Antenatal Care - Testing and Counseling

1. Routinely offered testing that is voluntary and accompanied by counseling is acceptable to most women.

A systematic review with ten studies from 1998 to 2009 from antenatal care settings in Europe, USA, Kenya, Botswana, Zimbabwe, Malawi, Ethiopia and Uganda found that following the introduction of provider-initiated testing, testing increased by a range of 9.9% to 65.6%, with testing uptake of over 85% in eight studies. When reported, pre-test information was provided to between 91.5% to 100% of the women; post-test counseling was provided to 82% and 99.8% of pregnant women. Linkages for ARVs for PMTCT were reported in five studies and ranged from 53.7% to 77.2%. Where reported, provider initiated counseling and testing was considered acceptable by ANC attendees.

A survey on acceptance of HIV testing was conducted in Hong Kong’s maternal and child health centers during a two-month period. The response rate was 98.2% and 2,669 valid questionnaires were analyzed. Seventy per cent (N=1,825) of the respondents indicated their acceptance of the test. A significant association was noted between clients' acceptance and access to HIV information by means of posters, pamphlets, videos and group talks. Perceived benefits and health care workers' recommendation were the main reported reasons for acceptance, whereas no or low perceived susceptibility was the main reason for refusal. Acceptance was also positively correlated with level of education and HIV knowledge.

A retrospective analysis of 54,428 PMTCT records from 2002 to 2009 from a hospital in Uganda found that there was a significant increase of HIV testing among new ANC attendees from 22% when the policy was VCT to 88% once the policy had changed to routine testing. However, the numbers of male partners who tested remained low.

A cross-sectional survey of 388 women who attended antenatal care in Uganda in 2009 found that 98.5% reported positive attitudes towards routine HIV counseling and testing, with 99.5% tested for HIV and 98.5% receiving their same day result. However, some women reported they felt pressured to test for HIV. Women were asked: “Nowadays in this clinic, all mothers are tested for HIV unless they say no. What do you think about this system?” (Byamugisha et al., 2010a: 3).

A 2006 study surveyed 485 pregnant mothers who sought antenatal care at maternity hospitals in Ecuador and found that 94.3% of women reported they would accept an HIV test with a physician’s recommendation compared to 68.3% who were willing to accept an HIV test regardless.

A questionnaire administered to 146 women at 10 PMTCT centers in Zimbabwe who were interviewed during the period they were waiting for their HIV test result found that 57% were aware of the routine offer of HIV testing at the health institution they were using, with more than 94% aware that they were having an HIV test among other routine tests. Fifty percent of the women who accepted HIV testing directly after group education were not aware of the possibility of opting for individual pre-test counseling. Seven of the nine women who declined HIV testing did not feel that the offer of routine HIV testing would deter them from seeking ANC services. However, "it cannot be demonstrated from this study whether or not some women are not attending ANC services due to the implementation of routine offer of HIV testing, since this study was conducted among women who were already presenting at the health facilities" (Mugore et al., 2008: 663).

“Routine but not compulsory” testing was instituted in Botswana after a presidential declaration in 2004. After routine testing started, the percentage of all HIV-infected women delivering in the regional hospital who knew their HIV status increased from 47% to 78% and the percentage receiving PMTCT interventions increased from 29% to 56%. ANC attendance and the percentage of HIV-positive women who disclosed their HIV status to others remained stable. Interviews indicated that ANC clients supported the policy (Creek et al., 2007) (Gray V). A study to evaluate the first 2.5 years found that routine HIV testing has been widely accepted by the population. There has been a rapid scale-up of routine testing. A total of 60,846 persons were tested through RHT in 2004 versus 157,894 in 2005 and 88,218 in the first half of 2006. Testing rates in the population through routine testing were 40 per 1000 persons, 93 per 1000 persons, and 104 per 1000 persons, respectively. In 2005, 89% of those offered testing accepted, with 69% of those tested being female and 31% male. The proportion of men who tested HIV-positive was 34% versus 30% for women. The main reasons for testing in 2005 were patient's wish (50%), pregnancy (25%), medical examination (7%), clinical suspicion (6%), and sexually transmitted infection (2%). Attendance at voluntary counseling and testing centers has increased parallel to the scale-up of routine testing. Routine testing has been widely accepted by the population, and no adverse effects or instances have been reported. It has provided increased access to preventive services and earlier assessment for antiretroviral treatment.

