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1. ~ Pergamon 0277-9536(95)00145-X
So( Sci. '~led. Vol. 42. No. 5. pp. 733 743, 1996
Copyright ~ 1996ElsevierScienceLtd
Printed in Great Britain. All rights reserved
0277-9536,96$15.00+ 0.00
A REVIEW OF RESEARCH ON THE NATURE AND
QUALITY OF HIV TESTING SERVICES: A PROPOSAL
FOR PROCESS-BASED STUDIES
SUSAN BEARDSELL ~* and ADRIAN COYLE:
~Sigma Research, School of Health Studies, Unit 64. Eurolink Business Centre, 49 Effra Road, London
SW2 1BZ, England and :Department of Nursing and Midwifery, University of Surrey, Guildford, England
Abstract Considerable research has been conducted on various issues associated with HIV testing.
However, rather than conceptualizing HIV testing as a dynamic process which consists of interrelated
elements, this body of work has focused on discrete aspects of the HIV testing process. As an example of
such research, studies which have examined HIV testing in terms of various behavioural and psychological
outcomes are critically reviewed. Their limitations are attributed to their failure to account for all the
elements involved in the HIV testing process that--singly and in dynamic combination could have
produced the measured outcomes. It is contended that if research on HIV testing is to be of use in the
development and improvement of HIV testing services, it should be able to identify and describe in detail
the factors that might lead to various outcomes of testing. This requires an in-depth examination of all
aspects of the HIV testing process and their interrelationships from the perspectives of those undergoing
testing and those providing testing services.The principal process elements in HIV testing are described:
existing research on these topics is critically reviewed: and recommendations are made for future research.
The process elements of l-!IV testing are identified as making a decision to be tested: accessing testing services;
test counselling: and waiting for the test result. Of these, most consideration is accorded to the HIV test
counselling process. It is contended that research is needed which examines both clients' and counsellors'
expectations, experiences of and satisfaction with HIV test counselling. Specific issues that could usefully
be addressed by future research include the process of obtaining clients' informed consent for testing; the
ways in which test results are conveyed to clients; the strategies used in HIV counselling to help clients avoid
or reduce risk behaviours in the future: partner notification: and which professional groups are best placed
to conduct HIV test counselling. Flintily, the question of which research methods might be suitable ['or
process-based studies is considered. It is concluded that qualitative methods could be particularly
appropriate as they are well-placed to chart in detail the varied aspects of the HIV testing process and their
interrelationships.
Kcr words--HIV AIDS, HIV testing, HIV counselling, process research
INTRODUCTION
Since the HIV antibody test first became available in
the U.K. in 1985, the many contentious issues that it
raised has made HIV testing a topic of heated debate.
Earry publicity in the gay press actively discouraged
testing on the grounds that it could be used to
discriminate against gay men [1]. Some health
professionals and HIV/AIDS organizations did not
advocate testing because they felt that those who tested
positive risked considerable psychological distress and
that clinically there was little to offer them [2, 3]. More
recently, however, arguments have shifted to focus on
the importance of early diagnosis for access to
monitoring, prophylaxis, treatment, counselling and
social services support and to facilitate reproductive
decision-making and a reduction in behaviours that
carry risks of HIV transmission. As the demand for
HIV testing has increased, the Department of Health
*Author for correspondence
has moved towards a more proactive policy on testing
[4]. Some services in some locations, e.g. antenatal
services and genitourinary medicine (GUM) clinics,
are now offering the test to all clients instead of waiting
for clients to request one [5 7].
Everyone who wishes to consider having an HIV test
should be able to access HIV counselling and testing
services easily in order to help them assess their risk of
having contracted HIV and the need for them to have
a test. The Patient's Charter has emphasized the
importance of health services being responsive to the
needs, views and preferences of service users [8] and
the NHS Management Executive has stated that "'(i)f
health authorities are to establish a champion of the
people role, their decisions should reflect, as far
as practical, what people want, their preferences,
concerns and values" [9] (p. 3). However, relatively
little research has been undertaken into the nature and
diversity of HIV testing experiences in order to create
services that are client-centred and responsive to
clients* needs. Instead, research has concentrated on
the outcomes or 'effects' of HIV testing or on discrete
733

2. 734 Susan Beardselland Adrian Coyle
elements of the testing process. This paper provides
a critical review of HIV testing research to date
and argues that, if research is to produce realistic
recommendations for the improvement and develop-
ment of HIV testing services, an analysis of the whole
process of HIV testing is required.
