title: Could you have said no? A mixed-methods investigation of consent to HIV tests in four African countries.
abstract: BACKGROUND
  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.
authors.affiliation: Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon; cm39@aub.edu.lb.
authors.forename: Carla Makhlouf
authors.initials: CM
authors.lastname: Obermeyer
authors.affiliation: Independent Consultant, Dakar, Senegal.
authors.forename: Cairn
authors.initials: C
authors.lastname: Verhulst
authors.affiliation: Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
authors.forename: Khalil
authors.initials: K
authors.lastname: Asmar
mesh_terms: D015492:AIDS Serodiagnosis; D000293:Adolescent; D000328:Adult; D002050:Burkina Faso / Q000453:epidemiology; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007258:Informed Consent / Q000523:psychology; D007630:Kenya / Q000453:epidemiology; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D012959:Socioeconomic Factors; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult
keywords: Consent; HIV; ethics; qualitative; sub-Saharan Africa; testing