HIV testing in antenatal clinics: the impact on women

One hundred and fifty-five women attending antenatal clinics in an inner city area where the rate of AIDS reporting is high were interviewed to examine the acceptability of different modes and purposes of antenatal HIV testing. Eighty-two per cent of women felt the test should be available in antenatal clinics, but only 48% reported that they themselves would take the test. Seventy-four per cent would accept anonymous testing. Potential anxiety levels surrounding the HIV test were significantly higher than for other (currently routine) tests in antenatal clinics. The implications of these findings for policy are discussed.     

A review of HIV testing policies and procedures for pregnant women in public maternity units of Porto Alegre, Rio Grande do Sul, Brazil

HIV/AIDS is considered one of the major public health issues in Brazil, with 120,399 notified AIDS cases by 1998 (Aristedes Barbosa et al., 1998). Rio Grande do Sul (RS) reports the highest HIV prevalence in women in the country (Louireiro et al., 1998) and local sero-surveillance studies note an increase in HIV prevalence in pregnancy from 2.6% in 1996 (Buchalter et al., 1996) to 3.3% in 1997 (Ferreira & Valente, 1997). As a result, the Ministry of Health has recommended that all pregnant women are offered an HIV test. This study reviewed HIV testing policies and procedures, reported by obstetric staff in public health care centres in Porto Alegre. The beliefs and practices of obstetric health care professionals towards HIV testing and prevention for pregnant women were also examined, given the crucial role of obstetric staff in the implementation of successful antenatal HIV testing procedures. In total, 106 (69.3%) of eligible obstetric health care professionals responded to a postal questionnaire during April and June 1998. Eighty-six (83.5%) of respondents reported a policy of universal offer of HIV testing. A few reported selective offer (n = 9, 8.7%) and eight (7.8%) reported a policy of testing on request only. When selection was operational, respondents reported aiming at women who disclosed intravenous drug use (88.9%), women whose partner had a history of injecting drugs (77.8%), recipients of blood products prior to 1985 (66.7%), women who reported one or more sexually transmitted diseases (STDs) (88.9%) and women whose current or previous partner ever had sex with a man (77.8%). Respondents reported that consent for an HIV test was acquired 'verbally' by the majority (n = 90, 88.2%), whilst ten (9.8%) acquired consent in writing. Two (2.0%) reported that women's consent for an HIV test was not asked for. Units with universal antenatal HIV testing policy were significantly more likely to have had pregnant women test HIV-positive compared with non-universal policy units (U = 13.500, p = 0.050). It appears that whilst the majority of the public health centres were offering an HIV test to all pregnant women in Porto Alegre by 1998, a lack of structured auditing of the actual uptake of HIV testing by pregnant women still remains. Local HIV testing strategy would greatly benefit from such data.     

Couple counselling and testing for HIV at antenatal clinics: views from men, women and counsellors

The purpose of this study was to gain insight from views of Tanzanian men and women on couple voluntary counselling and testing (CVCT) for HIV at antenatal clinics (ANC) in Tanzania. Data collection was through focus group discussions with women aged 25-48 years (n=8), women 18-24 years (n=10), HIV counsellors (n=11), men aged 20-34 (n=8) and men aged 35-75 years (n=8) and in-depth interviews (IDI) with five men and eight women. Participants were asked their views concerning men volunteering for CVCT for HIV, motivation of couples to receive results together and effective ways of counselling sero-discordant couples. Many participants agreed on the importance of incorporating CVCT at ANC, while others expressed reservations due to the cultural belief that ANC is for women. The importance of love, care and respect between sero-discordant couples was stressed; nonetheless, many anticipated that disclosure of HIV-positive status to an HIV-negative spouse could result in abandonment, divorce or violence against the woman whether she was sero-negative or -positive. Couple counselling and testing at ANC incorporating the suggestions made by study participants could become an important intervention for the prevention of HIV transmission and maintenance of good relations between sero-discordant partners.     