Most of the research that will be discussed was
conducted either in Britain or the U.S.A. and therefore
is only applicable to areas where a system of voluntary
HIV testing supported by pre- and post-test
counsellingis operative. As a result of dissatisfactions
with previous research on HIV testing, the authors are
currently conducting qualitative research on the HIV
testing experiences of service users and providers
in London and Essex from a process perspective,
which will address some of the issues raised here.
Consequently,this paper is written very much from the
British viewpoint but will have applications elsewhere
where similar testing procedures operate.
OUTCOMEINVESTIGATIONSOF HIVTESTING
Outcome investigations measure the results of
activities and gauge how effective these activitiesare in
meeting pre-defined objectives [10]. Some research,
mainly from the U.S.A., has looked at HIV testing
from an outcome perspective. Researchers have
pre-defined outcomes in terms of changes in HIV risk
behaviours or mental health functioning.
Risk reduction has been identified as an important
aim of HIV testing [5, 11-15]. It has been argued that
HIV test counsellingprovides a prime opportunity to
engage in one-to-one health education and thus bring
about a reduction in or a cessation of behaviours likely
to put the individual at risk from future infection if
HIV negative. For those who test positive, HIV test
counselling is seen as bringing about behaviour
change to protect them from reinfection with HIV or
infection with other sexually transmitted diseases and
to protect their future sexual partners or people they
share injecting equipment with. Reviews of studies
of behaviour change associated with HIV testing and
counselling have, however, revealed inconsistent
findings and methodological limitations [4, 16].
Moreover, most are based on questionable theoretical
assumptions regarding the testing process and the
nature of behaviour change [4]. Those who seek HIV
testing may have already made significantbehavioural
changes prior to testing and other factors--apart from
having undergone the HIV testing procedure--may
have caused any behaviour change that is detected
[4, 14, 17-19]. Of greater concern is the possibilitythat
no behaviour change is detected because this issue is
not addressed during the HIV testing process. A
survey of general practitioners (GPs) in London
revealed that 27% never or only sometimes raised the
issue of safer sex when patients asked them about an
HIV test [20]. Indeed, 11% never or only sometimes
offered counselling to patients who requested HIV
tests.
Apart from changes in risk behaviour, researchers
have also hypothesized that HIV testing can affect
mental health. Various psychometric tests have been
used to assess anxiety, stress, depression and
psychiatric symptomatology. This research has,
however, yielded inconsistent results and has
sometimes been marked by methodological inadequa-
cies (summarized by Jacobsen et al. [18]).For instance,
Cleary et al. [21], not unexpectedly, found that blood
donors exhibited high levels of psychological distress
after beingtold that routine HIV antibody tests carried
out on their blood had yielded positive results.
However, pre-disclosure levels of psychological
distress were not measured and comparisons were not
made with blood donors who were found to be HIV
negative. Three other studies did provide these sorts of
comparisons but are limited because they did not
examine individuals who had voluntarily sought an
HIV test: Ostrow et al. [22] and Moulton et al. [23]
tested all those who had enrolled in longitudinal
studies of gay men and gave participants the option of
receiving their test result. Perry et al.'s [24] study of
men and women who had been tested was more
naturalistic but participants were recruited by offering
them a free HIV test. All these studies found that
receiving a negative HIV test result had a positive
impact on mental health. For those who were found
to be HIV positive, no significant increases in anxiety
and depression were reported following notification
and by ten weeks, levels of anxiety and depression were
lower than at entry. Moulton et al. [23] found no
significant increases in anxiety, mood and hopeless-
ness effects at two weeks, three months, six months and
12months after the disclosure of HIV test results, with
the exception of increased anxiety after a year. Ostrow
et al. [22] also found an increase in psychological
distress at a year's follow up. The time between
notification and follow-up is one explanatory factor
and any effects at one year may be attributed to any
number of factors associated with being HIV positive.
Such studies often assume that the notification of
test results causes the mental health outcomes that
they describe and fail to consider other possible
causative factors. However, even if available outcome
evaluations of HIV testing provided consistent
evidenceas to its effects, we need to know how and why
such outcomes were achieved if we are to plan and
develop effective services. This can only be done by
examining all aspects of the testing process in detail.
For example, the role of HIV counsellingin mediating
psychological reactions to HIV test results has largely
been overlooked in psychological outcome studies.
