Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe

Systematic review and meta-analysis of seroprevalence of human immunodeficiency virus serological markers among pregnant women in Africa, 1984-2020

BACKGROUND

Human immunodeficiency virus (HIV) is a major public health concern, particularly in Africa where HIV rates remain substantial. Pregnant women are at an increased risk of acquiring HIV, which has a significant impact on both maternal and child health.

AIM

To review summarizes HIV seroprevalence among pregnant women in Africa. It also identifies regional and clinical characteristics that contribute to study-specific estimates variation.

METHODS

The study included pregnant women from any African country or region, irrespective of their symptoms, and any study design conducted in any setting. Using electronic literature searches, articles published until February 2023 were reviewed. The quality of the included studies was evaluated. The DerSimonian and Laird random-effects model was applied to determine HIV pooled seroprevalence among pregnant women in Africa. Subgroup and sensitivity analyses were conducted to identify potential sources of heterogeneity. Heterogeneity was assessed with Cochran's Q test and I2 statistics, and publication bias was assessed with Egger's test.

RESULTS

A total of 248 studies conducted between 1984 and 2020 were included in the quantitative synthesis (meta-analysis). Out of the total studies, 146 (58.9%) had a low risk of bias and 102 (41.1%) had a moderate risk of bias. No HIV-positive pregnant women died in the included studies. The overall HIV seroprevalence in pregnant women was estimated to be 9.3% [95% confidence interval (CI): 8.3-10.3]. The subgroup analysis showed statistically significant heterogeneity across subgroups (P < 0.001), with the highest seroprevalence observed in Southern Africa (29.4%, 95%CI: 26.5-32.4) and the lowest seroprevalence observed in Northern Africa (0.7%, 95%CI: 0.3-1.3).

CONCLUSION

The review found that HIV seroprevalence among pregnant women in African countries remains significant, particularly in Southern African countries. This review can inform the development of targeted public health interventions to address high HIV seroprevalence in pregnant women in African countries.

Understanding the relationship between the public sector healthcare workers and NGO-based HIV counsellors while providing HIV counselling and testing services to pregnant women: A Qualitative Study in Suva, Fiji

Human immunodeficiency virus (HIV) counselling and testing plays a significant role in the prevention of mother-to-child transmission of HIV. HIV counselling and testing during pregnancy is an essential gateway for HIV prevention, timely treatment, and care services. Lack of proper counselling could jeopardise the quality of services. This paper aims to understand the relationship between the government employed hospital healthcare workers and the Non-Governmental Organisation based counsellors while providing HIV counselling and testing services to pregnant women attending antenatal clinic in one of the main hospitals in Suva, Fiji. Data were collected via individual, in-depth, interviews held in a single hospital and an associated reproductive health centre in Suva in April-May 2013. A total of 15 healthcare providers including doctors (n = 4), midwives (n = 5), nurses (n = 4), and counsellors (n = 2) were interviewed. The data were analysed using thematic analysis. Ethical approvals were obtained. We found that there was tension between the government employed hospital healthcare workers and the Non-Governmental Organisation based counsellors involved in the provision of HIV counselling and testing services to pregnant women. The predominant causes of tension were poor referral for HIV test counselling, long counselling time, lack of cooperation and conflict due to the differences in counselling approaches. Tension between the government employed hospital healthcare workers and the Non- Governmental Organisation based HIV counsellors appear to be the main challenge to effective provision of HIV test counselling services in the hospital. Ongoing tension between both groups could restrict healthcare workers abilities to provide quality HIV counselling services. Our findings would be useful in developing strategies to overcome tension amongst healthcare workers as it would be an imperative step in providing streamlined HIV counselling services to women attending antenatal clinic in Fiji.

"There Are Just Too Many Rooms Here!" Perception of Clients and Health Care Workers on the Implementation of Test and Treat Strategy at Area 25 Health Center in Lilongwe, Malawi

Background: Malawi adopted World Health Organisation test-and-treat policy in 2016. The policy initiates early antiretroviral treatment to all clients diagnosed with HIV, irrespective of their CD4 count. However, some facilities record low linkage following the strategy. Perceptions of clients and health care workers on the implementation of test-and-treat strategy were explored in Malawi. Methods: A descriptive qualitative approach was conducted in which 21 in-depth interviews, 9 key informant interviews, and 15 non-participatory observations were conducted. Data were analyzed following thematic approach. Results: Most participants had positive perceptions of the test-and-treat strategy. However, negative perceptions stemmed from the fragmented structure of the facility with multiple rooms in which the client navigates through as well as limited privacy. Conclusion: Optimal implementation of the test-and-treat strategy will need to strengthen privacy and minimize unintended disclosure that is inherent in the organization of services.

The cost of implementing the Systems Analysis and Improvement Approach for a cluster randomized trial integrating HIV testing into family planning services in Mombasa County, Kenya

BACKGROUND

Although HIV testing in family planning (FP) clinics is a promising approach for engaging women in HIV treatment and prevention services, HIV testing rates are low in FP clinics in Kenya. In 2018, a cluster randomized trial was implemented in Mombasa, Kenya applying the Systems Analysis and Improvement Approach (SAIA) to integrate HIV testing into FP services (1K24HD088229-01). We estimated the incremental costs and explored cost drivers of the FP HIV SAIA implementation in Mombasa, Kenya.