Knowledge and perception of HIV/AIDS among pregnant women attending antenatal clinics in Ogun State,Nigeria

Mother-to-child transmission of HIV (MTCT) is responsible for more than 90% of the cases of HIV infection in infants and children in sub-Saharan Africa. Accurate data on the knowledge and perceptions of HIV/AIDS among women attending antenatal clinics in Nigeria are scarce. A cross-sectional survey of 804 women attending antenatal clinics in Ogun State, South-West Nigeria was done using interviewer-administered questionnaires. Approximately 90% of the women respondents had heard of HIV/AIDS, but only about 27% knew HIV could be transmitted from mother to child; of those, almost 94% believed in the reality of HIV disease; in contrast, the majority (64%) believed they were not at risk of HIV infection, and a slightly greater proportion (70%) did not understand the benefits of voluntary HIV counselling and testing (VCT). Nonetheless, almost 90% of respondents were willing to know their status following health education about VCT. Those that were older, attending public hospitals, and with a higher level of education had more knowledge and better perceptions about HIV. The results suggest an urgent need for public health education on HIV/AIDS and the benefits of VCT to control MTCT, particularly targeting young women and those with little or no education.     

Perceived risks and benefits of HIV testing, and predictors of acceptance of HIV counselling and testing among pregnant women in Zimbabwe

This project evaluated perceived risks and benefits and determined predictors of acceptance of voluntary HIV counselling and testing (VCT) among pregnant women in Zimbabwe. One hundred and seventy pregnant women attending an urban antenatal clinic were surveyed. Implications of a negative or positive HIV test result and of telling a partner or community members that one is HIV positive were queried. Forty women (23.5%) consented to VCT, and 16 (40%) were HIV positive. Women who saw VCT as lower risk (odds ratio [OR] = 2.3, 95% confidence interval [CI] [1.1-5.0]) and women who had had a stillbirth or child die (OR = 0.4, 95% CI [0.16-0.97]) were more likely to consent. Prenatal HIV VCT offers the best opportunity for prevention of mother-to-child transmission of HIV; however, less than 25% of women consented. If such interventions are to be successful, attention must be directed towards developing culturally appropriate strategies to address women's concerns and improve future acceptance of VCT in Zimbabwe.     

Uptake of HIV and syphilis testing of pregnant women and their male partners in a programme for prevention of mother-to-child HIV transmission in Uganda

Objective To describe uptake of HIV and syphilis testing in a prevention of mother‐to‐child HIV transmission programme in Uganda. Methods Analysis of data from routine HIV and syphilis testing at Entebbe Hospital antenatal services. Results A total of 20 738 women attended antenatal services. Exactly 62.8% of women, but only 1.8% of their male partners, accepted testing for HIV; 82.2% of women, but only 1.1% of their male partners accepted syphilis testing. Partners of women with positive HIV results were more likely to come for subsequent testing. Of 200 couples whose partners accepted HIV‐testing within 30 days of one another, 19 (9.5%) were HIV‐discordant, representing 65.5% of couples with at least one partner HIV‐positive. HIV prevalence was 12.6% for women and 10.8% for men; syphilis prevalence was 4.0% for women and 6.2% for men. Conclusion Uptake of HIV and syphilis testing was fairly good among pregnant women attending antenatal clinics at Entebbe Hospital, but very low among their male partners. The level of HIV‐discordant couples was high. These clinics should be made more couples‐friendly to identify both HIV‐positive men for treatment and discordant couples for HIV prevention.     

HIV testing and counselling for women attending child health clinics: an opportunity for entry to prevent mother-to-child transmission and HIV treatment

This study assessed the potential for HIV testing at child health clinics to increase knowledge of HIV status, and entry to infant feeding counselling and HIV treatment. At a provincial hospital in Mombasa, Kenya, HIV testing and counselling were offered to women bringing their child for immunization or acute care services. Most women said HIV testing should be offered in these clinics (472/493, 95.7%), with many citing the benefits of regular testing and entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%) received test results, 97.6% on the same day. After 50 participants, point-of-care testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with point-of-care testing (95% confidence interval = 1.4-5.1; P = 0.003). Of 124 women who had not accessed HIV testing during pregnancy, 98 tested in the study (79.0%). Measured by uptake and attitudes, HIV testing in child health clinics is acceptable. This could optimize entry into HIV treatment, infant feeding counselling and family planning services.     