In May 2004, PMTCT services were established in the antenatal clinic (ANC) of a 200-bed hospital in rural Uganda; in December 2004, ANC PMTCT services became opt-out, and routine opt-out intrapartum counseling and testing was established in the maternity ward. This study compared acceptability, feasibility, and uptake of maternity and ANC PMTCT services between December 2004 and September 2005 and found that counseling and testing acceptance was 97% (3591/3741) among women and 97% (104/107) among accompanying men in the ANC and 86% (522/605) among women and 98% (176/180) among their male partners in the maternity. Thirty-four women were found to be HIV-positive through intrapartum testing, representing a 12% (34/278) increase in HIV infection detection. Of these, 14 received their result and nevirapine before delivery. The percentage of women discharged from the maternity ward with documented HIV status increased from 39% (480/1235) to 88% (1395/1594) over the period.

An exploratory cross-sectional survey was conducted in 6 PMTCT sites in rural Zimbabwe to assess the acceptability of opt-out HIV testing. Of 520 women sampled, 285 (55%) had been HIV tested during their last pregnancy. Among the 235 women not HIV tested in ANC, 79% would accept HIV testing if opt-out testing was introduced. Factors associated with accepting the opt-out approach were being less than 20 years old, having secondary education or more, living with a partner, and the existence of a PMTCT service where the untested women delivered. Thirty-seven women of 235 (16%) would decline routine HIV testing, mainly because of their fear of knowing their HIV status and the need to have their partner's consent. Among the 285 women already tested in ANC, 97% would accept the opt-out approach.

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2. Involving partners, with women’s consent, can result in increased testing and disclosure and may reduce risk of vertical transmission and infant mortality.

A pre-test/post-test study in India between 2000 and 2003 in six antenatal care clinics found that counseling that included male partners of pregnant women had a positive impact on male involvement in maternity care and increased dual protection and condom knowledge and use. Of the six clinics, three were used as intervention sites and three as controls. A total of 2,836 women and 1,897 husbands attending the clinics for antenatal care participated in the pre-test survey, however, only 327 women and their husbands completed the intervention and post-test survey and 302 women and their husbands from the control group completed the post-test survey. Women and husbands at the intervention site were counseled at individual, couple, and same-sex group levels on a variety of reproductive health issues, including the prevention of STIs and correct condom use. Pregnant women were screened for syphilis and men identified as having urethral discharge and genital ulcers via syndromic management were treated. Twelve doctors and 12 nurse midwives were trained to provide counseling to both couples and individuals at the intervention sites. Women and husbands who attended the control clinics received the standard care for pregnant women, including nutritional information and tetanus vaccination, but no additional counseling was provided. Knowledge related to dual protection benefits of condom use increased among both males and females in the intervention group, however, gender disparities continued to pervade as 89% of the males exhibited dual protection knowledge compared to only 48% of the females. Use of family planning increased significantly during the six-to-nine months postpartum period among intervention participants when compared to controls, 59% versus 45% among women and 65% compared to 48% among men. Of the methods employed for family planning purposes, condoms were the most commonly used in both groups, as 66% of women in both groups and 71% of men in both groups reported using condoms. Additionally, intent to use condoms in the future was found to be higher among the intervention group than among controls. Men in general tended to have more knowledge related to STIs, 66% versus 32% of females, and knowledge and couple communication related to STIs was not found to have increased after the intervention. Lastly, couples who had attended counseling sessions at the intervention clinics were more likely to discuss family planning with their partners than those attending clinics at the control sites, 84% compared to 64%, and intervention couples were also more likely to report making reproductive health related decisions together, as a couple, than were control couples, 91% versus 71%.

