Antenatal Care - Testing and Counseling
In 2007, only an estimated 18% of pregnant women were offered HIV tests (ITPC, 2009). "The purpose of antenatal VCT should be to help a woman prepare for a possible positive HIV diagnosis [and] to provide her with information about PMTCT options" (De Bruyn and Paxton, 2005: 145). In developing country settings, between eight and ten percent of women report having received PMTCT interventions (Pai and Klein, 2009).
HIV Testing for Pregnant Women Must Respect Their Rights
"I revealed my status to my partner... my partner helped me through this difficult time, we became highly dependent on each other as we were both HIV+ and thanks to the medication the children are HIV-negative." -Woman patient on ARVs in South Africa (Gilbert and Walker, 2010: 142)Until recently, testing and counseling had been offered based on opt-in principles that relied on women to seek counseling and testing. Many programs have now shifted to routine or "opt-out" testing in which clients are routinely tested in various health care settings unless they decide not to be tested. [See HIV Testing and Counseling for Women] "The rationale behind the switch to opt-out testing is that stigmatization will be decreased (that is, women do not feel they are singled out for HIV testing if everyone undergoes the test) and higher percentages of women are then tested" (De Bruyn, 2005: 4). Additional rationales for opt-out testing are that opt-out testing is less resource intensive to scale-up and thus can be made available to more women (WHO and UNAIDS, 2007) and also that there is a public health argument for testing as many women and men as possible so that appropriate prevention and care services can be provided with regard to status (De Cock et al., 2003). "A disadvantage of opt-out testing is that it may be routinely imposed and women may not realize they can refuse the test or dare to do so..." (De Bruyn, 2005: 4). This practice must be carefully monitored to ensure womens rights are respected. A recent study among pregnant women in Ukraine found that providers told women that they had to get HIV testing in order to access financial support during antenatal care. But even if pregnant women refused testing, their child would be tested: If I refuse to be tested for HIV, then once my child is born he will be tested for HIV irrespective of my consent (Finnerty et al., 2010: 22).
Steps Must be Taken to Avoid Negative Repercussions for Women Who Test During Pregnancy
Women have often received HIV tests as part of PMTCT programs. While women are often faced with opt-out testing or even mandatory testing during antenatal care, men rarely access health care in situations where they would be subjected to opt-out or mandatory testing. "The ethics of routine testing has a conspicuous gender dimension... women and girls are more likely to present at formal health care services than are men and hence are more likely to come under a routine testing policy. Women and girls are also the most likely to face stigma, violence and abuse when their HIV-positive status becomes known..." (Rennie and Behets, 2006: 84).
"There is a great difference between VCT and testing and counseling during pregnancy. In the first case, the woman wants to know her HIV status... In the second case, the pregnant woman has come to learn how her pregnancy is developing... Learning her HIV-positive status this way can be a very difficult experience" (Msellati, 2009: 808)While routine testing is showing some promising signs of being acceptable and feasible, it is important to ensure that routine testing does not discourage women from seeking needed medical care or cause unanticipated outcomes for women, such as increased violence. Opt-out testing, while showing an increase in the number of women who are tested during antenatal care, raises concerns about whether women living with HIV will avoid antenatal care services in order not to be tested (Druce and Nolan, 2007). A special analysis of pregnant women in India found that women often go to a different facility than the one nearest to where they live for HIV testing (Kandwal et al., 2010), possibly to avoid HIV stigma and to ensure confidentiality. Other recent qualitative studies have found that women avoid antenatal care altogether in order not to test for HIV, or as one woman from Soweto, South Africa put it: "I didn't book at an antenatal clinic because I was afraid that they would test me for HIV" (Laher et al., 2012: 94). Some studies have shown that testing in violation of human rights standards discourages women from accessing services or may lead to increased violence against women (Turan et al., 2008a; Bwirire et al., 2008; Zabina et al., 2009; PHR, 2007a; Center for Reproductive Rights and Federation of Women Lawyers, 2007; HRW, 2003b). Women have reported adverse events following testing at antenatal care: "When I came to this antenatal clinic, I was tested for HIV and found to be positive. When I went home and disclosed my status to my husband... he left me" (Twenty year old mother of two in Malawi; Ostergaard and Bula, 2010: 216).