HIV counselling and testing: overemphasizing high acceptance rates a threat to confidentiality and the right not to know

OBJECTIVE: To examine factors affecting the readiness for HIV-related voluntary confidential counselling and testing (VCT). METHODS: In a population-based HIV survey in selected urban and rural areas in Zambia, adults aged > or = 15 years were selected by stratified random cluster sampling. The participants were asked to provide a saliva sample for anonymous HIV testing (n=4812, consent rate 93.5%) and, as a part of an interview, were asked about previous HIV testing experience and if they wished to be counselled and tested for HIV. Those indicating interest (initially willing) were provided with an invitation letter to see a counsellor. In rural areas, VCT was provided by personnel brought in from outside the local community, whereas in urban areas it was provided by locally recruited staff. RESULTS: The overall HIV test rate was 6.5%, but rates appeared to be considerably biased towards higher educational groups. The proportion initially willing was 37% while 3.6% actually came for counselling and were tested (9.3% of those initially willing), of which 47% returned for the result. Actual use was four to five times higher in rural compared with urban areas. Self-perceived risk and high-risk behaviour were positively associated with initial willingness but not with actual use. CONCLUSIONS: The readiness for VCT in the general population was found to be very low. Provision factors such as concerns about confidentiality and length of time waiting for the test result contributed to the low utilization rate. Results of this study contrast sharply with reported VCT acceptance rates of 70-90% among women attending antenatal care in Zambian and in other African populations, suggesting an urgent need to evaluate testing policy and practice of antenatal VCT in particular.     

Use of routine data collected by the prevention of mother-to-child transmission program for HIV surveillance among pregnant women in Rwanda: opportunities and limitations

To compare HIV prevalence measured by antenatal clinics (ANC) sentinel surveillance and by the prevention of mother-to-child transmission (PMTCT) program in Rwanda. We compared HIV prevalence from anonymous testing performed under ANC surveillance, and that measured from voluntary counselling and testing performed under the PMTCT program, in a random sample of the same population of pregnant women attending for their first antenatal visit at 29 ANC surveillance sites with a PMTCT program in 2007 in Rwanda. All of the 13,318 pregnant women recruited in the ANC surveillance accepted to participate in the PMTCT program. HIV prevalence measured by sentinel surveillance was 4.35% whereas that measured for 1873 pregnant women (out of the total sentinel population) by the PMTCT program was 3.49% (p=0.07). For 3% of the PMTCT population, HIV test results were missing from the counselling logbook versus 0.3% in the ANC laboratory logbooks. For 10 pregnant women, HIV test results were divergent between the PMTCT and the ANC laboratory logbooks. After missing data and errors were corrected, HIV prevalence results from PMTCT was 3.27% (significantly different from ANC surveillance: p =0.03). High uptake of PMTCT program among pregnant women was observed in Rwanda in 2007. HIV prevalence measured by the ANC surveillance and PMTCT program were significantly different. Poor performance in HIV testing practices and PMTCT/laboratories data management could explain this difference. Improvement in HIV testing practices and in PMTCT/laboratory data management are needed in order to use PMTCT data for HIV surveillance and to ensure good performance of all the package of care provided by the PMTCT program.     

Attitudes to voluntary counselling and testing prior to the offer of Nevirapine to prevent vertical transmission of HIV in northern Tanzania

