The respect for patients' confidentiality is a fundamental principle in medical ethics, and also a legal duty that health care providers owe to their patients. However, the respect of absolute confidentiality has been a subject of debate [24–26]. With the advent of the HIV/AIDS epidemic, this debate has been re-echoed if confidentiality should be compromised when HIV-positive patients refuse to voluntarily notify those at risk of infection, especially their sexual partners [27–29]. Disclosing one's HIV status is particularly difficult because HIV is often associated with sexuality, coupled with the double stigma and discrimination experienced by patients co-infected with TB and HIV [20, 30]. Our study revealed that counsellors experienced the dilemma between upholding their professional ethics by not disclosing their patients' HIV status to their sexual partners, and being morally upright by doing so when confronted with patients who refused voluntary disclosure. This therefore indicates the need to visualise the complexity of partner notification in order to move forward.
Our study demonstrated that upholding confidentiality and respecting patients' autonomy is emphasized during the counsellors' training and practice in all the study settings. However, the absence of a professional code of ethics within some centres is a call for concern since it is important for counsellors to know the existing laws regarding confidentiality and their professional ethics. Moreover, to foster a lasting patient-provider alliance and maintain patients' trust in the health care system, it is inevitable that patients are properly educated on their rights to confidentiality and autonomy.
Partner notification for HIV is generally regarded as an ethical and legal issue, and position one underscored the importance of respecting patients' confidentiality and autonomy. This position is drawn from the personal autonomy framework that is much more linked to biomedicine. Participants who held this opinion were mostly young and relatively inexperienced, and this could be understood from their apparent lack of adequate counselling skills. This might have limited their negotiating power to encourage patients to voluntarily inform their partners about their HIV status. They however provided justification for upholding this position which had both legal and ethical dimensions since they asserted that a counsellor's duty to the patient supersedes every other duty. Consequently, patients should not be forced to disclose such information for the benefit of others. This argument is consistent with Kantian theory which postulates that human beings deserve to be treated with respect as ends in themselves and not as means to another individual's ends .
The dilemma in public health between respecting individual rights in order to foster a trusting patient-provider relationship versus protecting the collective rights of the sexual partners was highlighted in position two. Resolving such conflicts was a daunting task to the counsellors since it entailed acting within the limits of the law, their professional ethics and morality. The salient difference between the participants in this position and those in position one lies in the fact that they were 'morally autonomous'. This implies that their decisions were based on moral principles and understanding of the situational facts from which they acted upon their considered judgment . This is expected since the participants who held this position were mostly older and more experienced counsellors. Although they respected the law and professional ethics regarding confidentiality, they did not literally pursue these rules without appreciating the rationale for applying them. This was reflected in the various strategies which they devised to encourage uncompromising patients to voluntarily notify their sexual partners about their HIV status. This position regarding counselling and disclosure of HIV status seems to be the dominant position, and it is the policy recommended by UNAIDS and WHO [3, 6]. This policy incorporates the human rights framework into public health as a response to the HIV/AIDS epidemic. Human rights is a reflection of deeply held values of what states and governments should not do and what they should ensure to all its citizens . The UNAIDS/WHO policy therefore promotes and protects public health, and also ensures that the human rights and dignity of HIV-positive people are not violated. In developing countries where the brunt of the HIV epidemic exists, patient referral has been found to be the most preferred method in partner notification strategies . However it does not address the situation whereby patients deliberately conceal their status from their partners thereby placing them at risk despite counsellors' efforts to encourage voluntary disclosure.