Yet, given that the aims, methods and content of
pre-and post-HIV test counselling may vary widely
[25], it is clear that variation in the quality of HIV
counsellingmay explain variation in the psychological
consequencesof being notified of a positive result. This
is suggested by one study's finding that high levels of
distress were associated with dissatisfaction at how
the test result had been communicated and with

3. A reviewof HIV testing research 735
insufficient opportunity to discuss the result [26]. The
counsellingdimension therefore needs to be taken into
account in HIV testing research.
PROCESS INVESTIGATIONS OF HIV TESTING
Perhaps the main reason why HIV counselling has
not been accorded greater prominence in outcome
research is that HIV testing has been conceptualized
as a series of discrete events rather than as a dynamic
process that consists of related elements, with HIV
counsellingas a key component. Adherence to such an
approach has led some researchers to claim to have
studied the effects of the notification of positive HIV
test results without taking account of the larger HIV
testing process within which notification is embedded.
If outcomes are to be measured, they must be
conceived of as outcomes of the HIV testing process
rather than as outcomes of discrete constitutiveevents.
The concept of process-based research has been
defined as "the linking of sequences of action/inter-
action as they pertain to the management of, control
over, or response to, a phenomenon" [27] (p. 143).
Process-based research which aims to evaluate any
service, programme or intervention is concerned with
those factors that make the service what it is; the
strengths and weaknesses of the service: how clients
are brought into the service and how they then
progress through it: and the nature of interactions
between staff and clients [28]. It represents a move
away from describing outcomes or delineating
developmental steps within the phenomenon being
evaluated and a move towards accounting for how
and why different outcomes are achieved. Whereas
outcome research can determine whether or not a
particular service is achieving desired results, process
research can identify the reasons why a service is
failing to or succeeding in achieving these results and
can thereby provide an informed basis for amending
or developing the service.
Having an HIV test can be conceptualized as a
macro-process which comprises a number of subordi-
nate processes. These processes can be viewed as
consisting of sets of HIV testing experiences that
interact in a dynamic way to produce an outcome
(e.g. accessing a testing service; making a decision to
proceed with a test: changing HIV risk behaviours).
Unfortunately, as with outcome research, studies that
have been conducted on clients' experiences of HIV
testing have tended to consider only discrete elements
without charting their dynamic interdependence
[29-33], thereby ignoring the potential for analyzing
HIV testing experiences in process terms. Further-
more, with the exception of the work by Beevor and
Catalan [32] and Hankins et al. [33] on women's
experiences of HIV testing, these studies have tended
to focus on the experiences of gay (and bisexual) men.
Taking an HIV test may well have different meanings
and implications for different social groups, so this
field of inquiry needs to be extended.
SSM 425 H
A thorough examination of the processes involved
in HIV testing needs to take account of the experiences
of different groups of people and needs to begin with
the pre-test period and extend through to a
consideration of the behavioural and psychological
consequences of being tested. We would argue that the
processes that need to be considered and the research
issues pertinent to each one are as follows:
The decision-making process
What disposes someone to decide to have an HIV
test at a particular time? It is an important decision yet
very little is known about the decision-makingprocess.
Studies in the U.S.A. [34-36] and in the U.K. [37]have
claimed to study factors which impact upon the
intention or decision to take an HIV test or to return
for the result and for post-test counselling. However,
they have merely succeeded in identifyinga variety of,
often sociodemographic, factors that were statistically
associated with their dependent variables. Such
findings tell us nothing about the nature of the
decision-makingprocesses involved in being tested for
HIV.
Investigators in the U.S.A. [23, 38, 39], Canada [33],
the U.K. [30 32, 40-43] and other European countries
[44,45] have asked respondents to identify their
reasons for having or not having a test or for returning
or not returning for the result. Reasons for testing can
be divided into four main categories, i.e. a belief that
they could ha,,e been exposed to HIV based on, for
example, an acknowledgement of past risk behaviour
or having symptoms that could be HIV-related: a
desire for reassurance and to relieve the psychological
stress associated with not knowing their HIV status:
reasons related to present or future decision-making
regarding health, reproduction and sexual practices:
or because they were advised to take the test by friends
or health professionals. Reasons for not being tested
focused on fears of not being able to cope with a
positive result; anxiety about employment, insurance
or mortgages: concerns about the confidentialityof the
result: negative implications for relationships: not
wanting to know their serostatus: or not having felt
that they had been at risk.