In developed countries much progress has been made in reducing vertical transmission of HIV using antiretroviral therapies. To achieve similar gains in Africa the acceptability of routine HIV testing of pregnant women is becoming increasingly important. Evidence of reluctance of pregnant women to undergo HIV testing has led to suggestions to offer antiretroviral therapy to pregnant women without prior HIV testing. In this study we set out to identify risk factors for preferring to avoid HIV testing among women attending an antenatal clinic in northern Tanzania in the context of a hypothetical offer of Nevirapine and to explore the issues raised in more detail in focus group discussions. Two hundred and fifty women attending an antenatal clinic in late pregnancy were interviewed. Almost half of the women preferred to be offered Nevirapine without HIV testing. In a multiple logistic model having a partner with a history of a sexually transmitted disease (OR 2.72, 95% CI 1.14-6.47, p = 0.02) and having a partner who had another sexual partner in the last year (OR 1.89, 95% CI 1.04-3.45, p = 0.04) were positively associated with a preference to avoid HIV testing; while the presence of a partner living at home or feeling able to ask their partner to go for an HIV test were negatively associated with a preference to avoid HIV testing (OR 0.46, 95% CI 0.24-0.89, p = 0.02 and OR 0.56, 95% CI 0.3-1.05, p = 0.07 respectively). FGDs (focus group discussions) suggested that the major concern of women was for the reaction of their male partners to the possibility of a positive HIV test and low confidence in the confidentiality of HIV testing. This fear may lead to low uptake of antiretroviral programmes and treatment without prior testing should be considered.     

Costs and benefits to the mother of antenatal HIV testing: estimates from simulation modelling.

OBJECTIVE: To assess the health service costs and benefits for the woman of an earlier HIV diagnosis as a result of antenatal HIV testing. DESIGN: A model of maternal disease progression was developed based on the rate of decline in CD4 cell counts and applied to two matched simulated cohorts of women with identical initial CD4 cell levels and decline rates but whose HIV diagnosis occurred at different times as a result of antenatal HIV testing. UK data on CD4 cell count at HIV diagnosis and annual health service costs of care excluding antiretroviral therapy (ART) incurred at defined states of CD4 cell count were taken from published UK data. Costs of triple ART were added and effectiveness modelled by retarding the rate of CD4 cell count decline. Discounting costs at 6% and life-years at 2% per year, the additional costs per life-year gained by screening were calculated. Uncertainty was explored using sensitivity analysis. RESULTS: Costs per life-year gained by antenatal diagnosis of women were pound sterling 51258 ($76887) assuming untested women were diagnosed a median of 20.4 months later than tested women, ART was initiated at a CD4 cell count of 350x10(6) cells/l and ART efficacy retarded decline in CD4 cell counts by 40% for life. Sensitivity analyses showed results were most sensitive to the assumed efficacy of lifetime ART and time assumed to HIV diagnosis for women not tested in pregnancy. CONCLUSION: This model provides a way of estimating the additional costs and benefits of future care for the woman resulting from an earlier HIV diagnosis through antenatal testing. These should be included with the paediatric costs averted and life-years gained from interventions to reduce mother-to-child transmission in order to evaluate the cost-effectiveness of antenatal screening in different populations and settings.     

Acceptance of HIV testing among women attending antenatal care in south-western Uganda: risk factors and reasons for test refusal

A problem commonly encountered in programs for prevention of mother-to-child-transmission (PMTCT) of HIV in sub-Saharan Africa is low rates of HIV test acceptance among pregnant women. In this study, we examined risk factors and reasons for HIV test refusal among 432 women attending three antenatal care clinics offering PMTCT in urban and semi-urban parts of the Mbarara district, Uganda. Structured interviews were performed following pre-test counselling. Three-hundred-eighty women were included in the study, 323 (85%) of whom accepted HIV testing. In multivariate analysis, testing site (Site A: OR = 1.0; Site B: OR = 3.08; 95%CI: 1.12-8.46; Site C: OR = 5.93; 95%CI: 2.94-11.98), age between 30 and 34 years (<20 years: OR = 1.0; 20-24 years: OR = 1.81; 95%CI: 0.58-5.67; 25-29 years: OR = 2.15; 95%CI: 0.66-6.97; 30-34 years: OR = 3.88; 95%CI: 1.21-13.41), mistrust in reliability of the HIV test (OR = 20.60; 95%CI: 3.24-131.0) and not having been tested for HIV previously (OR = 2.15; 95%CI: 1.02-4.54) were associated with test refusal. Testing sites operating for longer durations had higher rates of acceptance. The most common reasons claimed for test refusal were: lack of access to antiretroviral therapy (ART) for HIV-infected women (88%; n=57), a need to discuss with partner before decision (82%; n=57) and fear of partner's reaction (54%; n=57). Comparison with previous periods showed that the acceptance rate increased with the duration of the program. Our study identified risk factors for HIV test refusal among pregnant women in Uganda and common reasons for not accepting testing. These findings may suggest modifications and improvements in the performance of HIV testing in this and similar populations.     