Position three is a wish to address the above concern since participants who held this stance advocated for conditional confidentiality and legal protection to notify patients' sexual partners. This position received legal backing with the premise that it is a violation of the sexual partners' human rights if health care providers refuse to inform them about their diagnosed partners' HIV status. However, this should be done for beneficial reasons in cases where such patients had refused to voluntarily do so. The legal backing was nonetheless restrictive in the sense that conditional referral advocated in such a scenario was limited only to partners in legal relationships. This implied that no protection would be available for unmarried partners which could eventually potentiate HIV transmission in the society. However, the assertions in this position are consistent with the argument that the right to confidentiality is only possible between morally sensitive people. Therefore, individuals who place themselves 'beyond the pale', implying that their actions are potentially harmful to others forfeit the right to confidentiality . The conditional referral strategy advocated for in this position is therefore grounded on utilitarianism which asserts that 'decisions should be judged by their consequences, in particular by their effect on the total sum of individual wellbeing' . Our study also revealed that the participants were sometimes frustrated when patients objected to voluntary partner notification especially if the participants were loyal to the sexual partners. There is a need for proper education and sensitisation of counsellors, and the society in general about sexual ethics. This is the ethics within partnerships of mutual respect, consent, and shared responsibilities for sexual behaviour and its social, emotional and health consequences  that are fundamental to human rights. Moreover, the creation and enforcement of an official AIDS law that protects both the rights of PLWHA especially against stigma and discrimination, and that of their partners would facilitate voluntary disclosure. In addition, the existing laws and customs which discriminate against women, favours male dominance, polygamy, adultery, and fails to criminalise domestic violence including rape against women needs to be revised . This is important as participants stated that patients were apprehensive of disclosure since it could attract negative consequences in relationships including divorce which have been reported in other studies [1, 13]. Furthermore, partner notification protocols should be made available, and the counsellors properly educated that the duty to protect partners at risk should be based on ethical and legal justifications and not because of personal sentiments and loyalty to a particular partner . Most importantly, the concept of 'proportionality'  should be applied in cases of provider referral. This implies that in scenarios where public health ethics confronts individual human rights, public interests subvert individual rights but there should be absolutely minimal infringement on the individual rights. These measures will help to address some of the complexities in HIV counselling and facilitate voluntary partner notification.
Besides the fact that conditional referral could exacerbate the negative consequences of voluntary disclosure, it was highlighted in this study that enforcing conditional referral could also deter prospective patients from seeking treatment. This is consistent with the views of the proponents of unconditional confidentiality [24, 25]. This is a worthy concern especially in developing countries where alternative medicine is an integral part of the health care system , and could attract such disgruntled patients towards these services. Despite these arguments, there is lack of empirical evidence in support of the undesirable consequences of implementing provider referral approach in partner notification. Provider referral has been documented to be effective in identifying sexual partners at risk in developed countries [7, 38, 39], and is generally permitted as a supplement to patient referral in North America  and Europe [41, 42]. However, its feasibility and effectiveness in developing countries with different socio-cultural and political contexts is limited  and requires further evaluation.
The perception held in position four was that HIV should be regarded as any normal medical infection, whose diagnosis and disclosure should be based on medical as opposed to ethical or legal necessities. The implication of this approach is that HIV testing and partner notification could move from the counsellors to the physicians and thereby making the counsellors redundant. Alternatively, this position could normalise HIV/AIDS into a medical condition just as any other. The latter alternative was the premise for the participants' argument in support of routine HIV status disclosure since life-saving ARTs are now provided free of charge to all eligible persons in the country. Applying this approach would ultimately be beneficial both to the patients and those at risk since it would reduce HIV transmission, and increase patients' access to HIV services. It has been argued that 'HIV exceptionalism', whereby public health response in the early years of the HIV epidemic had been fundamentally different from other sexually transmitted infections and public health threats, has been the reason for the lag in global HIV prevention and control . It is further argued that 'exceptionalism' has enhanced the stigma associated with HIV infection and led to the confusion between secrecy and confidentiality, and consequently promoting the silence around HIV/AIDS . These arguments have prompted the advocacy for routine HIV testing , and third party disclosure  as a norm in health care settings in order to demystify HIV infection as highlighted in position four. The justification being that 'normalization' of HIV/AIDS is not a threat to individual human rights but rather failure to prevent HIV infection is an infringement on human rights' .
Using a positional map in this study was very useful in delineating the full spectrum of the reflections regarding partner notification for HIV within and across groups of counsellors. This enabled us to visualise positions that were taken in the data which ultimately facilitated the formulation of ideas regarding the implications of these positions in counselling practice, and in HIV prevention and control. However, there are limitations in our study that deserve consideration. First of all, our study sites were purposively selected and therefore the participants' perceptions do not necessarily reflect those of the entire counsellors in the region. Notwithstanding, since our study sites are approved TB/HIV treatment centres which also serve as referral centres in the region, we believe they share similar characteristics and challenges to the other smaller centres. Additionally, since the first author was acquainted with the participants, either they may have provided less information assuming he was already familiar with the settings or they could have provided favourable responses to demonstrate their achievements. Although these limitations might affect the extent to which our results could be generalised within the region and to similar contexts with generalised HIV epidemics, we believe our findings have provided valuable insights into the complexities faced by counsellors in the process of encouraging voluntary partner notification of HIV status and how these could affect policy.