METHODS

We conducted a costing evaluation from the payer perspective for the FP HIV SAIA randomized control trial. We identified relevant activities for the intervention including start-up, training, research and FP HIV SAIA. We estimated activity time burden using a time-and motion study. We derived unit costs through staff interviews and programmatic budgets. We present cost estimates for two different scenarios: as-implemented including research and projected costs for a Ministry of Health-supported intervention. All costs are reported in 2018 USD.

RESULTS

For an annual program output of 36,086 HIV tests administered to new FP clients, we estimated the total annual program cost to be $91,994 with an average cost per new FP client served of $2.55. Personnel and HIV rapid testing kits comprised 55% and 21% of programmatic costs, respectively. Assuming no changes to program outputs and with efficiency gains under the MOH scenario, the estimated cost per new FP client served decreased to $1.30 with a programmatic cost reduction of 49%.

CONCLUSION

FP HIV SAIA is a low-cost and flexible implementation strategy for facilitating integrated delivery of HIV testing alongside FP services. Although cost implications of the FP HIV SAIA intervention must continue to be evaluated over time, these findings provide context-specific cost data useful for budget planning and decision-making regarding intervention delivery and expansion.

TRIAL REGISTRATION

The trial was registered on December 15, 2016, with clinicaltrials.gov (NCT02994355).

Are prevention of mother-to-child HIV transmission service providers acquainted with national guideline recommendations? A cross-sectional study of primary health care centers in Lagos, Nigeria

Background

Implementation of interventions for the prevention of mother-to-child transmission (PMTCT) of HIV in low- and middle-income countries, faces several barriers including health systems challenges such as health providers’ knowledge and use of recommended guidelines. This study assessed PMTCT providers’ knowledge of national PMTCT guideline recommendations in Lagos, Nigeria.

Methods

This was a cross-sectional survey of a purposive sample of twenty-three primary health care (PHC) centers in the five districts of Lagos, Nigeria. Participants completed a self-administered 16-item knowledge assessment tool created from the 2016 Nigeria PMTCT guidelines. Research Electronic Data Capture (REDCap) was used for data entry and R statistical software used for data analysis. The Chi square test with a threshold of P < 0.05 considered as significant was used to test the hypothesis that at least 20% of service providers will have good knowledge of the PMTCT guidelines.

Results

One hundred and thirteen (113) respondents participated in the survey. Most respondents knew that HIV screening at the first prenatal clinic was an entry point to PMTCT services (97%) and that posttest counselling of HIV-negative women was necessary (82%). Similarly, most respondents (89%) knew that early infant diagnosis (EID) of HIV should occur at 6–8 weeks of life (89%). However, only four (3.5%) respondents knew the group counselling and opt-out screening recommendation of the guidelines; 63% did not know that haematocrit check should be at every antenatal clinic visit. Forty-eight (42.5%) service providers had good knowledge scores, making the hypothesis accepted. Knowledge score was not influenced by health worker cadre (p = 0.436), training(P = 0.537) and professional qualification of ≤5 years (P = 0.43).

Conclusion

Service providers’ knowledge of the PMTCT guidelines recommendations varied. The knowledge of group counselling and opt-out screening recommendations was poor despite the good knowledge of infant nevirapine prophylaxis. The findings highlight the need for training of service providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08152-6.

Geographic variation in missed opportunities for the prevention of mother-to-child transmission of HIV among women receiving antenatal care in Nigeria

There are missed opportunities for the prevention of mother-to-child transmission of HIV (PMTCT) in Nigeria. However, little is known about the geographic variation. We examined the geographic pattern in the missed opportunities for HIV testing among antenatal care (ANC) attendees and initiation t on antiretroviral therapy (ART) in Nigeria. This study was an analysis of aggregated state-level data on 2,875,370 ANC attendees from the 2019 national HIV/AIDS health sector data. We performed descriptive statistics and explanatory spatial data analysis. Overall, the missed opportunity for HIV testing was 9.3%, ranging from 1.8% in the South South to 14.5% in the North West. The missed opportunity for HIV testing ranged from 0.2% in Imo State to 25.2% in Kaduna State. The local indicator of spatial association cluster map showed a concentration of cold spots in the South and hot spots in the North. The overall missed opportunity for ART was 9.5%, ranging from 7.4% in the South West to 11.1% in the NorthCentral. It was lowest in Adamawa State (0%), while Enugu State had the highest (32.2%). Missed opportunities for PMTCT among women attending ANC in Nigeria occur at varying degrees across the states, with higher levels in the northern region.

Behavioral economics of substance use: Understanding and reducing harmful use during the COVID-19 pandemic

Behavioral economic research demonstrates that alcohol and drug consumption is (a) an inverse function of constraints on access to the substance and (b) a direct function of constraints on access to alternative rewards. Physical distancing interventions and economic consequences of the COVID-19 pandemic have resulted in unprecedented reductions in many of the constraints on substance use and in critical evolutionarily salient sources of alternative reward, such as social interaction, physical activity, leisure activities and hobbies, and academic and occupational pursuits. Thus, behavioral economics suggests that the pandemic and necessary public health response have created a "perfect storm" for exacerbation of individual-level and population-level substance use problems and also points to multilevel intervention strategies. We summarize this perspective and research by highlighting 3 critical behavioral processes that will influence drug and alcohol consumption. First, the sudden absence of many effective constraints on substance use (work, school, community, or service obligations) will reduce the actual and perceived cost of use. Second, physical distancing measures will reduce the availability, and increase the cost, of many rewarding substance-free activities and commodities. Third, increased uncertainty around current and future events increases discounting of delayed rewards. These effects will be especially pernicious among populations with existing health disparities. Next, we outline interventions suggested by behavioral economics to mitigate the impact of COVID-19 on substance use that are aimed at increasing perceived costs of use; increasing access to substance-free activities, including treatment; and lengthening the timeframe for behavioral allocation and altering environmental contexts to promote healthy choices. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Barriers to uptaking HIV testing among pregnant women attending antenatal clinics in low- and middle-income countries: A systematic review of qualitative findings

