Culture, Health & Sexuality

An International Journal for Research, Intervention and Care

ISSN: 1369-1058 (Print) 1464-5351 (Online) Journal homepage: http://www.tandfonline.com/loi/tchs20

A qualitative analysis of multi-level barriers to HIV

testing among women in Lebanon

Kirsty A. Clark, Danya E. Keene, John E. Pachankis, Omar Fattal, Nesrine Rizk
& Kaveh Khoshnood

To cite this article: Kirsty A. Clark, Danya E. Keene, John E. Pachankis, Omar Fattal, Nesrine
Rizk & Kaveh Khoshnood (2017): A qualitative analysis of multi-level barriers to HIV testing among
women in Lebanon, Culture, Health & Sexuality, DOI: 10.1080/13691058.2017.1282045

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Culture, Health & Sexuality, 2017
http://dx.doi.org/10.1080/13691058.2017.1282045

A qualitative analysis of multi-level barriers to HIV testing

among women in Lebanon
Kirsty A. Clarka, Danya E. Keenea, John E. Pachankisa, Omar Fattalb,c, Nesrine Rizkd and
Kaveh Khoshnooda
a
Yale School of Public Health, New Haven, USA; bLebanese Medical Association for Sexual Health, Beirut,
Lebanon; cDepartment of Psychiatry, New York University, New York, USA; dDepartment of Internal Medicine,
American University of Beirut, Beirut, Lebanon

ABSTRACT ARTICLE HISTORY

While the number of HIV cases in the Middle East and North Africa Received 4 August 2016
region is low compared to other regions, recent studies show that Accepted10 January 2017
incidence is increasing especially among high-risk populations; in
KEYWORDS
particular, little is known about women and HIV in the region. Through HIV; women; HIV testing;
semi-structured interviews with sexual healthcare providers and staff barriers; Lebanon; stigma
at non-governmental organisations, we sought to understand barriers
to HIV testing among women in Lebanon. Using snowball sampling,
key informants were recruited from greater Beirut (12 physicians, 9
non-governmental organisation staff ). Data were analysed using a
grounded theory framework. Findings identified barriers to HIV testing
among women at each level of an adapted social-ecological model
(i.e. social-cultural barriers, policy barriers, interpersonal healthcare
provider barriers and intrapersonal barriers). Primary findings include
the culture of sex as taboo; lack of sexual health education among
women; fear of disclosing HIV testing and diagnosis; financial barriers
linked to stigmatising insurance policies; and provider attitudes
towards women. Findings can be used to inform HIV-related sexual
health interventions at multiple levels for women in Lebanon and
the greater region.

Introduction
Research and reporting surrounding womens sexual health in the Middle East and North
Africa is scarce (Azar, Kroll, and Bradbury-Jones 2016). As of 2017, there is limited data on
rates of sexually transmitted infections, including HIV among women; level of sexual health
knowledge; or information regarding access points of sexual healthcare. Further, there is
growing concern about the HIV epidemic in the region: while the number of HIV cases in
the regain is still low, reported new infections have tripled in the past decade, one of the
fastest increases of HIV in the world (Chahil-Graf and Madani 2014). While worldwide AIDS-
related deaths fell 35% between 2005 and 2013, the Middle East and North Africa region
instead saw a 66% increase in deaths (Gkengin et al. 2016). Due to the lack of reliable