A recent study in Tanzania found that of 426 pregnant women, women have little authority, with 78.6% reported that they had asked their partners for permission to get an HIV test. A pregnant wife asking to use condoms was seen as endangering the marriage as this was a decision to be made only by the husband (Falnes et al., 2011). "Deep-seated ideas about gender roles emerged as a bigger challenge to partner testing" (Falnes et al., 2011: 6). Only 3% of male partners accessed testing. One man stated: "Generally our women should not tell us men what to do, even though the advice comes from the doctor" (Falnes et al., 2011: 6), with men admitting that if their pregnant wife tested HIV-positive, they would blame her and "chase her out" (Falnes et al., 2011: 7). Other men however, said if their pregnant wife tested HIV-positive, "If only she is infected, I will care for her till the end" (Falnes et al., 2011: 7). Yet, despite the increased risk for violence during pregnancy, few PMTCT programs include risk assessments or services for violence (Betancourt et al., 2011). [See also Addressing Violence Against Women]
In addition, voluntary consent is called into question when the first time women are offered testing is during labor and delivery (Center for Reproductive Rights, 2005). Yet numerous research studies conducted in Brazil, Mexico, Cameroon, Russia, Rwanda, Nigeria, Uganda, Zambia, Peru and India have demonstrated successful implementation of a rapid HIV testing program in labor and delivery (Kissin et al., 2008; Rahangdale et al., 2007; Sagay et al., 2006 cited in Pai and Klein, 2009). The impact of rapid testing during labor and delivery for the HIV-positive woman has yet to be assessed (Jurgens, 2007a). Further evaluation of routine and provider-initiated testing is urgently needed to assess whether informed consent and confidentiality is adequately protected (Gruskin et al., 2008a).
Good Antenatal Care is Essential for Safe Motherhood
Clinical exams, rapid syphilis tests, tetanus toxoid, supplementation with iron and folic acid are all considered the standard of care for pregnant women (Villar et al., 2001). Of critical importance is to inform women, their partners, families and communities of the danger signs during pregnancy and ensure access to emergency obstetric care. Antenatal care is also an opportunity for HIV counseling and testing. Women who test HIV-negative still need information and support to remain HIV-negative. [See Prevention for Women, Prevention for Key Affected Populations, and Strengthening the Enabling Environment] Women who test HIV-positive need to be informed of their treatment options, both for their own health and to prevent vertical transmission. Women who test HIV-positive also need information and counseling concerning infant feeding options. Improving quality of care in maternal health services can increase the likelihood that women will go to health facilities in case of obstetric emergencies, thus increasing the chances of positive maternal and infant health outcomes (Gay et al., 2003). Women living with HIV also need sexual and reproductive health services and treatment for critical co-infections. Further efforts are needed to screen and treat pregnant women for co-infections that potentially increase mortality for women and their infants. [See also Meeting the Sexual and Reproductive Health Needs of Women Living With HIV and Preventing, Detecting and Treating Critical Co-Infections] "Given that the primary users of antenatal services in sub-Saharan Africa are young women under the age of 30 years, transforming delivery of PMTCT programs with greater emphasis on couple counseling, preventing unwanted pregnancies, keeping HIV-negative mothers uninfected, early initiation of HIV-infected mothers on antiretroviral treatment and ensuring safe infant feeding practices could make a substantial difference to current maternal and infant mortality rates and life expectancy patterns in women in these settings" (Abdool Karim et al., 2010a: S125-S126).
Syphilis co-infection can be especially dangerous in pregnancy, particularly for HIV-positive pregnant women. There is some evidence that HIV-syphilis co-infection may increase the risk of perinatal HIV transmission. While numerous countries have policies to provide universal screening for syphilis for pregnant women, not enough women are actually screened and treated in practice. In 2007, WHO estimated that syphilis prevalence in pregnant women in Africa ranges from 415% (WHO and UNAIDS, 2007). As a result, infants are dying from syphilis despite access to ARVs for mothers and infants (Peeling et al., 2004). Universal screening and treatment for syphilis in pregnancy could prevent 492,000 syphilis-related stillbirths and perinatal deaths per year in sub-Saharan Africa (Saloojee et al., 2004). Syphilis testing and treatment in conjunction with HIV testing can prevent congenital syphilis and may reduce HIV transmission. Screening for TB in pregnancy, especially in settings of high HIV prevalence, is also needed (Mnyani and McIntyre, 2010; Smart, 2012a).
Antenatal care is also an opportunity to discuss with pregnant women and their partners the benefits of infant male circumcision, which may reduce HIV acquisition and transmission when the infant becomes sexually active. Male circumcision has now been shown in three randomized clinical trials to reduce the risk of HIV acquisition for men by 5060% (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). Male circumcision at birth as part of postnatal care could result, upon sexual initiation and for his lifetime, in a reduction in the risk of HIV acquisition and transmission (Weiss et al., 2009; Nagelkerke et al., 2007). [See also Voluntary Medical Male Circumcision]
"Structural factors in country health systems are one of the largest challenges to implementing effective programs for prevention of MTCT of HIV infection. At the country level, maternal, newborn, and child health services, in which programs for prevention of MTCT are targeted, are usually separate from programs, laboratories, and services for treatment and care of HIV infection. Thus, antepartum and postpartum care systems are not equipped to test all women for HIV, conduct CD4 cell count testing to stage disease in HIV-infected women, and provide antiretroviral treatment to women who need it and antiretroviral prophylaxis to others" (Mofenson, 2010a: S144). [See also Structuring Health Services to Meet Women’s Needs]
HIV Counseling for Both Men and Women Is a Critical Component of Antenatal Care
"Yes, (he agreed to use a condom) for the sake of the baby." -HIV-positive pregnant woman (Matthews et al., 2011)Counseling on safer sex during pregnancy should be an important part of HIV testing. "...Parents desire healthy children and are willing to modify their behavior to protect them from harm" (Tavengwa et al., 2007: 101). Male partners and/or husbands can influence whether a woman accesses HIV testing (Ghanotakis, 2010). It is therefore critical to involve the male partners of pregnant women--with women's consent. Some ANC clinics and maternity hospitals have no place (literally) for men; and health workers in maternal health clinics rarely have received training in addressing male partners. "In addition, many men believe that their wives' HIV test results would mirror their own. Mass information campaigns should address this incorrect belief" (Msellati, 2009: 809). National guidelines can help. In Rwanda, national guidelines to encourage HIV testing for male partners of HIV-positive women in antenatal care has resulted in 81% of male partners getting tested for HIV (WHO et al., 2011b).