BACKGROUND

Human immunodeficiency virus (HIV) testing is a gateway to HIV treatment, care and preventive services for pregnant women attending antenatal clinics. Despite this, uptake of HIV testing is not optimal among pregnant women in many low- and middle-income countries (LMICs) and it could negatively impact the effectiveness of prevention of mother-to-child transmission of HIV programs.

AIM

To understand the factors that hinder the uptake of HIV testing among pregnant women attending antenatal clinics in LMICs.

MATERIALS AND METHODS

A systematic search of the CINAHL, EMBASE, JSTOR, Medline, PubMed and Web of Science electronic databases was performed. We limited the search to peer-reviewed qualitative studies including mixed method studies. The titles and abstracts of the retrieved publications were screened for relevance then information was extracted.

RESULTS

Our search yielded 2179 citations, out of which 312 full-text articles were reviewed and 22 studies that met the eligibility criteria were included in this review. We found that a lack of HIV testing kits, poor health infrastructure and shortage of healthcare workers were the main health system-related factors. Poor HIV knowledge, fear of HIV test results, HIV-related stigma and social exclusion negatively influenced pregnant women's decision to be tested for HIV.

CONCLUSION

This review has identified that pregnant women faced a wide range of health system, individual, social and lack of women's empowerment related challenges that negatively influenced the uptake of HIV testing among pregnant women in LMICs. Our findings would be useful in developing strategies to overcome barriers that could enhance the uptake of HIV testing among pregnant women.

Coverage of HIV testing among pregnant women in Nigeria: progress, challenges and opportunities

OBJECTIVE

This study assessed the progress, opportunities and challenges in scaling up of HIV testing for pregnant women in Nigeria.

METHODS

Data were retrieved from the 2016-2017 fifth multiple cluster survey. Adjusted and unadjusted logistic regression models were used to examine demographic factors associated with HIV testing while controlling for geopolitical zones.

RESULTS

At the population level, the coverage of HIV testing among pregnant women increased by 10% points from 32.8 to 42.7% between 2013 and 2017. Also, the coverage of antenatal HIV testing grew by 20 points, from 50.1 to 70.5% over the period. However, women were still more likely to be tested for HIV during pregnancy if they were older than 24 years [adjusted odds ratio (AOR) 1.33, 95% CI 1.04-1.69], had higher education [AOR 6.94, 95% CI 5.07-9.49], resided in urban areas [AOR 1.26, 95% CI 1.07, 1.50] and belong to richest wealth quintile [AOR 7.43, 95% CI 5.72-9.66].

CONCLUSION

Our findings suggest that progress has been made in scaling up of antenatal coverage of HIV testing. However, the level of HIV testing during pregnancy remains low and far below the 95% national target. Appropriate interventions are needed in resource-poor communities where antenatal care utilization is very low.

Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa

BACKGROUND

We investigated if initiating preventive care against HIV vertical transmission by antenatal HIV screening is independent of the patients' source of financial reimbursement for the care received in sub-Saharan Africa (SSA).

METHODS

Using information from the WHO's Global Health Expenditure Database and the Demographic Health Surveys Database for 27 sub-Saharan countries, we used Spearman's correlation and adjusted survey logistic regression to determine the potential relationship between enrollment in health insurance and the likelihood that expectant mothers would be offered antenatal HIV screening.

RESULTS

We found that expectant mothers covered by health insurance were more than twice as likely to be offered antenatal screening for HIV compared to the uninsured. The likelihood differed by the type of insurance plan the expectant mother carried.

DISCUSSION

Health insurance is more of a financial tool that this study finds to be necessary to boost the uptake of preventive and therapeutic HIV care in SSA.

CONCLUSION

The ensuing disparity in receiving proper care could hinder the goals of 90-90-90 and the forthcoming 95-95-95 plan in SSA.

Uptake of provider-initiated HIV and syphilis testing among heterosexual STD clinic patients in Guangdong, China: results from a cross-sectional study

OBJECTIVES

Underscreening of HIV and syphilis in clinical settings is pervasive in resource-constrained settings. Heavy patient loads and competing health priorities in these settings inhibit provider's ability to meet screening coverage targets. The objective of this study was to examine determinants of provider-initiated HIV and syphilis testing uptake at sexually transmitted disease (STD) clinics in China.

DESIGN

A cross-sectional study was performed between July 2016 and December 2016.

SETTING

Seven STD clinics in Guangdong Province, China.

PARTICIPANTS

Heterosexual STD clinic patients met the inclusion criteria, regardless of their interest in receiving HIV or syphilis testing.

OUTCOME MEASURES

The syphilis and HIV testing uptake determined by patient receipt of results.