CONTACT Kirsty A. Clark kclark13@ucla.edu

2017 Informa UK Limited, trading as Taylor & Francis Group
2 K. A. CLARK ET AL.

information from the Middle East and North Africa regarding womens sexual health, coupled
with increasing concern around HIV incidence, a call was released in 2015 through the
American University of Beirut urging an expansion of research focused on women and HIV
in the region (DeJong and Battistin 2015).
A 2015 call to action, entitled Women and HIV: The Urgent Need for More Research and
Policy Attention in the Middle East and North Africa Region (DeJong and Battistin 2015),
stressed that there is likely an under-detection of HIV infections among women in the Middle
East and North Africa. Recent epidemiological literature focused on the Middle East and
North Africa region highlights that the primary route of transmission among women is
through heterosexual sexual intercourse, but the primary detection of newly reported HIV
infections is primarily among high-risk men (i.e. men who have sex with men, men who have
sex with female sex workers) (Abu-Raddad et al. 2010). The gender disparity in detection of
new cases raises concern and requires further investigation.
In Lebanon, the most recent published data from the National AIDS Program is from 2014,
in which the number of HIV cases was reported to be 1671 (UNAIDS 2014). The prevalence
of HIV in Lebanon is low (0.1%), and just 12% of prevalent cases in 2014 were reported to
be women (UNAIDS 2014). Previous literature points to the fact that under-detection of
incident cases of HIV may be the key factor influencing the countrys low prevalence
(Abu-Raddad et al. 2010; Azar, Kroll, and Bradbury-Jones 2016; DeJong and Battistin 2015).
While Lebanon has a number of voluntary counselling and testing centres for anonymous
and subsidised HIV/STI testing, womens voluntary counselling and testing centre
participation in Lebanon is limited, with a 2009 study showing that over 60% of voluntary
counselling and testing centre patrons were men (Awad 2009).
The broader structural and healthcare context in Lebanon may also contribute to under-
detections of HIV infections. Lebanon has been embroiled in civil war and political instability
over the past 40years, leading to an ineffective state government that has stimulated an
unregulated privatised healthcare system (Van Lerberghe et al. 1997). Of the population,
43% is uninsured, while 57% are insured through private insurance, the National Social
Security Fund (largest publicly managed social insurance fund for employers) and a handful
other insurance schemes, which all focus on the private sector (El-Jardali et al. 2014). Over
56% of healthcare costs in Lebanon are paid out-of-pocket by patients, a figure that the
WHO considers disastrous (El-Jardali et al. 2014).
Additionally, research suggests that social vulnerabilities may position women in
Lebanon and the Middle East and North Africa at increased risk for HIV infection relative
to men (Remien et al. 2009). The Middle East and North Africa rank next to last behind
sub-Saharan Africa on the UNDP gender empowerment measure, a global index of gender
inequality derived from measures of reproductive health and education among women
(UNDP 2015). While Lebanon is often promoted as being more progressive than other
countries in the Middle East and North Africa, there is no national school-based sexual
health curriculum and sexual health knowledge among the population remains low
(Barbour and Salameh 2009; DeJong et al. 2005, 2007; El Kak 2014; Ghandour et al. 2014;
Santina et al. 2013). Furthermore, prior research from Lebanon shows that women living
with HIV face severe stigmatisation around their illness (Kaplan et al. 2016). Low levels of
health knowledge and stigma surrounding sexually transmitted infections and HIV may
contribute to limited HIV testing among Lebanese women, though more research is needed
in this area.
 CULTURE, HEALTH & SEXUALITY 3

Given the pervasive lack of research on HIV and womens sexual health in Lebanon, we
conducted a qualitative investigation to understand potential barriers to HIV testing among
women from the perspective of sexual healthcare providers and non-governmental
organisation staff. The overall purpose of this study was to investigate and identify potential
barriers to uptake of HIV testing among women in Lebanon.

Methods
Recruitment and sample
Key informants were recruited for participation from greater Beirut. Of the 21 key informants
who participated in the study, 12 were physicians and 9 were staff (non-physicians) at
voluntary counselling and testing centres and non-governmental organisations focused on
sexual health. All participants were professionals involved in: (1) delivering sexual health
and harm reduction programmes, (2) working clinically with patients diagnosed with sexually
transmitted infections or HIV and/or (3) delivering sexual and reproductive healthcare to
patients.
We used a snowball sampling recruitment strategy. Seed key informants were selected
based on the nominations of study investigators, two of whom are Lebanese physicians
familiar with the landscape of the sexual health provision in Lebanon. Efforts were made to
ensure that these initial informants represented a cross-section of sexual health-related
occupations; were from a variety of organisations including governmental and non-
governmental agencies; and worked with a diverse subset of populations. Snowball sampling
was used to identify additional sexual health providers of varying occupations (i.e.
obstetricians, gynaecologists, infectious disease physicians, sexologists) along with additional
non-governmental organisation staff who were then contacted via email for participation.
Additionally, the study team contacted all voluntary counselling and testing centres in Beirut
with a request for participation.

Data collection and analysis

Individual, semi-structured interviews were conducted between May 2015 and July 2015 in
and around Beirut. Interviews were conducted by the first author and lasted between 30
and 60 minutes. Interviews covered broad themes, including perceived sexual health knowl-
edge among women, HIV in society and perception of sexual healthcare. The interview guide
was created in collaboration with all study investigators, drafts were reviewed for clarity and
cultural relevance and prior to data collection the final interview guide was pilot tested with
three healthcare providers who had extensive qualitative interview experience. Feedback
from pilot testing was used to finalise the interview guide.
Data were analysed using a grounded theory inductive framework (Strauss and Corbin
1994) and as themes emerged, subsequent interviews were tailored to prompt questions
around those themes. Transcripts were transcribed verbatim. Emergent themes and codes
were refined through discussion among the authors and used to develop a codebook used
throughout the coding process. Transcripts were coded using Dedoose software. To ensure
effectiveness of the codebook and relevance of codes to the dataset, two additional coders
who were not affiliated with the study analysed selected transcripts for consistency. Coding
discrepancies were discussed among coders until resolved.
4 K. A. CLARK ET AL.

Figure 1. Adapted social-ecological model of barriers to HIV testing among women.