A randomized controlled trial in South Africa from 2006 to 2007 which compared 1) written invitations for the male partners of pregnant women for VCT and 2) a written invitation for her male partner to attend pregnancy information sessions found that written invitations for VCT that were given by pregnant women to their male partners resulted in increased numbers of men who tested for HIV and decreased reports of unprotected sex during pregnancy with no differences in reports of intimate partner violence between the two groups. However, 17 pregnant women reported intimate partner violence. The interventions were accompanied by community sensitization activities includes flyers and posters in places frequented by men, meetings and radio shows. At one week and twelve weeks after randomization, both men and women were interviewed. The pregnancy information session discussed danger signs for mothers and infants; the VCT session consisted of HIV risk behavior, serodisclosure; benefits of testing; and offered VCT. Men who attended the pregnancy information sessions were offered VCT twelve weeks after randomization. At baseline, no male partner attended ANC with his pregnant partner. Of the 500 pregnant women who agreed to invite their male partners for VCT, 175 brought their partners, of whom 161 of the male partners had an HIV test. Of the 500 pregnant women who agreed to invite their male partners to a pregnancy information session, 129 brought their male partners and 57 of these men had HIV testing, with 32% of men having an HIV test in the VCT group and 11% of men having an HIV test in the pregnancy information group. Men who received a written invitation to attend VCT with their pregnant partners were 2.82 times more likely to have an HIV test compared to male partners invited to a pregnancy information session. The VCT invitation letter was associated with increased male attendance at the ANC clinic. “…Potential secondary benefits of male partner attendance include earlier diagnosis and better treatment outcomes for men… and less transmission to female partners and referral for circumcision for HIV-negative men” (Mohlala et al., 2011: 6).

A 1999-2005 prospective cohort study encouraged 456 HIV-positive mothers attending antenatal clinics to invite male partners to counseling and HIV testing in Kenya. During the antenatal period, 31% of men attended a clinic visit (140 of 456). After 12 months follow-up of mother-infant pairs, the study found that vertical transmission risk was over 40% lower for infants of women with partner attendance and with reported previous partner HIV testing than those without, when adjusting for maternal viral load. In addition, when adjusting for maternal viral load and breastfeeding, combined risk of HIV or infant mortality was lower with male attendance and report of prior male HIV test. HIV-negative infants born to women with partners who participated had a 58% lower mortality risk, which after adjusting for infant feeding, was further reduced to 63%. However, if the infant was HIV-positive, infant mortality was higher even for those whose partners attended clinic visits. The study followed mothers with current male partners from 32 weeks gestation until delivery and then followed mother-infant pairs monthly for one year. Mothers filled out questionnaires at enrollment, including information on previous partner testing. According to Kenyan national guidelines, all mothers received zidovudine from 34-36 weeks gestation through delivery. Male partners who attended antenatal visits received counseling on vertical transmission and prevention methods, as well as voluntary counseling and HIV testing. About 54% (75 of 140) of male partners accepted an HIV test at an antenatal visit, 56% (42 of 75) of who tested positive. Women reported that 52% of partners had previously been tested for HIV. About 32% of women intended to formula feed, 78% reported disclosure of status to partner and 49% reported discussing PMTCT with partner. Previous male HIV testing was significantly associated with male partner attendance at antenatal visits (adjusted odds ratio 24.5). Women who reported previous male HIV testing were more likely to formula feed their infants. The study followed 392 infants until 12 months postpartum or death and found that 69% of infants were breastfed (314 of 456) for a median duration of six months. By 12 months of age, 19% of infants (82 of 441) tested HIV-positive, with 27 testing positive by 48 hours after birth. At 12 months, 71 infants had died: 28 who were HIV-positive, 31 who were HIV-negative and 12 with unknown HIV status.