RESULTS

A total of 1943 individuals were recruited in this study. Among those participants, 60.6% (1177/1943) and 74.3% (1443/1943) conducted HIV testing and syphilis testing during the study, respectively, of whom, 2.2% (26/1177) and 21.5% (310/1443) were found to be HIV-positive and syphilis-positive, respectively. The most common reason for rejecting HIV and syphilis testing was a low self-perceived risk of HIV and syphilis infection. After adjusting for covariates, condom use in the last sexual act, consistent condom use in the last 6 months, having paid sex in the last 6 months and having received any kind of HIV/STD-related knowledge during the last 12 years were positively associated with both HIV and syphilis testing uptake.

CONCLUSIONS

The low-level of HIV and syphilis testing uptake, alongside with the high-level of engagement in risky sexual behaviours among heterosexual STD clinic patients, warranted a more targeted and intensive behavioural interventions to promote HIV and syphilis testing in this population.

Understanding the role of interpersonal violence in assisted partner notification for HIV: a mixed-methods study in refugee settlements in West Nile Uganda

BACKGROUND

Assisted partner notification (APN) for HIV was introduced in refugee settlements in West Nile Uganda in 2018 to facilitate testing of sexual partners. While APN is an effective strategy recommended by the World Health Organization, its safety has not been evaluated in a refugee settlement context in which participants have high prior exposure to interpersonal violence. The extent to which interpersonal violence influences APN utilization and the frequency with which post-APN interpersonal violence occurs remains unknown.

METHODS

To explore the relationship between APN and interpersonal violence, a cross-sectional mixed-methods study was conducted at 11 health centers in refugee settlements in West Nile Uganda. Routinely collected index client and sexual partner data were extracted from APN registers and semi-structured interviews were conducted with health workers.

RESULTS

Through APN, 1126 partners of 882 distinct index clients were identified. For 8% (75/958) of partners, index clients reported a history of intimate partner violence (IPV). For 20% (226/1126) of partners, index clients were screened for post-APN IPV; 8 cases were reported of which 88% (7/8) concerned partners with whom index clients reported prior history of IPV. In qualitative interviews (N = 32), health workers reported HIV disclosure-related physical, sexual and psychological violence and deprivation or neglect. Incidents of disclosure-related violence against health workers and dependents of index clients were also reported. Fear of disclosure-related violence was identified as a major barrier to APN that prevents index clients from listing sexual partners.

CONCLUSIONS

Incidents of interpersonal violence have been reported following HIV-disclosure and fear of interpersonal violence strongly influences APN participation. Addressing HIV perception and stigma may contribute to APN uptake and program safety. Prospective research on interpersonal violence involving index clients and sexual partners in refugee settlements is needed to facilitate safe engagement in APN for this vulnerable population.

The declining trend of HIV-Infection among pregnant women in Cameroon infers an epidemic decline in the general population

Background

HIV remains a generalised epidemic in Cameroon, with regular sentinel surveillance surveys (SSS) conducted among pregnant women to monitor the epidemiological dynamics, and for strategic policy making. Our main objective was to actualise data on HIV epidemiology, and compare the trends overtime among pregnant women versus data from the general population in Cameroon.

Methods

Sentinel surveillance was conducted in 2016 among pregnant women in the 10 regions (60 sites) of Cameroon, targeting 7,000 first antenatal care (ANC-1) attendees (4,000 in urban; 3,000 in rural). HIV testing was done following the serial national algorithm at the National Public Health Laboratory. Results of 2016 were compared with 2009 and 2012 dataset, alongside reports from the general population; with p < 0.05 considered statistical significant.

Findings

A total of 6,859 ANC-1 (97.99% sampling) were enrolled in 2016, with 99.19% (6,513/6,566) acceptability for HIV testing; similar to performances in 2009 and 2012 (>99%). National prevalence of HIV was 5.70% (389/6,819), similar between urban (5.58%) and rural (5.87%) settings. HIV prevalence among pregnant women declined significantly from 2009 (7.6%), 2012 (7.8%) to 2016 (5.7%), p < 0.0001; with a similar declining trend in the general population: from 2004 (5.5%), 2011 (4.3%) to 2017 (3.4%), p < 0.0001. Difference between SSS and the population-based survey was non-significant (r = 0.6; p = 0.285). Following geographical settings, HIV prevalence was higher in urban vs. rural settings from 2009-2012 (p < 0.0001), followed by similar rates in 2016. Early-age infection (15–24 years) decreased from 6.7% in 2009 to 3.4% in 2016, with remarkable declines in new infections within the age ranges 15–19 years (5.1%–1.57%) and 20–24 years (7.8%–4.39%).

Interpretation

With high acceptability in HIV testing, the prevalence of HIV-infection through SSS indicates a declining but generalised epidemic among pregnant women in Cameroon. Of note, as the declining prevalence among pregnant women also reflects an epidemic reduction in the general population, SSS represents an efficient strategy to understand the dynamics of HIV epidemics in the general Cameroonian population, pending validation by periodic population surveys.