Themes corresponding to figure: (1) Socialcultural barriers: Extramarital sex as taboo; Emphasis placed on virginity; Monitoring
of womens sexuality; HIV viewed as dirty disease; Sex stigma around HIV; (2) Policy barriers: Lack of sexual health education;
Cost of HIV test (not subsidised); HIV-related insurance policies; Fear of losing patients; (3) Interpersonal provider barriers:
Provider attitudes and beliefs surrounding HIV and female patients; Mens health needs valued over womens; (4) Intrapersonal
barriers: Fear of a lack of anonymity; Avoidance of HIV testing.

Theoretical framework
Analysts identified themes through a process of inductive coding to form a coding tree in
accordance with the social-ecological model of health (McLeroy et al. 1988), a model that
explains the social and structural drivers of individual health-related behaviours (Baral et al.
2013). The social-ecological model contextualises individual behaviours within greater
socio-structural dimensions. The social-ecological model is utilised here to present the emer-
gent themes regarding barriers to HIV testing among women in Lebanon in different
socio-structural levels (see Figure 1). Investigators also identified links across levels of the
social-ecological model highlighting the multi-level context in which barriers to HIV testing
occur among women in Lebanon.

Ethical considerations
Investigators obtained verbal consent from all participants prior to participation and con-
ducted interviews in a setting of the participants choice, generally a room at the place of
work of the participant. One participant consented to the interview but refused audio record-
ing. In this instance, the lead investigator took detailed notes.
The Yale University Human Subjects Committee and the American University of Beirut
Institutional Review Board granted approval for the study.

Findings
Demographics
The demographic characteristics of the sample are presented in Table 1. The group was
highly educated (100% Bachelors degree or higher). All physicians specialised in providing
 CULTURE, HEALTH & SEXUALITY 5

Table 1.Demographic characteristics of sample.

Demographic variable N = 21
Age: mean (SD) 43.2 (15.6)
Years in healthcare: mean (SD) 15.5 (11.2)
Sex: n (%)*
Male 16 (76.2)
Female 5 (23.8)
Place of work: n (%)
Hospital/clinic 12 (57.1)
Non-governmental organsiation 8 (38.1)
Government 1 (4.8)
Highest level of education: n (%)
Bachelors degree 4 (19.1)
Masters degree 4 (19.1)
MD/PhD 13 (61.9)
Nationality: n (%)
Lebanese 21 (100.0)
Medical specialty (n = 12)
Obstetrician-gynaecologist 6 (50.0)
Infectious disease physician 5 (41.7)
Sexologist 1 (8.3)
*Percent frequency may not add up to 100% due to rounding.

HIV and sexual healthcare (i.e. obstetrician-gynaecologist, infectious disease physician and
sexologist). The average length of experience working in healthcare among the sample was
15.5years (SD=11.2). All were citizens of Lebanon and spoke proficient or fluent English,
as is common among healthcare professionals in Lebanon. The sample was predominately
male (76.2%). The average age of the key informants was 42.3years (SD=15.6).

Social-cultural level barriers

People think that if youre clean, quiet, you wear perfume, you dress nicely, that they are not at
risk [of HIV], but there is no correlation. (Male, obstetrician-gynaecologist)
Social-cultural barriers to HIV testing among women in Lebanon are influenced by cultural
factors such as overarching beliefs, ideologies and norms of a society. Participants perceived
sex as taboo, and specifically extramarital sex, and as the main barrier influencing womens
willingness and access to HIV testing. A focus on virginity among young women, as repre-
sented by an intact hymen, is a cultural norm that a number of participants used as an
example of sexual taboo. For example, one participant recalled the following patient
interaction:
I had a patient two months ago she came here they come, they want to examine their hymen.
They tell you, I fell down I, want to see if I still have an intact hymen. I know this is not the cause
of coming here. (Female, obstetrician-gynaecologist)
That patients will misconstrue the cause of a broken hymen highlights the complex
social-cultural barriers affecting sexual healthcare and patient-provider interactions in
Lebanon.
One male participant explained the effects of taboos around sex as a hindrance to
preventative sexual healthcare practices outside of the healthcare setting, stating:
Its unpleasant to buy a condom from a pharmacy, especially if the pharmacy has a girl whos
veiled. Or if the pharmacy is too close to your home, you have to go to another pharmacy. Or if
you go to the pharmacy, you try to look for them, but its not displayed where you can just grab
6 K. A. CLARK ET AL.

