Abstract #226  -  HIV testing among Young Married Women in an Observational Study in Bangalore, India: Ethical Challenges and Testing Uptake
Authors:   Presenting Author:   Dr. Suneeta Krishnan - RTI International
Additional Authors:  Mr. Sujit Rathod, Ms. Corinne Rocca, Ms. Kalyani Subbiah,
Aim: India has one of the world’s highest numbers of HIV/AIDS-affected populations. Available evidence indicates that gender inequities are a key factor underlying women’s susceptibility to HIV and other sexually transmitted infections (STIs). The aim of our research was to examine the relationship between dimensions of gender-based power and young married women’s susceptibility to HIV, including their uptake of HIV testing. In this paper, we describe the ethical challenges associated with and the results of offering HIV testing to this vulnerable group. Specifically, we describe the factors we considered when developing an ethical, rights-based testing strategy, the approach we ultimately adopted, and testing uptake.
Method / Issue: A convenience sample of 744 married women aged 16 to 25 years were recruited from two low-income neighborhoods in Bangalore, India. Study visits, which occurred at baseline, 12- and 24-months, were conducted between 2005 and 2008 at two public primary health centers. At enrollment, women participated in a face-to-face interview. Pre-test counseling was conducted based on guidelines issued by the Indian National AIDS Control Organization and United States Centers for Disease Control and Prevention, and participants who consented underwent HIV testing. Questions were posed to assess reasons underlying refusals to undergo testing. Interviews were conducted at 12- and 24-month follow up visits, while HIV testing was offered again at the 24-month visit.
Results / Comments: Given the focus of our research on the influence of gender-based power on women’s susceptibility to HIV, we were particularly concerned with ensuring that women were able to make informed and autonomous decisions regarding HIV testing. In recognition of the hierarchical nature of physician-patient relationships in India, at baseline, we decided that HIV counseling and testing services would be offered by study-trained lay counselors. Based on observations of testing uptake at baseline, we decided to have physicians rather than lay counselors offer counseling and testing (similar to provider-initiated testing recommended by the World Health Organization). In addition, we offered rapid HIV testing, which requires only a finger prick blood specimen. Because of lingering concerns regarding women’s autonomy, we retained the opt-in approach with written informed consent. At baseline, 17% of women who did not report a history of HIV testing consented to undergo screening. At the 24 month visit, however, 52% of women who did not report a history of testing consented.
Discussion: In conclusion, we discuss the potential impact of changes in HIV screening practices on testing uptake in relation to the ethical challenges we encountered. We argue that in contexts characterized by social inequities, retaining opt-in testing may be essential to ensuring authentic consent. Finally, because the success of the testing process in upholding ethical principles is heavily dependent on the implementers, capacity building of health care providers to respect individual autonomy in decision-making will also be necessary.
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