Could you have said no? A mixed-methods investigation of consent to HIV tests in four African countries

J Int AIDS Soc. 2014 Mar 17;17(1):18898. doi: 10.7448/IAS.17.1.18898. eCollection 2014.


Introduction: Although most studies report high frequencies of consent to HIV tests, critics argue that clients are subject to pressure, that acceptors later indicate they could not have refused, and that provider-initiated HIV testing raises serious ethical issues. We examine the meaning of consent and why clients think they could not have refused.

Methods: Clients in Burkina Faso, Kenya, Malawi and Uganda were asked about consenting to HIV tests, whether they thought they could have refused and why. Textual responses were analyzed using qualitative and statistical methods.

Results: Among 926 respondents, 77% reported they could not have said no, but in fact, 60% actively consented to test, 24% had no objection and only 7% tested without consent. There were few significant associations between categories of consent and their covariates.

Conclusions: Retrospectively asking clients if they could have refused to test for HIV overestimates coercion. Triangulating qualitative and quantitative data suggests a considerable degree of agency.

Keywords: Consent; HIV; ethics; qualitative; sub-Saharan Africa; testing.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • AIDS Serodiagnosis*
  • Adolescent
  • Adult
  • Burkina Faso / epidemiology
  • Cross-Sectional Studies
  • Female
  • Humans
  • Informed Consent / psychology
  • Kenya / epidemiology
  • Malawi / epidemiology
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care / psychology*
  • Socioeconomic Factors
  • Uganda / epidemiology
  • Young Adult