Optimal defaults as a strategy to improve selections from children's menus in full-service theme park dining

An "optimal default" refers to a pre-selected default option that promotes an outcome intended to be favorable to the individual and/or society at large. Optimal defaults preserve the decision-maker's ability to opt-out of the default and choose an alternative option. This behavioral economics strategy has been shown to nudge both child and adult consumers toward healthier food selections. Full-service restaurants with children's menus are key settings for implementing this approach. The current field study manipulated children's menus at two theme park restaurants, testing the effects of three different item presentations (i.e., lower-energy-dense default, standard fare default, and free array menus). Each menu was presented to consumers for 1 week at a time, in random order. Full choice was preserved with all menu options appearing across conditions, with non-default items listed as available upon request. The restaurants tracked food orders during each of the three weeks. Results showed that positioning lower-energy-dense foods as default menu choices increased the likelihood of lower-energy-dense menu selections and decreased the likelihood that customers would "opt-out" for standard fare. There were also significant differences in total caloric value of food ordered across conditions, with the optimal default menu condition promoting the lowest potential energy intake. This study further supports the effectiveness of optimal defaults to increase healthy food choices for children.

Factors Affecting Voluntary HIV Testing Among General Adult Population: A Cross-Sectional Study in Sarawak, Malaysia

Objective: Voluntary HIV testing is one of the key strategies in the HIV/AIDS prevention and control program. New National Strategic Plan for 2016-2030 in Malaysia, adapt three zeros viz. 'zero new infections of HIV/AIDS, zero discrimination and zero AIDS-related deaths'. This study aimed to determine the predictors of voluntary HIV testing in Sarawak. Materials and methods: A cross-sectional study was conducted with a total of 900 respondents (450 males and 450 females) from the state of Sarawak, aged 18 years and above, who were selected by gender-stratified multistage cluster sampling. Data were obtained by face-to-face interview using a pretested questionnaire. Binary logistic regression analysis was done to determine the potential predictors for voluntary HIV testing. Results: The prevalence of HIV testing was higher among female respondents (26%) compared to male respondents (14.2%), and the difference was statistically significant (p < 0.001). Binary logistic regression analysis revealed that household income more than MYR 1501 (p = 0.009), not living with a partner (p < 0.001) and discussion on HIV/AIDS (p = 0.019) appeared to be predictors for the male respondents, while, ethnicity was statistically significant for female respondents (p < 0.001). Conclusion: The utilisation of HIV testing was low in both males and females. Thus, the finding of this study could be considered when designing HIV education and screening program in Sarawak.

Utilization of Provider-Initiated HIV Testing and Counseling as an Intervention for PMTCT Services Among Pregnant Women Attending Antenatal Clinic in a Teaching Hospital in Ethiopia

Purpose: Little is known about acceptance of provider-initiated HIV testing and counseling (PICT) as an intervention for prevention of mother to child transmission of HIV (PMTCT) in many parts of sub-Saharan Africa including Ethiopia. This study aimed at assessing the utilization and acceptance rate of PICT as an intervention for PMTCT among pregnant women attending University of Gondar referral and teaching hospital (UoGRTH), Ethiopia.

Methods: A hospital-based cross-sectional study was conducted on 364 pregnant women attending antenatal care clinic at UoGRTH through an interviewer-administered questionnaire. Frequencies, means, and percentages were used to report different variables. Univariate analysis and multivariate logistic regression analysis were used to come up with factors associated with acceptance of PICT services.

Results: Out of 364 respondents, 298 330 (81.7%) of them accepted provider-initiated HIV testing and counseling. Rural residency (AOR: 364, 95% CI: 2.17–6.34), higher educational status (AOR: 3.15, 95% CI: 1.86–6.82), planning of HIV test disclosure to male partners (AOR: 7.81, 95% CI: 3.17–13.14), and a higher average monthly income (AOR: 4.01, 95% CI: 2.32–7.61) were found to be strong predictors of acceptance of provider-initiated HIV testing and counseling.

Conclusions: The present study revealed a higher rate of acceptance of PICT among pregnant women. Enhancing access to and consistent use of antenatal care service among pregnant women and encouraging the active involvement of male partners are recommended to further increase the uptake of provider-initiated HIV testing and counseling.

Antenatal care presentation and engagement in the context of sex work: exploring barriers to care for sex worker mothers in South Africa

BACKGROUND

Late presentation combined with limited engagement in antenatal care (ANC) increases risk of vertical transmission among mothers living with HIV. Female sex workers (FSW) have more than four times greater burden of HIV than other women of reproductive age in South Africa and the majority of FSW are mothers. For mothers who sell sex and are at increased HIV acquisition risk, timely and routine ANC seeking is especially vital for prevention of vertical transmission. This study represents a mixed-methods study with FSW in Port Elizabeth, South Africa, to characterize factors influencing ANC seeking behaviors in a high HIV prevalence context.

METHODS

FSW (n = 410) were recruited into a cross-sectional study through respondent-driven sampling between October 2014 and April 2015 and tested for HIV and pregnancy. A sub-sample of pregnant and postpartum women (n = 30) were invited to participate in in-depth interviews (IDIs) to explore their current or most recent pregnancy experiences. IDIs were coded using a modified grounded theory approach and descriptive analyses assessed the frequency of themes explored in the qualitative analysis among the quantitative sample.

RESULTS

In the quantitative survey, 77% of FSW were mothers (313/410); of these, two-thirds were living with HIV (212/313) and 40% reported being on antiretroviral therapy (ART) (84/212). FSW in the qualitative sub-sample reported unintended pregnancies with clients due to inconsistent contraceptive use; many reported discovering their unintended pregnancies between 4 and 7 months of gestation. FSW attributed delayed ANC seeking and ART initiation in the second or third trimesters to late pregnancy detection. Other factors limiting engagement in ANC included substance and alcohol use and discontent with previous healthcare-related experiences.