it, you have to ask for it. Then youre like, Fuck it, Im not going to do it. Theres a lot of hindrances
to safe sex. (Male, non-governmental organisation)
While sex in general is viewed as taboo in Lebanon, womens experiences with sex and
sexuality were perceived as particularly restrictive. One participant explained that womens
sexuality is governed by social expectations: Its not really accepted by the community, you
know, that women have sex just for having sex. Theres a lot of supervision, lots of monitoring
on what women do, and what they do with their bodies (Male, non-governmental organisation).
This monitoring of womens bodies was further elucidated by numerous participants who
explained the overarching societal view of women who engage in sex: When you see, who
has sex? What women have sex? Its always, like, sex workers, so as to create a divide between
a woman that does and a woman that does not have sex (Female, non-governmental
organisation). The view that sex workers are the only women having sex emerged as a barrier
to HIV testing and HIV risk perception: by perceiving only sex workers as potentially having
HIV, the societal norm is that unless you are selling sex or having intercourse with someone
who is selling sex, you are immune to infection. As one participant stated:
When the guys come in for tests, and you ask why, they say, Well, I had sex with a sex worker.
Thats their main concern. Like, if they have sex with people who are not like girls, not for
money its fine, its not risky. But if they have [sex] one-time with a sex worker, then they come
in for a test. (Female, non-governmental organisation)
Due to the fact that HIV is overwhelmingly sexually transmitted, it is considered to be
transmitted only among dirty people: as one participant explained:
It is very taboo, and people talk about [HIV] with disgust and shame because theyre not well-
aware about the risk, and they feel its related to dirty sex or something bad its not seen
positively, and we do not have enough awareness, and we have a lot of misconceptions. (Female,
sexologist)
Another health provider reiterated this idea of stigma being attached to HIV because it
is a disease that is sexually transmitted:
Its still a taboo. People are terrified of this disease, I think. A lot of people give stigmas to people
with HIV, and for them HIV means sex. It is how people think about that. Its still a taboo. A lot
of people are not accepting. (Male, obstetrician-gynaecologist)
Not only is HIV stigmatised due to its connotation as a sexually transmitted, dirty disease,
but one participant explained that HIV is also viewed by society as a moral failing seen as a
punishment from a higher power:
If you got [HIV], it means you have been morally wrong and that you have to be ashamed
people think that those dont deserve to live or be treated. A majority of people would say: Good
for him, he gets the God wrath [to] punish him. (Male, infectious disease physician)
Stigma surrounding HIV and the perception that only certain people are at risk negatively
influences uptake of HIV testing among women. Further, due to the social-cultural barriers
to HIV testing detailed above, including sex as taboo, monitoring of womens bodies and
the phenomenon of HIV being perceived as a dirty disease and a punishment from a higher
power, participants also highlighted the difficulties they have faced in trying to institute any
sort of HIV-specific health campaigns:
It is very difficult to do, because [HIV] is a sexually transmitted infection. Sex in this country is
taboo. So if you try to talk about sex on TV, which I did a few years ago, and people they were
not happy: Why are you talking sex, this is not acceptable, our kids cannot hear this. Its still a
taboo thing. (Male, obstetrician-gynaecologist)
 CULTURE, HEALTH & SEXUALITY 7

Policy-level barriers

Since insurance companies dont recognise HIV, that it is an illness, they dont cover. (Male,
infectious disease physician)
Policy barriers to HIV testing among women in Lebanon are those that are influenced by
policies, laws and regulations that impact a womens access to HIV testing. One participant
highlighted that policies may influence uptake of HIV testing and HIV-related data being
produced by Lebanons National AIDS Program:
It is very important to look critically at the numbers that National AIDS Program produced about
people living with new [HIV] infections and new incident cases its always men, its always
men, theres no women. Is it actually, like, women are at low risk? Or is it that youre not catching
enough women who arent doing tests and therefore, youre not thinking critically about it,
and therefore, your policy doesnt target the women? (Male, non-governmental organisation)
A policy barrier that was emphasised by almost every participant was the lack of sexual
health education programmes. Due to the aforementioned social-cultural taboos surround-
ing sex, there is no national school-based sexual health education programme. One partic-
ipant, highlighting the limited sexual health knowledge among his patients, explained his
personal frustration about the lack of available sexual health education programming in
schools:
Its not something done by the Ministry of Health. In the school where my children go, they
brought a dentist to speak about all the benefits of brushing the teeth. A dentist? Brushing teeth?
Okay, its important, but [sexual health] is more important. (Male, infectious disease physician)
Participants highlighted that there is very little understanding of sexuality and sexual
health among patients. In order to elucidate the effects of this, one participant recounted a
troubling patient interaction:
I have a patient who came last week. She told me that she is married to her husband, and when
I examined her I discovered that she knows nothing about intercourse after three or four
months of marriage I examined her and found an intact hymen. They think they are doing the
sexual intercourse in the normal way. They were coming because she was not getting pregnant
and when examined her I discovered that they know nothing about their sexual life. (Female,
obstetrician-gynaecologist)
This participant was asked if the patients were having anal sex rather than doing sexual
intercourse in the normal way (i.e. penile-vaginal intercourse), but the participant explained,
Just intercourse from the outside without entering. This significant lack of sexual health
education and knowledge is also tied to misinformation surrounding HIV, including serious
misconceptions around treatment. As one participant explained:
Considering HIV, its badly still considered as a sin disease like syphilis in the old times. And
people think theyre going to die, and this is another big problem. Because every time I have
a positive diagnosis I have to convince the patient that it is like other chronic diseases. You
have to take your medication and continue follow-up with your physician and thats it. (Male,
infectious disease physician)
Financial issues with respect to reimbursement of HIV testing were also emphasised as a
policy barrier to HIV testing among women. In Lebanon, HIV treatment is provided free of
charge by the Ministry of Health to anyone who is diagnosed with the disease. HIV testing,
however, is not reimbursed by the government or by insurance companies. One participant
described this irony, stating: Yes, the treatment is offered for free. But testing is paid for out
8 K. A. CLARK ET AL.