In a study conducted in Kenya with 1,993 pregnant women who informed their male partners of the availability of HIV testing, 16% of the men came to the ANC clinic. Among these 313 men, 95% received HIV testing with 62% who were counseled individually and 10% of men testing HIV-positive. At two-week follow up, male disclosure of HIV test results to female partners was reported by both partners in 75 of 106 couples (71%). In the remaining 29 couples, men reported that they shared their test results with their female partner but had not done so according to their female partners. Rates of confirmed disclosure by women were significantly higher than by men, 93% compared to 71%. However, the level of serostatus disclosure by men to women is among the highest reported levels in the literature.

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3. Informed and appropriate counseling during ANC can lead to increased discussion between partners and increased protective behaviors such as condom use.

A study in Côte d’Ivoire from 2001 to 2005 with 306 HIV-positive, 352 HIV-negative, and 52 pregnant women who refused HIV testing, found that prenatal HIV counseling and testing led to increased discussions between partners regarding STIs and sexual risks, and increased condom use when sexual activity was resumed after delivery. After prenatal counseling and testing, HIV-positive women were enrolled in a PMTCT program and were followed for 2 years. Women who tested HIV-negative and untested women received reproductive health related follow-ups for 2 years. Prior to prenatal counseling and testing, two-thirds of HIV-negative and untested women reported having had discussions about STIs with male partners, while afterwards over 90 percent of women reported discussing STIs, suggesting that their partners be tested for HIV, and encouraging condom use in extramarital sexual relations. For HIV-positive women, discussions about STIs with partners increased from 28 percent to 65 percent, 72 percent suggested that their partners be tested for HIV, and 58 percent encouraged condom use in extramarital relations. Additionally, condom use increased from 36 to 59 percent of HIV-negative women, 52 to 57 percent of untested women, and 23 to 49 percent of HIV-positive women when sexual activity was resumed after delivery. However, data were collected from women only and therefore actual discussions with partners may be overrepresented.

An evaluation of UNICEF-funded PMTCT programs in 11 developing countries in 2002 involving review of progress reports, interviews with PMTCT program managers, rapid assessments in Rwanda and Zambia and site visits in Honduras and India found that PMTCT programs did not discourage use of ANC but helped women to disclose their HIV testing experience and serostatus to their partners and family, thus fostering discussions and normalizing HIV testing and HIV care.

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4. Testing for and treating syphilis in conjunction with HIV testing for pregnant women will reduce congenital syphilis and can reduce perinatal transmission HIV.

A 2007-2010 retrospective cohort study in Zambia analyzed data on 1,813 HIV-positive pregnant women attending antenatal clinics to assess various exposures of mother-to-child-transmission. The study found that a positive maternal syphilis test increased the odds of vertical transmission 3.8-fold compared to a negative syphilis test. In this cohort, mother-to-child-transmission of HIV occurred in 3.3% of infants (59 in 1813). Mother-infant pairs were considered eligible for this study if mothers began HAART during pregnancy and if their infants had an HIV test result from 3-12 weeks of age. Infant HIV status was the primary outcome. Electronic records provided comprehensive mother and newborn data through the first six weeks, which included HAART initiation, gestational age, demographic characteristics, infant birth weight and CD4 cell count. HAART duration was categorized as 4 weeks or less, 5-8 weeks, 9-12 weeks or 13 weeks or more. Maternal age, infant weight at birth, maternal BMI or hemoglobin levels, maternal CD4 cell count and gestational age were not found to be associated with infant HIV infection by 12 weeks.

A study from 2003 to 2005 in the Ukraine with 521 mother infant pairs with known infant HIV-positive serostatus found an association between maternal syphilis and perinatal transmission. Overall, 3.5% of pregnant women had serological test results that were positive for syphilis. The overall HIV perinatal transmission rate was 5.8% and was statistically significantly higher among women who were seropositive for syphilis. Having antenatal serological test results that were positive for syphilis was associated with a five-fold increased risk of MTCT univariably and a nearly 4.5-fold increased risk adjusting for ARV prophylaxis, premature delivery and elective cesarean delivery.

