Nakivale refugee participants in this study prioritized daily survival needs such as obtaining food, maintaining shelter, cultivating land, and ensuring safety. Attending to these priorities meant other needs had to be postponed or foregone. In this setting, there is a tension between meeting the needs of immediate survival and meeting needs perceived as less urgent, such as preserving health. For the refugees interviewed, testing tended to occur when the tension temporarily eased, allowing priorities to shift. For some, priorities shifted when illness prevented involvement in normal activities, including obtaining food. For others, priorities shifted when immediate survival needs were temporarily met or when barriers to testing were reduced, allowing an opportunity to test. Understanding survival needs allows the development of targeted interventions to encourage priority shifting, in ways such as those outlined below. Qualitative research does not aim for generalizability; rather, the goal is to learn from the study participants and apply the knowledge gained to generate ideas for future studies.
Interventions that increase the perceived benefit of testing are likely to be a successful approach, because they will help HIV testing become an attractive competing priority compared with usual survival tasks. Presenting HIV testing and knowledge of HIV sero-status as advantageous could be done using educational campaigns as public health campaigns about HIV/AIDS have been shown to increase knowledge and to have a positive impact on health [41–43]. Highlighting the utility of medical therapy for those who are positive and the need to focus on safe sexual practices to decrease the likelihood of transmission for those who are negative, may incentivize testing and lead refugees to appreciate the advantage of knowing if they are HIV-infected or not. Enhancing the perceived benefit of testing could also be accomplished by providing material incentives at the time of testing as has been demonstrated in other settings in sub-Saharan Africa [44, 45]. When offered a bar of soap or a small bag of maize, refugees may view having an HIV test as a reasonable priority over other competing demands.
Another potentially successful approach is to design interventions that help meet immediate survival needs. When able to disregard immediate needs, refugees will have the opportunity to use their time and energy to access available HIV testing services. This could be a temporary solution, seeking to provide respite for a short while, to encourage HIV testing during this time. Following the Partners in Health (PIH) model of care , which aims to alleviate the root causes of disease and provide long-term solutions to improve general health and well-being, interventions could focus on enhancing the quality of life of refugees rather than on providing a specific health service.
Perhaps the most promising and practical HIV testing interventions are those that focus on alleviating the barriers to testing. Given that HIV testing is provided free of charge, but that it is not conveniently located for many refugees, interventions designed to enhance accessibility are likely to yield increased utilization of services. A program that would build on this premise might be one that placed HIV counselors and testers in the waiting areas of health clinics in refugee settlements to offer HIV testing to people while they wait for clinical care, as has been demonstrated to be successful in other low resource settings in sub-Saharan Africa . Though the current goal in many clinics is Provider-Initiated Testing and Counseling (PITC) for everyone seen by the clinician [1, 5], the overwhelming number of patients seen daily by health care providers and subsequent time constraints make this impossible. By instead using lower-cost HIV counselors and testers to approach all-comers in the clinic waiting area, more refugees are likely to be offered testing and are more likely to utilize testing services.
If refugees are similar to other low-resource populations in Africa, a useful intervention might be mobile HIV testing units [30, 34, 44, 45, 48]. By bringing testing to remote communities, this makes accessing testing less time consuming and less costly. A more comprehensive but costly approach to mobile testing would be to offer home-based voluntary counseling and testing (HB-VCT) services to all refugees in the settlement. This type of program, though it would require significant resources, may have the biggest impact on helping more refugees test for HIV as it has been in non-refugee populations in sub-Saharan Africa [33, 49–53]. Any HB-VCT program in a refugee setting to meet the medical needs of the refugees diagnosed as HIV-infected. Ideally this would include referral to an HIV clinic and arrangement of transportation to the clinic.
A number of limitations of this study should be considered. The study population included refugees diagnosed with HIV/AIDS attending ART Clinic and did not include people who had never tested for HIV/AIDS or people who were HIV-infected but not attending ART Clinic. This means a number of relevant topics could not be explored, including: the knowledge of HIV/AIDS among refugees who have never tested, awareness of the availability of HIV testing among refugees who have never tested, and self-risk assessment among refugees who have never tested. Since the study was conducted at the HIV clinic, and because refugees are often given land based on their country of origin, it is likely that specific country groups housed closer to clinic are over-represented in the HIV clinic and in the study. The interviews were conducted by a male from the Democratic Republic of the Congo. The fact that the interviewer was a male could have led some women to be timid in sharing information. Given the interviewer was from the Democratic Republic of the Congo, this also may have influenced the dialogue. The Democratic Republic of the Congo has been the site of ongoing war with complex interactions involving surrounding countries.
While these possibilities cannot be excluded, all of the refugees invited to join the study opted to participate and by report, most spoke candidly and outwardly expressed gratitude for the opportunity to tell their story. In addition, the conceptualization that followed from the analysis was based on the population studied in Nakivale Refugee Settlement. It is possible that in other refugee contexts the survival needs and daily priorities may differ.