Offering HIV Screening Where At-risk Individuals Live: Challenges and Opportunities
Public health strategies to prevent AIDS focus on identifying HIV-infected people, getting them into treatment, and communicating with them about ways to prevent the spread of the virus. Previous efforts have sought to reach at-risk individuals where they hang out, such as bars, homeless shelters, and community clinics. Our study focused on another setting for screening: a housing complex where large numbers of at-risk people live. A residential setting offers the promise of convenience and higher visibility, but it could also cause concerns about privacy for the participants.
As part of a larger project that sought to identify effective strategies to encourage underserved women to seek regular reproductive sexual healthcare services, we partnered with a local nonprofit to provide HIV testing and counseling services within the women’s housing complex. The testing was conducted in the privacy of our university team’s field office, located on the second floor of the high-rise. However, residents were aware HIV screening was taking place. The free testing was conducted once a month, coinciding with a food pantry held in the building. The nonprofit organization staffed a table by the pantry, providing information about HIV and details about the free testing upstairs. Peer outreach workers from the nonprofit organization distributed flyers about the screening to people waiting in the food pantry line. Posters announcing the screening were displayed in the high-rise building for several days.
The free on-site testing was designed to offer residents convenience and time efficiencies. However, field observation and informal discussion with members of the community, combined with the fact that the testing was not utilized to capacity, suggested there might be concerns of privacy and confidentiality with on-site testing. Our study looked at how residents of a low-income housing high-rise viewed on-site HIV screening.
The Stigma of HIV Extends to Testing
The historic stigma of HIV, because of its association with death, drug abuse, and promiscuity, can carry over to individuals merely suspected of having the illness. Thus, some people may avoid HIV testing. Managing one’s privacy and protecting one’s health status in the eyes of one’s community becomes an important factor. Even being tested for the virus carries privacy risks.
Low-income communities are particularly vulnerable to poor health and illness, including HIV. Specifically, African-American women, who are overrepresented among the poor, are at high risk for contracting HIV. (African-American women are 20 times more likely than white women and five times more likely than Hispanic women to acquire the HIV infection.)
Perceptions of On-site Testing
For our study, we asked women who lived in the building for their thoughts about the on-site testing. We conducted interviews with 15 women who had participated in the screening and 17 women who had not. We asked them about the advantages and drawbacks of on-site HIV screening. We also wanted to understand how they managed their privacy concerns when being screened for HIV where they live.
Some women talked about how accessibility positively influenced decisions to be tested. Others shared their concerns about privacy and fear of stigmatization, which could serve as a barrier to the testing.
Pros and Cons of On-site Testing
The women spoke of the convenience of on-site testing, which removed the need to find transportation and took less of their time. They also spoke about the comfort of being tested where one lives. Some expressed the feeling that there was sufficient privacy and pointed to the visibility of the testing as a way to encourage others to get tested. The fact that the testing was taking place within their residential complex appeared to spark discussions among the women, some of whom encouraged others to get tested.
On the other hand, the problems with on-site testing the women described included concerns about confidentiality of results, privacy concerns related to the gossip that takes place within the social networks of the housing complex, and the stigma connected to HIV and HIV testing. As a result, some women said they couldn’t take a chance with confidentiality.
Through the lens of Communication Privacy Management Theory, as defined by Sandra Petronio, we analyzed the interviews and learned how the women managed their privacy concerns during interactions with others. These strategies included concealing their true actions of going to get tested, positioning their own health as paramount and more important than possible gossip, and encouraging testing for everyone. Several women had already normalized HIV testing as part of their healthcare routine and thought everyone should know their respective status.
Unexpected Advantages of On-site Testing
Through these interviews, we found there may be additional, unexpected advantages to testing in a residential setting, including a change in the meaning of testing and the ability to provide testing on a “then and there” basis.
Offering HIV testing where people live provides opportunities for the residents to see promotional signage every month and observe others going to get tested. The interviews suggest this regular process may be changing how people in the community think about testing; that is, they are beginning to think of HIV testing as more routine rather than something only done by those who have reason to think they might be in trouble. Locating testing within the residential environment could be a powerful way to destigmatize testing, but this is not likely to happen overnight.
Another advantage of offering on-site testing points to the role of immediacy and convenience in encouraging new health-related behaviors. By locating recruiting efforts in the building lobby, interactions take place in which women are approached and offered testing then and there. This differs significantly from the traditional situation where women must make their decision to be tested prior to interacting with recruiters.
The results of our study also lend themselves to practical recommendations. We found that bringing HIV testing into public housing of low-income minority and ethnic women offers a promising strategy for reaching more members of at-risk populations. The findings suggest that on-site testing and associated messages may encourage routinization of HIV testing within a community. This ties in well with public health initiatives that recommend HIV testing as part of other routine health care. Messages for on-site testing could be fine-tuned with the goal of attracting increased participation and encouraging the understanding that sexual health screening is a standard part of caring for one’s health.