Women are vulnerable to seroconversion during pregnancy. In a study in South Africa, 3.4% of 1,396 women seroconverted during pregnancy or within 12 months after delivery with much higher rates of vertical transmission: 20.5% compared to 9% of women who were not recently infected, a 2.3 greater risk of vertical transmission. Yet only 20% of those recently infected would have qualified for HAART with CD4 counts under 350, suggesting that all women who seroconvert during pregnancy should have access to HAART. However, it is challenging to identify recent seroconversions. [See HIV Testing and Counseling for Women and Treatment] None of 1,396 women reported condom use during pregnancy. Recent seroconversion was correlated with financial dependency. Women "...remain vulnerable during pregnancy and postnatally in settings where social norms and economic conditions encourage short-term relationships and multiple partners" (Moodley et al., 2011: 2031). [See Strengthening the Enabling Environment]
For HIV-negative pregnant women, avoiding unsterilized needles, avoiding blood transfusions which have not been screened for HIV; and continued condom use and/or mutual monogamy with one HIV-negative sexual partner are ways remain HIV-negative during the course of pregnancy and the postpartum period. However, fear of violence and lack of ability to assert control, such as feeling forced to have sex, may make it even more difficult for pregnant women to request condom use, as condoms cannot be talked about in the context of contraception (Kershaw et al., 2006). "...Healthcare providers need to address the issue of postpartum sexual activity and contraception early after delivery or even late in the last trimester to provide women with the appropriate knowledge to allow them to make informed decisions regarding their reproductive futures" (Balkus et al., 2007: 28).
For women who test positive, counseling is especially necessary during this time. Providers should also not place undue burdens on women who test positive. For example, in Ethiopia, women who test HIV-positive are told to inform their husbands to come to health services to get tested for HIV (CHANGE, 2009). Dealing with stigma is especially difficult. "...Coping with HIV-related stigma... is especially challenging during pregnancy and postpartum, when women may be preoccupied not only with the physical and psychological effects of having HIV, but also with preventing HIV transmission to their infants and/or avoiding disclosure of their HIV status to their families and communities" (Brickley et al., 2008: 1197). However, within the context of HIV testing, counseling is "not simply a human rights imperative: it is a medical intervention that is vital to support pregnant women with prevention efforts, disclosure, living with a life-threatening virus and adherence to treatment" (Gruskin et al., 2008a: 29).
Confidentiality Must Be Maintained
Confidentiality of all test results should be paramount, yet it is not always followed in practice. Stronger efforts are needed to ensure that provision of HIV test results of pregnant women to their male partners or anyone else should only be done with women's expressed permission. Criminal liability for unauthorized disclosure of HIV test results can be one way to increase women's confidence that HIV tests will be confidential: a qualitative study with semi-structured interviews with 25 medical providers and 60 pregnant women who had been tested in the past 60 days plus in-depth interviews with 30 women about HIV testing during their pregnancy in Ukraine found that "most women reported that they were not afraid of their HIV test results being disclosed to anyone... knowing that the confidentiality of their medical information is protected under Ukrainian law" (Finnerty et al., 2010: 19).
Policies should detail the risks of testing and clarity for women who refuse to test. Also, policies should specify whether parental consent is required to test infants. Pregnant women must have the opportunity to learn their HIV status but the autonomy to decline HIV testing without penalty in the health care setting. Confidentiality of test results is critical (Maman et al., 2008c). Women who test HIV-positive should be able to access PMTCT services, with follow-up treatment for herself and her child. HIV testing and PMTCT services have been successfully provided to women in all kinds of setting, including in refugee camps (Rutta et al., 2008). Using community volunteers to provide HIV testing to pregnant women may increase the number of women tested, especially where access to clinics is a challenge, as in Zimbabwe (Shetty et al., 2005).
The following interventions are specifically related to HIV testing and counseling in the context of preventing vertical transmission. Please see also HIV Testing and Counseling for Women for additional evidence on what works in HIV testing for all women.