Effectiveness of HIV counseling services on knowledge, attitude, behavior and practice (KABP) among pregnant women attending PPTCT program

Counseling services is an important component of National AIDS Control Program which aims at creating awareness and promoting changes in reducing high risk behavior against HIV/AIDS. Pregnant women attending antenatal clinics are being counseled about HIV/AIDS under prevention of parent to child transmission (PPTCT) program. The objective of this study was to assess (KABP) regarding HIV/AIDS among pregnant women attending PPTCT program before and after counseling at Lok Nayak Hospital, New Delhi. A Quasi-experimental study was conducted. Data was collected by interviewing 600 pregnant women attending ANC clinic during May 2006 to May 2007 using a pre-test and post-test interview schedule. About 69.2% of the pregnant women had heard about AIDS before the counseling. Knowledge regarding mother to child transmission of HIV was 53.5%. 38.2% knew that mother to child transmission can be reduced by drugs. The knowledge of pregnant women about AIDS was significantly different in pre-test (mean score = 15.3) and post test (mean score = 35.6) (P < 0.0001). Attitude of study participants towards people living with HIV/AIDS (PLWHA) indicated that individuals with HIV should be allowed to work (79.9%) and all commercial sex workers should compulsorily be tested for HIV (55.1%). There was significant difference between in pre-test and post-test attitude about PLWHA and HIV testing (p < 0.0001). The condom use among the study participants significantly improved after counseling (1.2% in pre-test and 58.6% after counseling) (p < 0.0001). Counseling services were effective in increasing knowledge and changes in attitude and behavior among pregnant women and the efforts needs to be sustained.     

Pregnant women's decisions on antenatal HIV screening in Hong Kong

Identification of HIV-infected pregnant women by antenatal screening is crucial to prevent mother-to-child transmission. In Hong Kong, little is known about women's opinions about the screening test. This cross-sectional study examines the decisions of Hong Kong Chinese pregnant women to undergo antenatal HIV screening and the reasons for their choices. Among 191 pregnant women studied, 147 (77.0%) indicated that they would opt for antenatal HIV screening if offered. Of those, 113 (76.9%) would do so for 'the health of their newborns' and 93 (63.3%) for 'their own health'. Fourteen (7.3%) would decline the test, because they have 'one stable sexual partner' (n=9, 64.3%) and believe that 'HIV infection was not their concern' (n=8, 57.1%). Women with a lower educational attainment (adjusted OR=3.77; 95% C.I., 1.12-12.67, p=0.03) were likely to choose antenatal HIV screening. Results of this study are predictive of pregnant women's responses to Hong Kong's newly enacted antenatal HIV screening programme.     

Mother-to-child transmission of HIV infection in Romania: results from an education and prevention programme

A pilot prevention of mother-to-child transmission (PMTCT) programme was implemented in Constanta County, Romania, between 2000 and 2002. The programme consisted of clinician training, routine antenatal HIV counselling and testing and the care of HIV-infected pregnant women and their infants. A total of 11,423 pregnant women (10,192 (89%) white Europeans, 862 (7.5%) Rroma, 369 (3.2%) Central Asians) were tested during the pilot, at a median of 24 weeks' gestation. Rapid HIV testing at delivery was introduced during the pilot, to supplement the antenatal testing, both of which required informed consent. Overall seroprevalence was 1.75 per 1,000 (95% confidence interval (CI) 1.07-2.70 per 1,000). HIV infection was associated with having a high-risk partner, prostitution and non-Caucasian ethnicity. Twelve infected women completed their pregnancies, of whom seven received antenatal antiretroviral therapy (ART); all neonates received prophylactic ART and five were delivered by elective caesarean section. Three infants were HIV-infected, giving a vertical transmission rate of 25% (95% CI 5.49-57.2%); all three were born to mothers not identified as infected until delivery, and who therefore received no antenatal ART. A key challenge for PMTCT in Romania will be the prompt identification of pregnant HIV-infected women, to allow the optimum application of interventions.     

