What Works for Women and Girls

Women Must Have a Choice in TestingGiven the consequences they face, including violence, women must have the right to opt out of“routine” testing. [See also Chapter 9C-1. Safe Motherhood and Prevention of Vertical Transmission:Testing and Counseling] Mandatory testing, besides being a human rights violation, may notlead to any positive outcomes in HIV prevention or treatment. For example, a study in Ethiopiafound that of 4,000 HTC clients, 14% were being tested because they planned to be married.Among pre-marital testers, 93% of men and 89% of women reported that the HIV test wasrequired. Male pre-marital testers were more likely than other single clients to believe couplestested for HIV before marriage do not need to test again for the duration of the marriage(40.2% of men; 30.4% of women). Male pre-marital HIV testers were 65% less likely thanother single clients to intend to use condoms for HIV prevention and female pre-marital HIVtesters were 65% less likely than other single clients to intend to use condoms for HIV prevention(Bradley et al., 2008b).Provider-initiated testing and counseling, implemented appropriately, has the potential toincrease testing. In the study of 1,268 respondents in Botswana, routine testing during antenatalcare increased the proportion of women undergoing HIV tests by 15%, with a doublingof those on treatment (Weiser et al., 2006a). However, some members of the InternationalCommunity of Women Living with HIV/AIDS (ICW) have reported that providers do not sufficientlyadvise women that HIV testing is a choice: “When I got pregnant at 16 I knew nothing.I didn’t know I had a choice not to be tested” (ICW member, South Africa, cited in Bell et al.,2007: 119). A study in the Ukraine in 2003 of 15 healthcare workers and of 40 HIV-positivewomen ages 16–33 who were either pregnant or had been pregnant in the last two years foundthat 24 of the women included in the study reported feeling that they had little or no choice inthe decision-making process to be tested for HIV. Only 12 reported their decision to be testedto be an independent one (Yaremenko et al., 2004). Further efforts are needed to ensure thatwomen are able to make their own choices in testing.Confidentiality and Consent Are Critical in Testingand CounselingIf women fear that they will be pressured into having a test or that the results will not bekept confidential, they may be less likely to use services. Focus group discussions along withinterviews of twelve health professionals in Brazil found concern that partner notificationwould prejudice the provider-patient relationship, possibly generating situations of violenceand stigma (Silva and Ayres, 2008). In interviews with HIV-positive women conducted in theDominican Republic in 2004 (no numbers given), HIV-positive women reported that they didnot access reproductive health services for fear of being subjected to an HIV test and losing148 CHAPTER 6 HIV TESTING AND COUNSELING FOR WOMEN