CONCLUSIONS

Late pregnancy discovery, primarily because pregnancies were unplanned, contributed to late ANC presentation and delayed ART initiation, increasing risks of vertical HIV transmission. Given limited ART coverage among participants, addressing the broader sexual and reproductive health and rights needs of mothers who sell sex has important implications for preventing vertical transmission of HIV. Integrating comprehensive family planning services into FSW programming, as well as providing active linkage to ANC services may reduce barriers to accessing timely ANC, decreasing risks of vertical transmission.

Uptake and determinants for HIV postpartum re-testing among mothers with prenatal negative status in Njombe region, Tanzania

Background

Uptake of Human Immunodeficiency Virus (HIV) re-testing among postnatal mothers who had previously tested HIV-negative is crucial for the detection of recent seroconverters who are likely to have high plasma viral loads and an increased risk of mother-to-child HIV transmission. Tanzania set a target of 90% re-testing of pregnant mothers who had tested negative during the first test. However, there is no statistics on the implementation, coverage and the factors determining re-testing among pregnant women in Tanzania. This study determined the proportion of newly-delivered, previously HIV-negative mothers who returned for HIV re-testing, and assessed the determinants of re-testing in Njombe Region in Tanzania.

Methods

A cross-sectional study was conducted in four health facilities in Njombe and Wanging’ombe districts during December 2015–June 2016. All newly-delivered mothers (≤7 days from delivery) presenting at health facilities and who had previously tested HIV-negative during pregnancy were included. A structured questionnaire was used to collect data on the determinants for re-testing. Records on the previous HIV testing was verified using antenatal clinic card. A multiple logistic regression model was used to calculate the adjusted odds ratio (AOR) with their 95% confidence intervals (CI) to quantify the association.

Results

Of 668 mothers (median age = 25 years) enrolled, 203 (30.4%) were re-tested for their HIV status. Among these, 27 (13.3%) tested positive. Significant predictors for HIV re-testing were socio-demographic factors including having at least a secondary education [AOR = 1.9, 95% CI: 1.25–3.02] and being employed [AOR = 2.1, 95% CI: 1.06–4.34]; personal and behavioural factors, reporting symptoms of sexually transmitted infections [AOR = 4.9, 95% CI: 2.15–6.14] and use of condoms during intercourse [AOR = 1.7, 95% CI: 1.13–2.71]. Significant health system factors were having ≥4 ANC visits [AOR = 1.8, 95% CI: 1.21–2.69] and perceiving good quality of HIV counselling and testing service at the first ANC visit [AOR = 2.14, 95% CI: 1.53–3.04].

Conclusion

Uptake of the HIV re-testing was lower than the national target. Education level, employment status, having ≥4 ANC visits, reporting sexually-transmitted infections, condom use, and good perception of HIV tests were significant factors increased uptake for re-testing. Identified factors should be incorporated in the Prevention of the Mother-to-Child Transmission (PMTCT) programme strategies to prevent HIV infection in new-borns.

Predictors of postpartum HIV care engagement for women enrolled in prevention of mother-to-child transmission (PMTCT) programs in Tanzania

Prevention of mother-to-child transmission of HIV (PMTCT) is a foundational component of a comprehensive HIV treatment program. In addition to preventing vertical transmission to children, PMTCT is an important catch-point for universal test-and-treat strategies that can reduce community viral load and slow the epidemic. However, systematic reviews suggest that care engagement in PMTCT programs is sub-optimal. This study enrolled a cohort of 200 women initiating PMTCT in Kilimanjaro, Tanzania, and followed them to assess HIV care engagement and associated factors. Six months after delivery, 42/200 (21%) of participants were identified as having poor care engagement, defined as HIV RNA >200 copies/mL or, if viral load was unavailable, being lost-to-follow-up in the clinical records or self-reporting being out of care. In a multivariable risk factor analysis, younger women were more likely to have poor postpartum care engagement; with each year of age, women were 7% less likely to have poor care engagement (aRR: 0.93; 95% CI: 0.89, 0.98). Additionally, women who had told at least one person about their HIV status were 47% less likely to have poor care engagement (aRR: .53; 95% CI: 0.29, 0.97). Among women who entered antenatal care with an established HIV diagnosis, those who were pregnant for the first time had increased risk of poor care engagement (aRR 4.16; 95% CI 1.53, 11.28). The findings suggest that care engagement remains a concern in PMTCT programs, and must be addressed to realize the goals of PMTCT. Comprehensive counseling on HIV disclosure, along with community-based stigma reduction programs to provide a supportive environment for people living with HIV, are crucial to address barriers to care engagement and support long-term treatment. Women presenting to antenatal care with an established HIV status require support for care engagement during the crucial period surrounding childbirth, particularly those pregnant for the first time.

Effect of default menus on food selection and consumption in a college dining hall simulation study

OBJECTIVE

To test an obesity prevention strategy derived from behavioural economics (optimal defaults plus delay), focused on changing the college dining hall service method.

DESIGN

After a uniform pre-load, participants attended an experimental lunch in groups randomized to one of three conditions: a nutrient-dense, lower-fat/energy lunch as an optimal default (OD); a less-nutrient-dense, higher-fat/energy lunch as a suboptimal default (SD); or a free array (FA) lunch. In the OD condition, students were presented a menu depicting healthier vegetarian and omnivore foods as default, with opt-out alternatives (SD menu) available on request with a 15 min wait. In the SD condition, the same menu format was used with the positioning of food items switched. In the FA condition, all choices were presented in uniform fonts and were available immediately.

