Antenatal Care - Testing and Counseling
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 Chapter 3. Prevention for Women, Chapter 4. Prevention for Key Affected Populations, and Chapter 11. 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 Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV and Chapter 10. Preventing, Detecting and Treating Critical Co-Infections]
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 4–15% (WHO, 2007d). 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.
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 50–60% (Auvert et al., 2005; Bailey et al., 2007; and 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 Chapter 3C. Prevention for Women: Male Circumcision]
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, to provide her with information about PMTCT options and to enable her to make informed decisions about continuing or ending a pregnancy if safe, legal abortion is available” (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
Until recently, testing and counseling had been offered based on opt-in principles that relied on women to seek counseling and testing. For the past few years, most programs have been shifting 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 Chapter 6. HIV Testing and Counseling for Women] This practice must be carefully evaluated to ensure women’s rights are respected. “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).
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). [See also Chapter 11B. Strengthening the Enabling Environment: 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, however (Jurgens et al., 2007a). [See also Chapter 6. HIV Testing and Counseling for Women]
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 (Drucell and Nolan, 2007). 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; Turan et al., 2008b; PHR, 2007a; Center for Reproductive Rights and Federation of Women’s Lawyers, Kenya, 2007; HRW, 2003b).
“…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). 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). 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).
HIV Counseling for Both Men and Women Is a Critical Component of Antenatal Care
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. However, many 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).
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). 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).
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. 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 mother to child transmission. Please see also Chapter 6. HIV Testing and Counseling for Women for additional evidence on what works in HIV testing for all women.