of pocket. And since insurance companies dont recognise HIV, that it is an illness, they dont
cover (Male, infectious disease physician).
While women who want to receive an HIV test from their doctor typically must pay out
of pocket, voluntary counselling and testing centres provide subsidised or free HIV tests.
However, since voluntary counselling and testing centres are often housed within sexual
health and/or drug clinics, the stigma associated with these locations may render these
services undesirable.
In addition to the cost of test itself, participants explained that HIV diagnosis, or even HIV
testing, can result in loss of insurance coverage in Lebanon:
Now medical labs at hospitals are sharing information [of who gets an HIV test] with insurance
companies. So an insurance company will directly drop you off their premium, just because
if you go for HIV. And theres nothing we can do about it. And the insurance contract says that
they can drop you off at any moment. (Female, non-governmental organisation)
Being dropped from an insurance policy for simply seeking out an HIV test highlights the
effects that policy-level barriers have on preventative sexual healthcare and access to HIV
testing in Lebanon.

Interpersonal healthcare provider-level barriers

Because of the years the providers have judged women for being sexually active, they just
stopped seeking help they dont dare to ask. (Female, non-governmental organisation)
Interpersonal barriers to HIV testing among women in Lebanon can exist at the provider
level. While sexual and reproductive healthcare providers are often the first access-point to
an HIV test for women, participants explained that judgment from healthcare providers is
frequently a hindrance to affirmative sexual healthcare:
Because of the years the providers have judged women for being sexually active, they just
stopped seeking help. And they dont dare to ask. When I first went to a gynecologist, and I heard
a lot of that from my friends, they ask if youre married or not. And they dont ask you if you are
sexually active. So if you are not married, they will not do any tests. Because they are related to
sex, and to being sexually active. (Female, non-governmental organisation)
One participant from a sexual health non-governmental organisation recounted one of
her clients traumatising interactions with a sexual healthcare provider:
One woman came here and she was crying, because she wanted to get a Pap smear. The [hospital
she had been to] shamed her. They made her cry and she left the hospital crying. And all that
because shes not married and shes asking for a Pap smear. They dont even follow the guide-
lines. They follow the values and norms, and people who are more vulnerable get shamed for
it. (Female, non-governmental organisation)
Shaming of women by healthcare providers for perceived sexual activity outside of mar-
riage was a theme that was repeated across interviews. Many participants highlighted that
gynecologists often assume female patients must be married. There is even a joke told
among women in Lebanon to elucidate this phenomenon: Theres always the joke when
a woman goes to a gynaecologist they always refer to her directly with Madame, always
assume, like, she has to be married if shes here (Female, non-governmental organisation).
In regards to HIV testing, participants explained that physicians often feel uncomfortable
discussing STIs with their female patients. A key informant who conducts sexual and repro-
ductive healthcare trainings for obstetrician-gynaecologists shared the uneasy response he
 CULTURE, HEALTH & SEXUALITY 9