Fatherhood and HIV-positive heterosexual men

OBJECTIVES: The study of HIV and issues of reproduction is women-focused. HIV-positive men are overlooked and understudied. This study examined views on reproduction of heterosexual HIV-positive men. METHODS: Systematic questionnaire data were gathered from HIV-positive men (n=32) attending an HIV clinic in London. RESULTS: Heterosexual men were rarely given medical advice on reproduction (only 9.4%). Few felt fully informed (21.9%), while many felt uninformed (46.9%) or needed more information (28.1%). Over half would value fertility/fathering consultations, up-to-date information and quick referral to fertility clinics. Nearly half (43.8%) had considered having children and 37.5% had had a child prior to HIV diagnosis. HIV status affected views on fathering, and the advent of new treatments changed views in over half of the men. Almost half (41%) believed they would experience discrimination if they conceived a baby and a quarter would withhold their HIV status when attending antenatal clinics. The majority (81%) believed that a child gave meaning to life and something to live for - only 3.1% felt a child would be a burden. Most men overestimated potential vertical transmission and would value time to discuss fathering and fatherhood. CONCLUSIONS: There are gaps in provision. The majority of men felt that children gave meaning to life and a reason to live. Reproduction issues are not raised with HIV-positive men who are uninformed and unclear where to turn for information. Fatherhood should not be shunned as an issue for all HIV-positive men.     

HIV infection among pregnant women in Bobo-Dioulasso, Burkina Faso: comparison of voluntary and blinded seroprevalence estimates

The objective of our study was to estimate the prevalence of HIV infection among pregnant women in Bobo-Dioulasso (Burkina Faso) according to 2 survey methods. Unlinked anonymous HIV screening was performed among women attending 2 antenatal clinics. Voluntary and confidential HIV counselling and testing were offered to women attending 2 other antenatal clinics in the same time period, September-October 1996. Voluntary HIV testing was performed in the context of a clinical trial on mother-to-child transmission of HIV (ANRS 049 clinical trial) with an acceptance rate of HIV testing of 93%. The first survey recruited 200 women and the second, 424. The mean age (24.6 years vs 24.8 years) and the mean number of pregnancies (3.1 vs 3.3) of women were comparable, in the 2 studies (P=0.69 and P=0.26, respectively). Prevalence of HIV infection in the blinded survey was estimated at 10.0% (95% confidence interval (CI): 6.4-15.2), while it was 9.4% (95% CI: 6.9-12.7) in the voluntary HIV screening programme. These 2 estimates were not statistically different (P=0.82). In the voluntary screening study, the prevalence of HIV infection was significantly different between age groups 15-24 years and 25-49 years (13.9% vs 4.5%, P < 0.001). In the age group 25-49 years, the prevalence of HIV infection estimated in the blinded study and in the voluntary screening study were significantly different (10.5% vs 4.5%, P=0.04) suggesting a potential participation bias among pregnant women of older age in the voluntary, confidential HIV screening group. In conclusion, for the purpose of HIV surveillance, the most reliable method for HIV prevalence remains the unlinked, anonymous testing.     

Prevalence of HIV and syphilis in pregnant women in Leon, Nicaragua

The objective of this study was to determine the prevalence of HIV and syphilis and to identify risk factors among pregnant women visiting antenatal clinics in León, Nicaragua. During February to April 2004, blood samples from pregnant women were collected after written consent had been obtained. The samples were tested for antibodies against HIV and Treponema pallidum. A questionnaire was also completed. In total, 1,059 women were included. Antibodies against HIV were not detected in any of the women, whereas antibodies against T. pallidum were detected in 16 (1.5%). Risk factors for syphilis included illiteracy, lower education, and two or more pregnancies. HIV does not seem to be highly prevalent among pregnant women in León (prevalence, 0%; 95% CI, 0.0-0.3). The higher proportion of women infected with syphilis than found in earlier studies suggests that sexually transmitted diseases are circulating in the general population and highlights the increasing importance of HIV prevention.