SETTING

Private rooms designed to provide a small version of a college dining hall, on two campuses of a Northeastern US university.

SUBJECTS

First-year college students (n 129).

RESULTS

There was a significant main effect for condition on percentage of optimal choices selected, with 94 % of food choices in the OD condition optimal, 47 % in the FA condition optimal and none in the SD condition optimal. Similarly, energy intake for those in the SD condition significantly exceeded that in the FA condition, which exceeded that in the OD condition.

CONCLUSIONS

Presenting menu items as optimal defaults with a delay had a significant impact on choice and consumption, suggesting that further research into its long-term applicability is warranted.

The Differential Effects of an Opt-Out HIV Testing Policy for Pregnant Women in Ethiopia When Accounting for Stigma: Secondary Analysis of DHS Data

Individual factors associated with HIV testing have been studied across multiple populations; however, testing is not just an individual-level phenomenon. This secondary analysis of 2005 and 2011 Ethiopia Demographic and Health Survey data was conducted to determine the extent to which the 2007 institution of an opt-out policy of HIV testing during antenatal care increased testing among women, and whether effects differed by women's stigmatizing beliefs about HIV. A logit model with interaction between pre-/post-policy year and policy exposure (birth in the past year) was used to estimate the increased probability of past-year testing, which may be attributable to the policy. Results suggested the policy contributed to a nine-point increase in the probability of testing (95% CI 0.06-0.13, p < 0.0001). A three-way interaction was used to compare the effects of exposure to the policy among women holding higher and lower HIV stigmatizing beliefs. The increase in the probability of past-year testing was 16 percentage points greater among women with lower stigmatizing beliefs (95% CI 0.06-0.27, p = 0.002). Women with higher stigmatizing beliefs were less likely to report attending antenatal care (ANC), testing at their last ANC visit, or being offered a test at their last ANC visit. We encourage researchers and practitioners to explore interventions that operate at multiple levels of socio-ecological spheres of influence, addressing both stigma and structural barriers to testing, in order to achieve the greatest results in preventing HIV.

Community engagement practices in Southern Africa: Review and thematic synthesis of studies done in Botswana, Zimbabwe and South Africa

Community Engagement (CE) is intended to enhance the participation of community stakeholders in research. CE is usually mentioned in publications as researchers discuss how they carried out community entry, consent and retained study participants but the actual CE activities are not always well documented. This paper reviews CE strategies employed in health research in Botswana, South Africa and Zimbabwe with reference to the development of a CE strategy for a multi-centre study to be conducted in these countries. The search was conducted using JANE (Journal/Author Name Estimator), Google Scholar and PubMed with known institutions and researchers providing context-specific material. The final synthesis includes 35 publications, 2 reports and 2 abstracts. There is evidence of CE being practiced in health research and eight closely related CE strategies were revealed. We conclude that since communities are heterogeneous and unique, CE activities will not have similar results in different settings. Even though there was insufficient evidence to determine which CE strategy is most effective, the review provides sufficient information to develop a CE strategy for a multi-centre study using the various strategies and activities described.

"If my husband leaves me, I will go home and suffer, so better cling to him and hide this thing": The influence of gender on Option B+ prevention of mother-to-child transmission participation in Malawi and Uganda

The role of gender in prevention of mother-to-child transmission (PMTCT) participation under Option B+ has not been adequately studied, but it is critical for reducing losses to follow-up. This study used qualitative methods to examine the interplay of gender and individual, interpersonal, health system, and community factors that contribute to PMTCT participation in Malawi and Uganda. We conducted in-depth interviews with women in PMTCT, women lost to follow-up, government health workers, and stakeholders at organizations supporting PMTCT as well as focus group discussions with men. We analyzed the data using thematic content analysis. We found many similarities in key themes across respondent groups and between the two countries. The main facilitators of PMTCT participation were knowledge of the health benefits of ART, social support, and self-efficacy. The main barriers were fear of HIV disclosure and stigma and lack of social support, male involvement, self-efficacy, and agency. Under Option B+, women learn about their HIV status and start lifelong ART on the same day, before they have a chance to talk to their husbands or families. Respondents explained that very few husbands accompanied their wives to the clinic, because they felt it was a female space and were worried that others would think their wives were controlling them. Many respondents said women fear disclosing, because they fear HIV stigma as well as the risk of divorce and loss of economic support. If women do not disclose, it is difficult for them to participate in PMTCT in secret. If they do disclose, they must abide by their husbands' decisions about their PMTCT participation, and some husbands are unsupportive or actively discouraging. To improve PMTCT participation, Ministries of Health should use evidence-based strategies to address HIV stigma, challenges related to disclosure, insufficient social support and male involvement, and underlying gender inequality.

