Background: To increase access to HIV testing, WHO recommended in 2007 provider-initiated HIV testing using a simplified but still exceptional approach in terms of pre-test counseling and consent. Cote d''Ivoire implemented in 2009 systematic HIV testing proposal in all medical consultations, irrespective of reasons. What are health care professionals (HCPs) perceptions and experiences related to testing proposal?
Methods: An ethnographic multi-site study was conducted in 3 general medical services (urban, semi-urban, rural) in 2 Ivorian health districts: 37 in-depth interviews with HCPs and 200 observed medical consultations (general medicine). A thematic analysis was performed on HCPs'' practices and discourses.
Results: The proportion of patients offered an HIV test was low (around 20%), due to HCPs'' reluctance to propose an HIV test in the absence of clinical suspicion. When offered, HIV test was more often prescribed than proposed. The analysis revealed 4 types of explanations in HCPs discourses.
(1) Due to stigma associated to HIV, HCPs feared a negative reaction from their patients: refusal, offence, distrust, loss of patients.
(2) Time-consuming specificity of HIV testing in terms of counseling, consent and administrative procedure (separate record and dedicated prescription) is perceived by HCPs as not useful and inducing a work overload that should be financially compensated or realized by dedicated providers, as it was before 2009.
(3) In the absence of clinical suspicion, they considered that proposing an HIV test during a general consultation is not medically justified and not their priority.
(4) Finally, HCPs felt that they are not sufficiently trained.
Conclusions: HCPs experiences and perceptions are negatively affected by the legacy of the successive HIV policies implemented since the beginning of the epidemy. Some complex procedures, historically implemented due to confidentiality and stigma issues, could maybe be simplified today. Integrating HIV testing in routine is a challenge considering that these activities were previously implemented with dedicated incentives, training and human resources. In a context of limited resources and mixed epidemic, how to prioritize and reorganize HIV testing in general consultations while motivating HCPs and being efficient in terms of public health?

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