Unfortunately, with the exception of individual
studies of women [32, 33] and injectingdrug users [40],
this research has focused on the experiences of gay and
bisexual men who may be more sensitized to their risks
of having contracted HIV. There is a need to
investigate further the reasons why other groups
decide to present for testing. Research conducted with
pregnant women in Sweden, for instance, has
produced a very specific set of reasons for taking up
an offer of a test that centre on the implications of
maternal seropositivity for the expected child [46]. In
addition, the full decision-making process in HIV
testing may well be more complex than is suggested by
the studies of reasons for being tested. The question
remains of what prompts people to act on these
reasons at a given point in time. The decision-making

4. 736 Susan Beardsell and Adrian Coyle
process about having a test involves more than simply
weighing these advantages and disadvantages in a
form of cost-benefit analysis. It involves a series of
decisions, each of which propel a person through the
testing trajectory and past various exit options. For
example, once the decision has been made to approach
a health professional, pre-test counselling may lead to
a decision about whether or not to proceed with a test.
After having given a blood sample, the decision must
then be made about whether or not to return for the
result. Hypotheses have been advanced about why
people might or might not make particular decisions
at these junctures [36]. In order to explore these
hypotheses in a comprehensive way, the interdepen-
dent stages of the decision-making process and the
various factors within and beyond the HIV testing
context that may impact upon this process need to be
charted.
The process of accessing HIV testing
Anyone considering having an HIV test should be
able to easily access HIV counselling and testing
services to explore whether testing is the most
appropriate course of action for them. It has been
recommended that process evaluations of services
should address the issue of accessing services as a
process component [28]. HIV counselling and testing
can be obtained from a variety of outlets--GUM
clinics, specialist HIV services, drug misuse services,
GPs, antenatal services, haemophilia centres and
private clinics. Additionally, clinicians may rec-
ommend and undertake HIV testing for diagnostic
reasons. In the U.S.A., research has been conducted on
people's knowledge of where HIV tests can be
obtained [47] and on the testing locations used by
various populations [48, 49]. However, there has
been no work done on the process by which
service users access HIV testing services or on how
accessibleor appropriate these are perceived to be. For
example, clients may access services themselves, be
referred by other health professionals or come via
'gatekeepers' such as help-lines and community
groups.
There is anecdotal evidence that some people may
feel uncomfortable going to their GP or attending
GUM clinics for testing and would prefer to attend a
clinic separate from other services [5]. Given the
negative attitudes that many GPs have expressed
towards HIV/AIDS-related issues [50, 51] and given
their ambivalence about whether they should be
offering an HIV testing service at all [20], this is not
surprising. The Department of Health [5] has
advocated the development of 'alternative' testing
sites. However, research has not yet addressed service
users' preferences for either current or alternative sites
and whether the latter would increase the accessibility
of testing services.
The HIV counselling process
The HIV counselling process consists of a number
of key components that require consideration. These
are addressed below.
HIV test counselling. Since 1985, it has been the
policy of the Department of Health that HIV testing
should be accompanied by pre-and post-test coun-
selling. There is limited research on what actually
occurs within HIV test counselling, the exception
being the work of Silverman and colleagues (for
example, Refs [52-57]). Using a conversation analytic
approach to real life counselling sessions, they have
identified substantial variation in the content of
sessions and in the way that counsellors work. Such
research, while valuable, does not provide information
about clients' or counsellors' perceptions of the
counselling process or their satisfaction with it.
However, one journalistic investigation of the HIV
testing process from a client viewpoint produced a
scathing evaluation of the HIV counselling component
[581.
Guidelines on HIV testing have stated that testing
should only be conducted after a client's informed
consent has been obtained [59-62]. Pre-test coun-
selling presents clients with the opportunity to have
their questions answered about the technical aspects of
the HIV test and to become informed about the
possible personal, medical, social and psychological
implications of taking a test [60]. However, research
has not documented the meanings that different health
professionals attach to informed consent in an HIV
testing context, nor the processes by which they obtain
informed consent. It is also worth considering the
process of obtaining informed consent in particularly
problematic situations, for example, when working
with clients who have learning disabilities or whose
first language is not that of the country in which they
are tested.
Given the range of issues that need to be addressed
within pre-HIV test counselling [63], one would
imagine that thorough, sensitive pre-test counselling
would take some time. However, two of the most
respected figures in the HIV counselling field in Britain
have stated that "(m)ost of our pre-test counselling
sessions ... last no more than 10-15 minutes" [64]
(p. 9). Furthermore, it has been contended that brief,
focused and effective pre-test discussions can be
delivered by a variety of health care workers in various
settings [65]. If this reflects current pre-test counselling
practice generally or indicates the intended future
direction of service development, then an evaluation
of the pre-test counselling process is required from
both service providers' and service users" perspectives
to determine the extent to which it is achieving its
objectives.