often receives when conducting trainings on HIV testing, explaining: For providers, they say,
She is this, she is that, she is veiled. How can I ask her to do an HIV test? (Male, obstetri-
cian-gynaecologist). Many participants explained that even in healthcare settings, societal
taboos concerning sex seeps into discussions of HIV/STIs and often leads to silence around
these issues. As one participant stated, Even in family planning and STI clinics they dont
talk about it. Even during doctors meetings or seminars. Its uncomfortable (Male, obstetri-
cian-gynaecologist). One participant explained that this occurrence is not solely because
physicians feel uncomfortable discussing sex with their patients, but rather that they are
concerned that discussing issues of a sexual nature with their patients may actually encour-
age their patients to have sex: Even some doctors do not want to talk about, for example,
the HPV vaccine, because shes opening the sexual issue. So its like youre encouraging
teenagers or young people to have sex (Female, sexologist).
A number of providers admitted that it is easier to not offer HIV testing for fear of a
negative reaction from female patients, who, as explained above, have limited understanding
of why an HIV test should be administered:
In Lebanon, people, they dont like to develop anxiety regarding anything. Any time we order
HIV [test] they cant sleep, they start having issues. Sometimes, Why are you testing me? [Im]
married! So they start accusing or, you know, From where would I get it?, stuff like that. So we
dont like to dig into trouble. (Male, obstetrician-gynaecologist)
Rather than explaining the need for HIV testing, or digging into trouble, some providers
admitted that it is often simpler to not offer an HIV test to their female patients at all. As one
provider explained:
Unfortunately, we do very little its not a routine testing, unfortunately. It is a part of recom-
mendations, but nobody does that. We know that we should be doing routine HIV testing
but we dont do them here. (Male, obstetrician-gynaecologist)
Across interviews with healthcare providers it was apparent that womens healthcare
needs in Lebanon come secondary to mens. For instance, even in situations in which an HIV
test is strongly indicated for example, a married man is found to be HIV-positive due to an
extramarital affair one physician explained that social-cultural norms around marriage and
sex often lead them to misrepresent facts about HIV to the wife, highlighting the multi-level
context in which barriers to HIV testing occur. In one example, a physician explained that
he waited over six months before testing a woman for HIV after discovering her husband
was HIV-positive and, even then, told the woman that he was testing her for malaria:
You need at least to wait, to gain some confidence with the patients, at least six months before
telling the wife, or getting the wife to get tested, or even testing the wife without her knowledge.
So there are several ways to do this without disrupting or disturbing the couple. Why do we do
this? Its not only me. When the wife comes to our office and we say, Your husband got malaria,
for instance, from Africa. They dont argue. We need to test if you have malaria. This is how we
do the [HIV] test, this is one of the tests that we can propose they dont ask questions it
doesnt fit in their head, or in the culture. (Male, infectious disease physician)
While misinforming a female patient about an HIV test could be viewed simply as a
patient-provider infraction of trust, it is important to understand these actions in the context
of the social-cultural landscape surrounding sex in Lebanon. We are careful to note that the
physicians did not view themselves as acting maliciously or unethically in denying HIV-
related knowledge to a woman; instead, they viewed these situations through the lens of
protecting the marriage. In Lebanon, divorce and separation are very uncommon (4.4%) and
10 K. A. CLARK ET AL.

marriage is viewed as a social necessity, the dissolution of which is a failure that brings
dishonour to a woman and her family (Breslau et al. 2011; Khoury and Wehbi 2014). As
another example of protecting the marriage above all else, one physician explained that if
a male patient transmitted HIV to his wife after an extramarital affair, he may attempt to
conceal the origin of the disease. The provider explained that a female patient had accepted
an erroneous explanation with little question:
Its difficult here to discuss [HIV] with the spouse, to tell his wife about the issue I had a woman
who had HIV, and just telling her, Yes, it is possible that your spouse did it. But you also have to
raise the - we know its not true but, It could always be that he got it from a surgical item that
was not clean. You need to give her an excuse not to break the marriage. You know that we are
lying to her. (Male, infectious disease physician)
In addition to the social-cultural considerations, physicians justified misconstruing infor-
mation to female patients surrounding sexual healthcare, not administering HIV tests and
agreeing with patient misconceptions by reasoning that if they did not do these things then
they would be more likely to lose patients. One participant highlighted these issues by
expressing that less trouble (i.e. not ordering HIV tests) was easier to deal with than poten-
tially losing patients: In Lebanon we want our things to flow. We want less trouble. Any time
a patient is anxious, like, Im pregnant, why are you ordering me [an HIV test]? you would
be losing patients for this (Male, obstetrician-gynaecologist).
Limited time allocated for provider visits as a result of the overburdened, privatised health-
care system in Lebanon also constrains provider ability to educate their female patients.
Furthermore, lack of knowledge regarding HIV among created an added burden for physi-
cians during these short visits. Physicians expressed frustration that limited time made it
difficult for them to explain the need for HIV testing to their patients: as one participant
explained, As busy practitioners, we dont have plenty of time to counsel these patients and
talk to them about how to do [HIV] testing (Male, obstetrician-gynaecologist).

Intrapersonal barriers

The girls, they say, I was hesitant, I dont really trust that its anonymous. Theres this prob-
lem thats keeping them from actually accessing the [HIV] test. (Female, non-governmental
organisation)
Intrapersonal barriers to HIV testing among women in Lebanon refer to sexual health-
related behaviours that are influenced by personal knowledge, attitudes and beliefs. While
patient behaviours in regards to HIV testing emerged as a theme, we are careful to note that
these reports are through the lens of healthcare providers and practitioners. Intrapersonal
behaviours, in particular, are examples of the multi-level context in which barriers to HIV
testing among women occur in Lebanon: personal decisions are influenced by social-cultural
norms, policies and interactions with healthcare providers.
Due to societal taboos around sex, participants explained that women are especially
concerned about accessing HIV testing for fear of diagnosis disclosure to family or fear that
they will be seen by people they may know who will then assume that they are sexually
active. As one provider noted, They are shy when they come in, the girls, they say, I was
hesitant, I dont really trust that its anonymous. Theres this problem thats keeping them
from actually accessing the test (Female, non-governmental organisation). Concern about
lack of anonymity in the context of a medical setting in Lebanon is not an unjustified concern.
 CULTURE, HEALTH & SEXUALITY 11

