“Even they can ask me, I can say I don't have it”: HIV nondisclosure within the South African health care system

Purpose: This paper illustrates key social and ethical challenges associated with health care integration for human immunodeficiency virus (HIV) and tuberculosis (TB) coinfection. Background: Escalating rates of HIV-TB coinfection have prompted the integration of HIV and TB services within high-burden countries. We undertook a qualitative study to characterize front-line experiences with integration efforts in KwaZulu Natal, South Africa Methods: In-depth interviews were conducted with 40 HIV-positive TB patients and 8 health care providers at 3 ambulatory clinics providing diverse models of HIV and TB care. Data was analyzed under a modified grounded theory approach. Findings: Coinfected patients perceived disparate levels of stigma, provider-trust and quality of care within HIV and TB clinics, which led some patients to hide their HIV status from non-HIV providers. HIV and TB providers balanced their imperative to earn patient trust and adhere to the principle of medical confidentiality against the transparent exchange of information between HIV and TB programs and facilitation of integrated care. Patient and provider accounts reflected important social and ethical issues relevant to the concurrent delivery of HIV and TB care, and help inform integration efforts in similar high-burden settings. Implications: HIV nondisclosure and medical confidentiality within the health care system may impede the effective integration of HIV and TB care. They warrant the implementation of stigma reduction efforts within the health care system, provider training to enhance patient communication and trust, and consensual procedures that facilitate open communication between HIV and non-HIV programs.