Exactly what the objectives of HIV counselling
are is a moot point. Few studies have specifically
addressed what counsellors perceive the aims and
objectives of their HIV counselling practice to be, or
what their experiences and expectations of the HIV
counselling process are. One study which did found
that counsellors in a South African hospital uniformly

5. A reviewof HIV testing research 737
described their objectives as being to provide
information on HIV/AIDS and the HIV test and to
provide emotional support through the testing process
[66]. Yet, differential emphasis was placed upon
guiding decision-makingaround testing and achieving
compliance with health promotion goals. Further
indications that counsellors' objectives may vary
are provided by those studies which have found
considerable variation from one clinic to another and
from one counsellor to another in the proportions of
clients who decide to proceed with testing after
counselling[67-69], Indeed, it has been said that some
counsellors pre-dispose clients towards taking or not
taking the test [25]. The aims and objectives of HIV
counsellors clearly meri: investigation.
If the test result is positive, the counsellor may find
it difficult to break the news to the client and may be
wary of the client's potential reactions to this news,
which may impact negatively upon their counselling
practice [70]. Significant proportions of the service
users studied by Mfinsson [29] and McCann and
Wadsworth [31]expressed reservations about the way
their test result had been conveyed to them and about
the lack of information given to them concerning the
implications of the test result. For the client, the news
of a positive result may be a source of great emotional
trauma. As the client may have difficulty in responding
to the counsellor's interventions at this stage,
follow-up sessions may be arranged. If the result is
negative, the client may be so relieved that their main
concern is to leave the counselling situation and put
the experience behind them. There is also the
possibility that the "certificate of health effect" [71]
will operate, i.e. the client will interpret a negative
result as a justification for their risky behaviour and
may use it to deny the need for behaviour change.
These factors can make it extremely difficult for the
counsellor to engage in any meaningful interventions
to help the client to examine their risk behaviours and
to devise strategies to help them avoid or reduce risk
in the future. However, it may not be feasible for the
counsellor to attempt this during the pre-test session,
as the client may be very anxious and there will be
many other issues to be addressed at this stage.
As has already been noted, research that has
examined changes in risk behaviours following HIV
testing has been conducted mainly from an outcomes
perspective. There is a need to elaborate this work,
which could be achieved by conducting detailed
longitudinalassessments of risk behaviours at the time
individualsare tested and beyond in order to measure
the extent and durability of any behaviour change
that occurs. This should then be followed by an
examination of those factors within and beyond the
HIV testing process which service users see as having
facilitated and/or inhibitedchanges in risk behaviours.
This could help establish the extent to which HIV
counsellingand testing (separately or in combination)
may contribute to behaviour change. If the testing
process does prove to be (potentially) an effective
medium for change, research could identify those
aspects that should be focused upon and developed in
order to promote behaviour change.
Partner not!/ication. U.S. studies have reported
considerable variation in the extent to which
newly-diagnosed people with HIV voluntarily inform
their sexual partners of their HIV status [72 77]. One
issue that may therefore be raised at the post-test
counselling stage and that has aroused considerable
debate is partner notification (see Refs [78-81]).
Several European countries and most states in the
U.S.A. have implemented partner notification pro-
grammes for HIV [80]. At present in the U.K., clients
who are found to be HIV positive are encouraged to
notify sexual and/or injecting contacts whom they
might have placed at risk [5].This procedure has been
termed ~patient referral', as distinct from "provider
referral', which would involve health care pro-
fessionals taking responsibility for contacting those
whom an index client might have placed at risk [82].
Provider referral has been described as -an integral
part of comprehensive programs of prevention and
control addressing HIV" [83] (p. 436). However, a
survey of GUM physicians and health advisers in the
U.K., conducted by Keenlyside et al. [84], found that
only about half would offer to do the contacting and,
in the Thames Regional Health Authorities ~withthe
highest concentration of people with HIV/AIDS and
HIV counsellors in the U.K. only 44% of the
consultants questioned and 29% of the health advisers
would offer to do so. The same survey found much
more favourable attitudes towards provider referral
among consultants than among health advisers.
However, a majority in both groups encouraged
clients with HIV to inform their partners themselves.
A U.S. clinic study reported generally favourable
attitudes towards notifiying partners among people
who were HIV positive [86]and there is evidence from
the U.K. that GUM clinic attenders may have
favourable attitudes towards partner notification [84].