In a 2015 study regarding disclosure of diagnosis of cancer in Lebanon (n = 343), 60% of

surveyed physicians reported disclosing a cancer diagnosis first to the parents of the adult
patient rather than to the patients themselves (Farhat et al. 2015). This example highlights
how medical information is often first disclosed to family members rather than patients in
Lebanon.
One provider in the current study specifically tied womens intrapersonal behaviours
regarding HIV testing to fear surrounding disclosure of diagnosis to family members,
explaining:
Sometimes [women] are worried because they feel that people will look at them strangely
if they go and do an STI test, sometimes they are worried about the anonymous part of the
[HIV] test. For women, if they do the test before getting married that means they are sexually
active and, oh maybe they will tell my parents. We have a lot of cultural obstacles and barriers.
(Female, sexologist)
Throughout the interview process, participants often mentioned that Lebanon is a country
where everybody knows everybody. Due to the lack of anonymity in daily life, participants
explained that a woman who obtains an HIV test will often go to great lengths to conceal
her identity. As one participant noted, A lot of people ask under a false name for an [HIV]
analysis (Male, obstetrician-gynaecologist). As an example of the lengths that women go to
conceal their identities in seeking HIV testing, one participant from a drug-specific non-
governmental organisation explained that many of their HIV testing clients are non-drug
users who simply know they will be less likely to encounter people they know at a drug-
testing centre:
Sometimes theyre just non-drug users, sometimes its just girls who are, you know, reluctant
to go to their doctors or the hospital to have [an HIV test] so, like, they see this centre that
is a drug testing centre and probably since theyre not drug users theyre not going to have to
interact with the drug users or the people who are working here. (Male, non-governmental
organisation)
Given the fear of disclosure that is pervasive among women seeking HIV testing, partic-
ipants stressed the necessity of completely anonymous HIV testing. Indeed, one physician
expressed frustration that his institution has moved further away from the goal of anony-
mous testing, resulting in reduced testing among his patients. He explained:
Here, since we were acquired by an American university, now they are mandating the individual
to give his ID card when he draws blood, so we have no more individuals who come for HIV test-
ing. People dont come. Before, we had plenty of people doing the test because I was organising
the system in a confidential manner. (Male, infectious disease physician)

Discussion
This study highlights barriers to HIV testing among women in Lebanon that exist at multiple
levels of a social ecological model (social-cultural barriers, policy barriers, interpersonal
healthcare provider barriers and intrapersonal barriers). These levels influence each other,
highlighting the multi-level context in which HIV testing uptake occurs. For instance, our
findings show that societal norms shape policy decisions and personal beliefs among sexual
healthcare providers, which in turn influence patient health-seeking behaviours.
While limited research has been conducted on HIV testing among women in the region,
there has been an increase in research from other regions of the world on womens
12 K. A. CLARK ET AL.

