Date Published: June 12, 2019
Publisher: Public Library of Science
Author(s): Moses Kelly Kumwenda, Elizabeth Lucy Corbett, Augustine Talumba Choko, Jeremiah Chikovore, Kruger Kaswaswa, Mphatso Mwapasa, Rodrick Sambakunsi, Tore Jarl Gutteberg, Stephen Gordon, Alister Munthali, Nicola Desmond, Jose A. Muñoz-Moreno.
Mandatory face-to-face counselling is necessary during HIV testing but difficult to implement within the context of HIV self-testing. We investigated adverse psychological effects and coping mechanisms following HIV-positive and HIV-discordant test results amongst self-tested individuals living in couples in urban Blantyre, Malawi.
Qualitative data from 35 in-depth interviews with self-tested individuals living in couples for more than 3 months were collected and analysed using thematic content analysis.
Adverse psychological effects seemed to mostly occur among individuals learning for the first-time that they were HIV-positive or living in HIV-discordant relationship. Irrespective of test outcomes, women living in couples expressed difficulty making important decisions about the future of their relationships while men seemed to shoulder the emotional burden associated with feeling or being seen as responsible for introducing HIV into the relationship. Post-test psychosocial support and ascertained positive behaviour change of the perceived index partner allowed some couples to overcome adverse psychological effects linked to test results.
Self-tested individuals living in couples may lack collective coping capability to collaboratively manage post-test adverse events after new HIV-positive or HIV-discordant results. Psychosocial support seemed to enable couples to foster both an individual and a collective ability to manage adverse psychological effects within the context of a couple. More research is needed to ascertain the magnitude of the deficiency of collective coping competency in couples following an HIV test.
HIV self-testing (HIVST) is a novel approach to HIV testing that has great potential for reaching under-served groups of people such as men, youth and key populations such as female sex workers and men who have sex with men (MSM). HIVST occur when “an individual collects his or her own sample; performs a simple, rapid non-laboratory test; and is the first to know ones results” . Blood-based and oral fluid-based test-kits options for HIVST are available with the latter having more empirical evidence on feasibility, acceptability and accuracy than the former [2,3]. Allowing individuals to perform their own HIV test introduces certain worries including a potential for abuse, for instance, through use on others people without the requisite consent, or through coercing partners in sexual relationships into testing . There are also concerns about the potential for adverse psychological effects following HIV-positive results and the problem of managing such effects especially when the test has been carried out in absence of a trained professional .
Demographic characteristics of study participants (Table 1) illustrate that male participants were older, better educated and more engaged in both formal and informal income generating activities than female participants. Study results from our qualitative analysis demonstrate presence of adverse psychological effects related to HIV-positive and HIV-discordant self-test results. Fig 1 shows post-test reactions following new HIV-positive and HIV-discordant results in relation to the level of coping competency while Table 2 contains quotes from participants on key themes.
Findings from this study have demonstrated evidence of post-test adverse psychological effects and described coping mechanisms amongst self-tested individuals living in couples following new HIV-positive and HIV-discordant test results. Heightened levels of adverse psychological effects are common amongst individuals recently diagnosed with HIV who often exhibit several symptoms including suicidal thoughts, impaired well-being, fear of reaction from family members, fear of social disgrace, depression, denial, weight loss and anxiety [30,31]. Adverse psychological effects after HIV-positive results such as a feeling of hopelessness, shock, crying and blaming oneself were also reported within PMTCT programme from rural Malawi . All new HIV-positive participants who experienced test-related adverse psychological effects in this study confirmed their HIV statuses through routine HTS within 7 days of testing where they received relevant post-test counselling and linkage information. However, insufficient information and support was provided to HIV-negative individuals who had an HIV-positive partner partly because of the lack of knowledge for managing complex relationship dynamics emerging because of serodiscordant results and their persistent pressure to meet cluster-level uptake targets for the trial . To deal with this problem, we included HIV-discordant management in the training curriculum of HIVST providers in subsequent large-scale HIV self-testing implementation programmes . A positive but an unanticipated finding was that scepticism and distrust towards authenticity of HIV-positive result from an oral-fluid based test kit encouraged self-tested individual to get a second opinion by confirming test results using conventional HIV-testing approaches at a facility. Psychological refusal to accept one’s HIV diagnosis has been reported to be prevalent especially where individuals perceive that their state of health is excellent . This unanticipated result provides certain amount of hope that individuals testing HIV-positive through HIVST may have a drive to visit healthcare facility to confirm their results and subsequently link to follow-up HIV care.
This paper has qualitatively discussed adverse psychological effects following new HIV-positive and HIV-discordant self-test results occurring amongst individuals living in couples. Self-tested participants living in couples seemed to lack both the individual and collective abilities to manage adverse psychological effects emerging after new HIV-positive and HIV-discordant results. This inability seemed to be amplified by the differing social and economic positions of men and women. Individuals testing HIV-positive or obtaining HIV-discordant results for the first-time within the context of a relationship undergo unique psychological challenges, as they must deal with the knowledge of an HIV infection at the intrapersonal level, but manage outcomes of having this information at the interpersonal level. Our findings suggest that the availability of post-test psychosocial support directed at management of relationship dynamics may be beneficial in reinforcing both individual and collective coping ability and resilience towards HIV-positive and HIV-discordant results. However, more research is required to quantify the magnitude of the deficiency in coping competency among heterosexual couples following an HIV self-test.