Yet, Smith et al. [85] found that those who perceive
themselves as being at risk from HIV have more
negative attitudes. This group favoured patient
referral whilst those who saw themselves at low risk
preferred provider referral. Comparable research is
now needed among clients who attend clinics
specifically for an HIV test. There is also the question
of how acceptable provider referral might be to those
who are contacted by health care workers. The vast
majority of notified partners in a U.S. study felt the
notificationprocedure to be acceptable [87]but similar
evaluative research will be needed in the U.K. if
provider referral becomes more common.
As Coyle [88] has pointed out, some forms of
partner notification programme could violate the
confidentiality of the index client with HIV and may
thereby discourage people from presenting for HIV
testing. This was the principal caveat issued about
partner notification by the HIV positive respondents
in Daniell et a/.'s study [86] and in Department of

6. 738 Susan Beardsell
Health guidelines [5]. If the adoption of a formal policy
of partner notification is to be considered, there is a
need for research that will identify and obtain detailed
feedback on those forms of partner notification that
users of HIV testing services would find acceptable.
Given the findings of Keenlyside et al. [84], it would
also be profitable to explore service providers' views in
greater depth. From their evaluation of a partner
notification programme, Giesecke et al. [89] noted that
speciallytrained counsellors were more proficient than
physicians in interviewing patients with HIV and in
locating their partners. There is therefore a need for
staff involved in partner notification procedures to
receive training on the sensitive handling both of index
clients with HIV and of their contacts. Finally, there
is a need for research that will systematically evaluate
any programme so that if it appears to be discouraging
people who have been at risk from presenting for
testing, this can be detected at an early stage and the
programme modified before any lasting damage is
done.
In addition to these psychosocial considerations,
research which has explored the economic effective-
ness of partner notification programmes also needs to
be examined [90]. The economic risk is that significant
resources could be channelled into partner notification
programmes which succeed in identifying only a very
small number of people who test positive and who
would not otherwise have considered being tested for
HIV.
Who should counsel? The giving of an HIV test result
and the provision of post-test counselling can
be problematic. In some testing centres in the
U.K., the same counsellor provides pre- and post-test
counselling and gives the test result. In others, the test
result is given not by the counsellor but by a clinician
who then refers the client to the counsellor for post-test
counselling. In others still, the client may see one
counsellor for pre-test counselling and may be faced
with a different one for the post-test session. It would
be worth investigating clients" evaluations of these
different counselling structures and gauging reactions
to the differing levels of continuity in counselling
represented by these different arrangements.
There is some disagreement over whether pro-
fessional counsellors are necessary for HIV coun-
sellingl particularly for pre-test counselling [63] and,
indeed, whether HIV test counselling is really
'counselling' as opposed to information-giving or
discussion. Clients' views on this issue have not
been sought, however. HIV test counselling may
be undertaken by a wide variety of health care
professionals, with much disparity in terms of their
qualifications, training, counselling experience and the
amount of counselling time and supervision available
to them [70]. Arrangements for the delivery of HIV
counselling may vary from one testing site to another.
Given this state of affairs, the aims, nature, content
and evaluations of pre- and post-test counselling
sessions merit empirical investigation from both a
and Adrian Coyle
service provider and service user perspective, together
with their relationship with other aspects of the HIV
testing process. Although clients' views of HIV
counselling have been studied--and have yielded
equivocal evaluations--this work has been conducted
in general terms and has not been related to specific
aspects of the HIV counselling process [91]. It may be
that the diverse backgrounds of HIV counsellors and
the diversity of HIV counselling practice matter little
to clients if the essential elements of HIV test
counselling--such as the giving of information and the
answering of questions--are satisfactorily delivered.
Waiting.[or the test result
After having given a blood sample to be tested for
HIV, waiting for the test result can be extremely
stressful. Davies et al. [42] found that a tenth of the gay
men they interviewed said they had decided not to be
tested because of the anxiety of waiting for a result.
This may be particularly acute when the client expects
the result to be positive. Ostrow et al. [22] found that,
over the period immediately before the test result
was disclosed, those who expected a positive result
reported having experienced significantly more sleep
difficulties than those who expected a negative result.
However, Perry et al. [24] found no significant
differences in anxiety levels between those who
expected positive and negative results immediately
prior to test result disclosure but found that both
groups reported significantly higher anxiety levelsjust
before disclosure than when they entered the study two
weeks previously.
