Antenatal Care - Testing and Counseling

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 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”.

“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 .A study to evaluate the first 2.5 years found that routine HIV testing (RHT) has been widely accepted by the population. There has been a rapid scale-up of RHT. 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 RHT 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 RHT. RHT 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 (Steen et al., 2007). (Gray V)

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.

A study from 2007 to 2008 in Mexico investigated the provision of a validated facilitated consent to pregnant women, which considered the emotional impact of potentially testing HIV-positive and included counseling before rapid HIV testing, in antenatal care settings where routine rapid HIV testing is not common. Of the 1,293 HIV tests given during the study period, 92% of women stated that the facilitated consent was “clear and sufficient to accept or reject the test” . (Abstract)

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.

Six hundred women from ten antenatal clinics in southern Uganda found that women who received pre-test counseling were more 1.84 times more likely to disclose their HIV status . (Abstract)

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 PMTCT program that included active community education and outreach to encourage couple counseling and testing was implemented in two antenatal clinics in Lusaka, Zambia. A subset of HIV-positive women was asked to report their experience of adverse social events 6 months after delivery. Nine percent (868) of 9,409 women counseled antenatally were counseled with their husband. Couple-counseled women were more likely to accept HIV testing (96%) than women counseled alone (79%). However uptake of nevirapine was not improved. Six months after delivery, 28% of 324 HIV-positive women reported at least one adverse social event (including physical violence, verbal abuse, divorce or separation). There were no significant differences in reported adverse social events between couple- and individual-counseled women.

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.

Data from 177 VCT centers in 2006 found that in Haiti, 75,122 pregnant women were tested for both HIV and syphilis. A national scale up of this strategy will reach at least 85% of pregnant women. Routine syphilis testing found syphilis in 3,404 pregnant women . (Abstract)

A study in Vietnam based on 38 HIV-positive pregnant women and mothers and 53 health workers with routine testing performed at ANC services when women were seven to eight months pregnant found that all 38 women felt that the timing of the test at ANC services was too late in the pregnancy. As one HIV- positive woman put it: “I would not have had a child if I had known that I was positive” . Three women who accessed VCT rather than routine testing via ANC tested early in pregnancy and two opted for abortion when the test was positive (Oosterhoff et al., 2008).

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%.

“…Circumcision prior to sexual debut [of male adolescents] will render the greatest lifetime protection”.

^[11] Note: While co-infection with syphilis is associated with increased risk of vertical transmission of HIV, it would be unethical to conduct any study that denied known treatment for syphilis to assess whether giving or withholding treatment increased risk of vertical transmission of HIV.