A study to determine the association between maternal syphilis and HIV mother-to-child transmission in a prospective cohort study of pregnant women admitted at Queen Elizabeth Central Hospital in Malawi found that maternal syphilis was associated with in utero and intrapartum and postpartum perinatal transmission of HIV. Women admitted in late third trimester were screened for HIV (by HIV rapid tests) and syphilis (by rapid plasma regain test and Treponema pallidum hemagglutination assay). HIV-positive women and their infants received nevirapine, according to the HIVNET 012 protocol. They were followed up at 6 and 12 weeks postpartum. Infant HIV infection was diagnosed by DNA PCR. Of the 1,155 HIV-positive women enrolled, 1147 had syphilis test results, of whom 92 (8.0%) were infected with syphilis. Only 751 HIV-positive women delivered live singleton infants who were tested for HIV at birth. Of these, 65 (8.7%) were HIV-infected, suggesting in utero (IU) HIV MTCT. Of the 686 infants who were HIV-negative at birth, 507 were successfully followed up. Of these, 89 (17.6%) became HIV-positive, suggesting intrapartum/postpartum (IP/PP) HIV transmission. Maternal syphilis was associated with in utero HIV MTCT, after adjusting for maternal HIV-1 viral load and low birth weight (LBW). Furthermore, maternal syphilis was associated with IP/PP HIV MTCT, after adjusting for recent fever, breast infection, LBW and maternal HIV-1 viral load. Screening and early treatment of maternal syphilis during pregnancy may reduce pediatric HIV infections.

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5. Counseling for both pregnant women and future fathers to circumcise male infants may reduce HIV acquisition and transmission when those male infants become sexually active young men. [See also Voluntary Medical Male Circumcision]

Randomized, controlled trials have determined the level of protective effect of male circumcision on HIV for men. Male circumcision at birth as part of postnatal care could reduce, upon the infant’s sexual initiation and for his lifetime, a reduction in the risk of HIV acquisition and transmission. Male circumcision has now been shown in three randomized clinical trials to reduce the risk of HIV acquisition for men by 50 to 60% (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007).

A 2008 study in Botswana found neonatal male circumcision to be acceptable to 92% of 60 mothers of newborn boys if performed in a clinical setting, with protection from HIV appearing as a major motivating factor. Before their male infant could be circumcised, 51 (85%) of the 60 pregnant women said “their partner would definitely have to agree to the procedure before their male infant could be circumcised” (Plank et al., 2010: 1200). In order to obtain a diverse sample, postpartum mothers were chosen from maternity wards in the capital city, Gaborone, the town of Lobatse, and the villages of Molepolole and Mochudi. Semi-structured interviews assessing prior knowledge, attitudes, and behaviors regarding male circumcision were administered to the mothers. Preceding the interviews, the mothers were given a pamphlet with an illustration of male circumcision and detailed information regarding potential risks and benefits of the procedure. Within a year leading up to the study, 57 (95%) out of the 60 women had been tested for HIV and 21 (35%) reported being HIV-positive. Currently, 15% of men in Botswana have been circumcised, but only rarely as neonates. When asked whether their partner was circumcised, 23 (38%) out of the 60 women reported their partner as circumcised and 2 (3%) did not know if their partner was circumcised. Looking specifically at acceptability, 32 (53%) participants thought circumcision of their male infant would be viewed positively by their community and 2 (3%) thought it would be viewed negatively. When asked about the primary decision maker in regards to circumcision of their male infant, 38 (63%) women indentified themselves and 13 (22%) identified their partner. For those women interested in circumcision for their male infant, 58 women chose a hospital or clinic as the preferred location, while 2 chose “home.” When asked who should circumcise their male infant, 56 (93%) women chose a “trained physician.”

“…Circumcision prior to sexual debut [of male adolescents] will render the greatest lifetime protection (Eaton and Kalichman, 2009: 191).”

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