Other factors apart from expectations about the test
result may influence the level of psychological distress
experienced by clients during the waiting period. As a
range of elements may interact to produce different
levels of distress, waiting for a test result can be
conceptualized in process terms. Clients" feelings and
experiences during the waiting period might usefully
be investigated not simply in terms of psychological
outcomes at given points in time but in a more detailed
form which taps their interrelationships. For example,
it may be useful to chart the nature of and reported
changes in clients" feelings from the time of giving a
blood sample to the time of visiting the testing centre
for the result. Factors associated with changes in
feelings may also be identified, together with strategies
used to help cope with any psychologicaldistress. Such
research would identify the nature and extent of
distress occurring during the waiting period and would
provide indications of how testing centres might
intervene during this period to prevent excessive
anxiety from arising or to deal with it if it does arise.
For example, clients might be encouraged to telephone
or visit the testing centre to speak to their HIV
counsellor if their anxiety becomes difficult to manage.
The length of time that clients have to wait may be
significant in determining the amount of anxiety they
experience and this may vary considerably. For
example, although 34% of the respondents in McCann

7. A review of HIV
and Wadsworth's study [31] who had been tested
within the previous two years had to wait about a week
for their result, 29% had to wait between two and three
weeks and 14% waited for over three weeks.
Participants in studies of HIV testing experiences have
expressed concern about these delays [29, 30]. Same
day testing services have been advocated by the
Department of Health [5] and are now increasingly
available. However, there has been no research
conducted which has compared the experiences of
clients using these services with those using services
that entail longer delays. Same day services drastically
reduce the waiting period and hence reduce the
potential for the testing process to generate
uncontrolled anxiety. On the other hand, they allow
the client only limited time to reflect upon and weigh
what has been discussed during pre-test counselling
and to make a considered decision about whether they
really wish to proceed with the testing process. The
perceived advantages and disadvantages of same-day
testing need to be evaluated from a client's perspective
before firm conclusions can be reached about its
merits.
PROCESS-BASED WORK AND APPROPRIATE RESEARCH
METHODS
The foregoing review of the HIV testing literatures
has highlighted a variety of issues that would benefit
from investigation within a process perspective. A
thorough consideration of the practical and psycho-
social aspects of HIV testing experiences would enable
links to be made between various aspects of the testing
process, something which previous, largely outcomes-
based work, has failed to do in a meaningful way. The
identification of problems with outcome research in
health domains and the advocacy of process-based
evaluative research is not new [92]. Consequently~ the
fact that process research is not more common in the
evaluation of health services in general and HIV
testing services in particular requires explanation.
Various reasons may be suggested to account for
researchers' unwillingness to embrace process evalu-
ations wholeheartedly, preferring instead to allude to
processes rather than charting their dynamic evol-
ution. One reason why process evaluations tend to be
overlooked may be because outcome evaluations
with their emphasis on identifying and measuring
dependent variables to determine the success of a
service---approximate closely to the scientific ideal
of verification [93] and are relatively simple to
conceptualize and conduct. The detailed conceptualiz-
ation of process evaluations, on the other hand, tends
to evolve during fieldwork as a picture is built up of
those factors that may impact upon the service under
study. The researcher who is considering process
research may therefore be concerned about becoming
embroiled in charting an unending sequence of cause
and effect within the research topic. However, it is not
necessary to capture all the change and movement that
testing research 739
could occur and indeed, it would be impossible to do
so. Instead, the researcher could identify a segment of
the phenomenon under study which embodies most of
the variables of interest [94]. They then endeavour to
capture the process sufficiently to provide a sense of
the flow of events over time [27]. Alternatively, they
could address the entire phenomenon but chart the
interaction of a selected subgroup of key variables in
process terms.
Another reason why outcome evaluations tend to be
favoured is that they generally use precise, convenient
and scientificallyacceptable methods of measuring key
variables affecting the service under study. Indeed,
previous work on HIV testing has usually applied
highly structured research instruments to large
samples. Whilst this approach can yield generalizable
findings, its ability to produce findings suitable for
framing policy or inlbrming practice is limited because
it has difficulty in examining a range of issues in
depth. Process evaluations are more likely to involve
the collection of unstructured data using qualitative
methods that tend to be labour-intensive and, because
they rely upon description and inference, may be seen
as less reputable than more structured approaches in
orthodox scientific terms [93].
The components of the HIV testing process that
have here been identified for consideration would
generally be most appropriately studied using a
qualitative research framework. This would permit the
elaboration of the psychosocial context in which the
discrete events that have been examined in previous
work on HIV testing are embedded. It would also
allow personally meaningful links to be forged
between these events, as opposed to sometimes
spurious statistical links. While a qualitative approach
to the evaluation of HIV testing services has been
advocated before [14], it has generally been
recommended as a precursor and adjunct to a more
structured approach. Yet, after describing the
limitations of quantitative approaches in H IV/AIDS
research on sexual behaviour and risk perception,
Lupton stated that ~'The standard quantitative
questionnaire.., has served its purpose well but now
needs reviewing" [95] (p. 450) and recommended the
use of inductive and interpretative methods instead.
