The Duty to Disclose in Kenyan Health Facilities: a Qualitative Investigation of HIV Disclosure in Everyday Practice

ABSTRACT

Disclosure of HIV status is routinely promoted as a public health measure to prevent transmission and enhance treatment adherence support. While studies show a range of positive and negative outcomes associated with disclosure; it has also been documented that disclosing is a challenging and ongoing process. This article aims to describe the role of health-care workers in Central and Nairobi provinces in Kenya in facilitating disclosure in the contexts of voluntary counselling and testing and provider-initiated testing and counselling and includes a discussion on how participants perceive and experience disclosure as a result. We draw on in-depth qualitative research carried out in 2008-2009 among people living with HIV (PLHIV) and the health workers who provide care to them. Our findings suggest that in everyday practice; there are three models of disclosure at work (1) voluntary-consented disclosure; in alignment with international guidelines; (2) involuntary; non-consensual disclosure; which may be either intentional or accidental; and (3) obligatory disclosure; which occurs when PLHIV are forced to disclose to access services at health facilities. Health-care workers were often caught between the three models and struggled with the competing demands of promoting prevention; adherence; and confidentiality. Findings indicate that as national and global policies shift to normalize HIV testing as routine in a range of clinical settings; greater effort must be made to define suitable best practices that balance the human rights and the public health perspectives in relation to disclosure