCT, a
majority still accepted testing when offered. While it is difficult Linkage to care is the next critical step following testing. As
to generalise individual motivations, factors including lack of part of our study, all newly diagnosed patients were counselled
social support and fear of stigma or rejection if tested HIV extensively on the importance of seeking follow-up care and
positive, especially in the presence of their partner or family were given a referral letter. Given that both NMAH and MRH
accompanying them to the ED, may otherwise underlie the see patients from a 100-km radius, it was challenging to ensure
greater tendency of women to decline HCT. 25 linkage to care, as it would depend on the area individuals
came from and the presence and ease of access to an ART
The top reasons reported for declining HCT in our ED, ‘does clinic. For patients who were local to Mthatha, we were able to
not want to know status’ and ‘does not believe they are at direct them to the Gateway Clinic – an ART centre – located
risk’, are interestingly established findings from high-income within the same campus as the hospital. With the consent of
countries and LMICs, across healthcare settings. 16,20,26,27,28,29 It all patients who were newly diagnosed as HIV positive, we
could be that patients prefer uncertainty rather than facing collected their names and contact details to conduct follow-up
the psychosocial consequences of an HIV-positive diagnosis, calls after 1 month, 6 months and a year. The follow-up calls
especially considering the imaginable stigma attached to will allow us to assess whether individuals have been able to
such a diagnosis. This could be tackled through targeted link to care and/or what challenges they are facing in doing
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pre- and post-counselling efforts. On the contrary, it is also so. Results from the follow-up calls will be collated and
possible that the small proportion of patients who declined analysed post-completion. Despite these challenges, 94.9% of
to be tested are not at risk of contracting HIV and were patients with a known HIV-positive diagnosis presenting to
accurately perceiving their risk. We did not include any risk the EDs reported having access to an ART clinic, and 85.4% of
measures in our survey and are thus unable to precisely those individuals reported regularly accessing the clinic.
indicate individuals who should have been tested. These rates are commendable and imply a willingness of
patients in this setting to seek follow-up care. However, these
A significant barrier to HCT in the ED and other healthcare are self-reported statistics and could be inflated as a result of
facilities frequently described in the literature are stigma social-desirability bias.
and the lack of confidentiality. 20,26,31 This finding is supported
by contextual knowledge, wherein anthropological studies Another interesting finding was that a small proportion of
exploring cultural perceptions and practices around HIV in patients with a known HIV-positive diagnosis (20, 5.4%)
Mthatha have reported pervasive stigma attached to requested a repeat test to confirm their diagnosis. Patients
HIV/AIDS, resulting in multiple forms of exclusion based on stated that they wanted to confirm whether they were truly
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sexism, racism and homophobia, The National HIV HIV positive and/or if they were still HIV positive. Upon
Prevalence Survey indicated that 26% of people would not be retesting, all 20 patients were HIV positive. The desire to retest
willing to share a meal, 18% were unwilling to sleep in the when an opportunity presented could likely be a result of
same room and 6% would not speak to PLWH. Yet, none of mistrust in the healthcare system or a result of the low health
2
the patients declining testing in our study reported reasons literacy in the region, which are both potential barriers to
implying real or perceived stigma or the lack of confidentiality. achieving high rates of testing and sustained linkage to care. 30,31
The studies supporting this notion conducted in-depth
interviews or had one-on-one conversations with patients, There are several study limitations to consider. The protocol
which likely allowed for deeper exploration of patient was to approach every patient presenting in the ED who met

http://www.sajhivmed.org.za 208 Open Access