It is difficult to be prescriptive about which specific
qualitative research methods would be appropriate for
addressing particular issues as this will depend upon
the nature of the issues being addressed and the
individuals under study. However, individual face-to-
face in-depth interviews, consisting largely of
open-ended questions and variants such as key
informant interviewing [96]--would be appropriate
across many research situations [97]. In one of the few
qualitative studies of HIV testing that have been
undertaken, this approach has been successfully used
to elaborate the reasons why gay men underwent HIV
testing and why they decided not to be tested [39].
Focus group interviews may also represent an
appropriate research tool in some instances [98, 99].

8. 740 Susan Beardselland Adrian Coyle
These have the advantage of being able to include
relatively large numbers of respondents within a
qualitative framework. Although it may be difficult to
overcome fears about breaches of confidentialitywhen
using a group context, this approach has been used
successfully in HIV/AIDS research in the past
[86, 100-103].
As well as providing insights into the processes
involvedin HIV testing, rich, in-depth qualitative data
could also contribute to the generation of theory
relevant to the issues involved. While HIV/AIDS has
generated much research, there has not been a
concomitant development of sociological and psycho-
logical theory about HIV/AIDS. Although HIV/
AIDS has sparked innovative theorizing within
political and sociocultural domains (e.g. Refs
[104-107]), too much HIV/AIDS research is either
atheoretical or is located within ill-fitting theoretical
frameworks [108]. Such deficiencies in theorizing are
understandable: in the midst of an epidemic, there is
a need for practical research that can inform policy
making and service provision. However, HIV/AIDS
represents a complex social phenomenon which has
the potential for challenging existing sociological
and psychological health-related theories and for
generating new ones. For example, studies of sexual
behaviour in the light of HIV/AIDS have challenged
accepted socio-cognitivetheories of behaviour change
and exposed the limitations of their underlying
assumptions of individualagency [42, 109-111]. There
is scope for existing sociological and psychological
theories to be applied to research on HIV testing
(for example, theories of decision-making) and for
new theories to be constructed on the basis of data
collected on aspects of the H1V testing process,
perhaps by adapting a grounded theory approach
[112].
CONCLUSION
In order to plan and develop HIV testing services
that are appropriate and effective, the range and
diversity of people's testing experiences need to be
investigated. Despite the many studies which have
looked at HIV testing, there is still very little in-depth
information that could be used to directly inform
testing policy and practice. To date, HIV testing
research has had two main foci. Testing and
counselling have been considered from an outcome
perspective or, alternatively, discrete aspects of the
testing process only have been evaluated. Outcomes
research has looked at the effects of testing and
counselling and the notification of test results on
sexual or drug taking behaviour and mental health
functioning.However, it has failed to consider aspects
of the testing process that may have led to any
observed outcomes.
HIV testing can be conceptualized as a macro
process consisting of various subordinate processes.
These processes concern making the decision to have
a test; accessing the testing site; HIV test counselling;
and waiting for the test result. While some
investigators have considered some aspects of these
processes, they have considered them as discrete
elements and have failed to account for their inter-
relationships. Moreover, a variety of issues connected
with these processes remain unexplored. These include
decision-making at various points through the HIV
testing trajectory; which professional groups are
best placed to provide HIV test counselling; the aims
and objectives of counselling; whether and how
counselling can be used to change risk behaviours:
managing stress while waiting for the test result; and
the most appropriate means of partner notificationfor
those who test positive. Present research is also limited
because the bulk of it has only studied gay or bisexual
men and there is a need to study other groups such as
heterosexual men, drug users, women, members of
different ethnic groups etc. Experiences at different
testing sites, such as GUM clinics, drug services,
specialist HIV services, GPs, etc. should be compared,
as well as those provided in hospitals or the
community. The experiences and views of health care
professionals who deliver the service must also be
explored in order to obtain a complete picture of the
HIV testing process. Due to their capacity for eliciting
detailed, contextualized data, qualitative method-
ologies are particularly appropriate for exploring the
myriad issues involved in the HIV testing process in
depth. A detailed process evaluation of HIV testing is
not only timely but imperative if services are to be
improved and developed so that they are responsive to
users' needs.
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