Normalization Discourse in the Practice of Provider-Initiated Counselling and Testing for HIV in Kenya

Saturday, 28 October 2017: 3:15 PM

Eunice Wambui Ndirangu, PhD, MSc, BScN1
Catrin M. Evans, PhD, MA, BSc2
Kristian Pollock, PhD, MA (Hons), PGCHE2
(1)School of Nursing & Midwifery, Aga Khan University, Nairobi, Kenya
(2)School of Health Sciences, University of Nottingham, Nottingham, United Kingdom


A change in the HIV testing approach and discourse has been largely driven by the need to normalize HIV and the testing process. This need arises from the understanding that treating HIV differently from other medical conditions is a key barrier to expansion of testing and HIV services uptake. In Kenya, nurses are often the main health policy implementers particularly the policy governing provider initiated counseling and testing for HIV. It has been suggested that healthcare systems may not be ready for integration and normalization of HIV. At the same time, the social environment is characterized by negative perceptions about HIV due to its association with immorality, promiscuity and death. The purpose of this study was to examine how PITC implementation by lay and nurse counselors impacts on normalization of HIV.


Qualitative research was adopted using multiple data collection methods (interviews, observations and audio recording of consultations). Data was collected from patients receiving PITC and lay and nurse counselors offering PITC in two public health facilities in Kenya. Ethical approval was obtained from the National Commission for Science, Technology and Innovation (formerly known as Kenya National Research Council), Kenya Medical Research Institute and the Aga Khan University Ethics Committee.


Findings suggest that there are competing repertories within the normalization discourse in PITC implementation in the Kenyan context. Normalization of PITC guidelines is a biomedical construct, yet the response to HIV and the practice of HIV testing are socially constructed. This was reflected in the tensions that existed as the lay and nurse counselors tried to reconcile the functional aspects of PITC with other competing agendas such as ensuring patients took up the test, managing a difficult interaction and respecting social norms of communication. In addition, the healthcare system was not adequately prepared for normalization and integration of HIV testing due to the limited number of trained counselors and high patient numbers.


When policy recommendations are far removed from the realities of the practice world, nursing practice is inevitably adjusted to suit the context. Therefore, in order to improve patient care, PITC policies need to be responsive to the existing constructs about HIV and social norms of patient provider interaction. We recommend that policy should be drawn from context realities rather than trying to enforce the context realities to suit divergent policies. It is therefore important to generate a mass of context relevant research from different settings such as this one which can in turn inform context appropriate policies and guidelines.