experiences with HIV and HIV testing (DiCarlo et al. 2014; Fedor, Kohler, and McMahon 2016;
Schaan et al. 2016; Schulkind et al. 2016). In accordance with our findings, a majority of the
prior literature highlights that social-cultural factors in particular shape HIV testing uptake
among women (Obermeyer and Osborn 2007). Literature from Middle East and North Africa
highlights that HIV is often viewed as punishment from a higher power for irreligious behav-
iour, which can be particularly shameful for women (Remien et al. 2009). Indeed, recent
literature from Lebanon highlights the negative influence of conservative societal norms on
sex and sexuality (Azar, Kroll, and Bradbury-Jones 2016). Across interviews, participants high-
lighted stigmatising social-cultural norms regarding womens sexuality and HIV as barriers
to HIV testing among women.
Findings also emphasise policy barriers to HIV testing among women in Lebanon.
Participants highlighted that the lack of school-based sexual health education programmes
greatly inhibits womens awareness around accessing HIV testing. These findings are con-
sistent with survey research from Lebanon. A 2015 study utilising data from the 2004
Lebanese Pan-Arab Project for Family Health found that just 21% of Lebanese women were
aware of HIV prevention methods and only 18% were knowledgeable about routes of HIV
transmission (Kobeissi et al. 2015). Other than limited sexual health education, financial
barriers to HIV testing and stigmatising HIV-related insurance policies also emerged as policy
barriers. Indeed, participants highlighted that the potential risk of being dropped from an
insurance premium for seeking out an HIV test was a barrier. Further, due to the out-of-pocket
expenditure associated with HIV testing outside of a voluntary counselling and testing centre,
there is limited incentive for women in Lebanon to access an HIV test unless they feel it is
absolutely necessary.
Participants also reported that women face barriers to HIV testing through interactions
with their sexual healthcare providers. Stigmatising provider beliefs with regards to HIV and
female patients, valuing mens health needs above womens and fear of losing patients by
simply offering an HIV test all serve as barriers to HIV testing among women in Lebanon.
Previous research shows that perceived stigma from healthcare providers is associated with
an interruption in healthcare among HIV-infected individuals, with perceived stigma from
healthcare providers consistently reported as being higher among female patients than
male patients (Magnus et al. 2013). Furthermore, literature investigating sexual healthcare
in a number of Arab countries highlights that healthcare providers do not recognise the
sexual and reproductive health needs of young people and are especially unwelcoming to
unmarried patients (DeJong et al. 2005).
At the individual level, our findings highlight that a lack of anonymity and fear of diagnosis
disclosure serve as barriers to HIV testing. Currently, there is limited investigation of intrap-
ersonal barriers to sexual healthcare among women in the Arab world. Conservative ideol-
ogies in Middle East and North Africa add to the strong stigmatisation of HIV and social
isolation of people living with HIV (Roudi-Fahimi 2007). Internalised stigma among people
living with HIV is associated with avoiding healthcare and medication adherence (Lee,
Kochman, and Sikkema 2002; Rintamaki et al. 2006). Our research highlights that HIV and
sex-related stigma may also be associated with HIV testing avoidance. Future research is
necessary to further explore these foundational results in the Middle East and North Africa
region.
 CULTURE, HEALTH & SEXUALITY 13

Limitations
While we believe that interviews with sexual healthcare providers and non-governmental
organisation staff provide a unique perspective that is not captured by other research, future
studies interviewing women about their sexual healthcare experiences are needed to under-
stand how women themselves experience the testing barriers described in this paper.
Furthermore, the findings from this study may not be transferable to experiences outside
of greater Beirut where our participants resided. Healthcare providers from more rural, con-
servative and religious regions in Lebanon may have different experiences in providing HIV
testing and sexual healthcare from providers in Beirut that should be explored. Religion in
particular should be further explored as it was a facet of sexual healthcare that was not
specifically addressed in our research or discussed by our participants. Finally, interviews
were not conducted in Arabic, participants first language, which may have affected the
responses.
Despite these limitations, this study is the first of its kind to investigate barriers to HIV
testing among women in Lebanon. In fact, such data are lacking across the greater Middle
East and North Africa region. By using qualitative interviews with healthcare providers and
sexual health non-governmental organisation staff, we garnered a unique vantage point to
better understand the interaction of multiple levels of socio-structural influence on HIV
testing uptake.

Programme implications
This research identifies factors that may influence the uptake of HIV testing among women
in Lebanon, including a lack of sexual health education among both providers and the
general public. It is imperative that future research explores the efficacy of HIV testing edu-
cation interventions. Training for healthcare providers on strategies to improve discussions
with female patients around HIV testing and sexual health would improve access to HIV
testing among this population. In the Arab region the training of medical students on HIV
has been effective in improving patient-provider discussions surrounding HIV testing
(Al-Mazrou, Abouzeid, and Al-Jeffri 2005). Further, findings from our interviews also highlight
that stigmatising healthcare and insurance policies impact womens access to HIV testing
in Lebanon. The privatised healthcare system in Lebanon makes it difficult to implement
protocols and guidelines regarding HIV testing, but interventions targeted at improving
insurance policies so that they can no longer drop clients for seeking an HIV test would help
assuaging patient fears.

Conclusion
Previous literature points to the fact that under-detection of incident cases of HIV may be a
key factor influencing the low reported prevalence of HIV infection among women in
Lebanon (Abu-Raddad et al. 2010; Azar, Kroll, and Bradbury-Jones 2016; DeJong and Battistin
2015). Barriers to HIV testing described in this paper may contribute to the low detection of
HIV cases among women.
Our findings suggest that actions to address barriers to HIV testing among women must
be implemented at multiple levels in order to affect meaningful change at the population
14 K. A. CLARK ET AL.

level. While the multi-level barriers described in this paper are each significant independently,
interventions must work to target relationships between levels; indeed, interventions that
influence only a single level of the social-ecological model may have limited success to the
multi-level context our findings demonstrate.

Acknowledgements
The authors thank the Yale Global Health Leadership Institute for funding support and the Lebanese
Medical Association of Sexual Health for logistical assistance. The authors also thank Helene Dabbous
and Rawad Chalhoub for support with transcription.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the Yale Global Health Leadership Institute [grant number Field Experience
Award].

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