Can Policy Interventions Affect HIV-Related Behaviors? A Systematic Review of the Evidence from Low- and Middle-Income Countries

In their response to HIV, many countries have adopted and enacted policies to reduce transmission and increase HIV-related service use. Theoretically, policy-level interventions for HIV prevention have the potential to improve health behavior outcomes. These policy interventions vary in their scale, from relatively minor changes in clinical policy to major national legal initiatives. Assessing the effectiveness of HIV policy interventions is a challenging undertaking. While many policies exist and guide HIV programmes, relatively few have specifically been evaluated for their effects on reducing HIV risk taking or increasing HIV health-seeking behaviors. Thus, questions on the effectiveness of policy interventions to prevent HIV and change HIV-related risk behaviors remain largely unanswered. To address this current gap in the literature, we systematically reviewed the existing evidence on the effect of HIV policy interventions on changing HIV-related behaviors in low-and middle-income countries.

Perceptions and experiences of pregnant women about routine HIV testing and counselling in Ghimbi town, Ethiopia: a qualitative study

BACKGROUND

Ethiopia has implemented routine HIV testing and counselling using a provider initiated HIV testing ('opt-out' approach) to achieve high coverage of testing and prevention of mother-to-child transmission of HIV. However, women's perceptions and experiences with this approach have not been well studied. We conducted a qualitative study to explore pregnant women's perceptions and experiences of routine HIV testing and counselling in Ghimbi town, Ethiopia, in May 2013. In-depth interviews were held with 28 women tested for HIV at antenatal clinics (ANC), as well as four health workers involved in routine HIV testing and counselling. Data were analyzed using the content analysis approach.

RESULTS

We found that most women perceived routine HIV testing and counselling beneficial for women as well as unborn babies. Some women perceived HIV testing as compulsory and a prerequisite to receive delivery care services. On the other hand, health workers reported that they try to emphasise the importance HIV testing during pre-test counselling in order to gain women's acceptance. However, both health workers and ANC clients perceived that the pre-test counselling was limited.

CONCLUSIONS

Routine HIV testing and counselling during pregnancy is well acceptable among pregnant women in the study setting. However, there is a sense of obligation as women felt the HIV testing is a pre-requisite for delivery services. This may be related to the limited pre-test counselling. There is a need to strengthen pre-test counselling to ensure that HIV testing is implemented in a way that ensures pregnant women's autonomy and maximize opportunities for primary prevention of HIV.

Feasibility Study of HIV Sentinel Surveillance using PMTCT data in Cameroon: from Scientific Success to Programmatic Failure

Background

In low-income countries (LICs), HIV sentinel surveillance surveys (HIV-SSS) are recommended in between two demographic and health surveys, due to low-cost than the latter. Using the classical unlinked anonymous testing (UAT), HIV-SSS among pregnant women raised certain ethical and financial challenges. We therefore aimed at evaluating how to use prevention of mother-to-child transmission of HIV (PMTCT) routine data as an alternative approach for HIV-SSS in LICs.

Methods

A survey conducted through 2012 among first antenatal-care attendees (ANC1) in the ten regions of Cameroon. HIV testing was performed at PMTCT clinics as-per the national serial algorithm (rapid test), and PMTCT site laboratory (PMTCT-SL) performances were evaluated by comparison with results of the national reference laboratory (NRL), determined as the reference standard.

Results

Acceptance rate for HIV testing was 99%, for a total of 6521 ANC1 (49 · 3% aged 15–24) enrolled nationwide. Among 6103 eligible ANC1, sensitivity (using NRL testing as the reference standard) was 81 · 2%, ranging from 58 · 8% (South region) to 100% (West region); thus implying that 18 · 8% HIV-infected ANC1 declared HIV-negative at the PMTCT-SL were positive from NRL-results. Specificity was 99 · 3%, without significant disparity across sites. At population-level, this implies that every year in Cameroon, ~2,500 HIV-infected women are wrongly declared seronegative, while ~1,000 are wrongly declared seropositive. Only 44 · 4% (16/36) of evaluated laboratories reached the quality target of 80%.

Conclusions

The study identified weaknesses in routine PMTCT HIV testing. As Cameroon transitions to using routine PMTCT data for HIV-SSS among pregnant women, there is need in optimizing quality system to ensure robust routine HIV testing for programmatic and surveillance purposes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-2119-5) contains supplementary material, which is available to authorized users.

Clinical outcomes of routine opt-out antenatal human immunodeficiency virus screening: a systematic review

AIMS AND OBJECTIVES

To evaluate the clinical outcome of routine screening of human immunodeficiency virus in antenatal clinic settings.

BACKGROUND

Despite the growing advances in human immunodeficiency virus management, nearly 30% of the estimated 1·5 million seropositive pregnant women are undiagnosed. Routine opt-out testing is a strategy endorsed by the World Health Organization in to increase testing rates in clinical settings.

DESIGN

A systematic review of relevant published literature.

METHODS

A comprehensive electronic search for relevant studies in Science Direct, MEDLINE, SCOPUS, CINAHL and PubMed was conducted with search terms (Box 2). Hand searches were also conducted for additional resources. There were no geographical restrictions. Searches were restricted to English language and studies conducted between 1998-2015; totaling 1097 were retrieved and carefully appraised for review. Eighteen studies were eligible for review: eight from Africa, five from the United States, three from Europe, one from Australia and one from Asia.

RESULTS

Fourteen studies reported increases in human immunodeficiency virus testing rate. Following the introduction of routine testing, human immunodeficiency virus testing rates increased from values ranging from 68-99·9% with median value of 88%. The comparison studies reported testing uptake of 22-93·5% with median value of 59%. Maternal human immunodeficiency virus case detection rates nearly doubled following adoption of routine testing at values of 99 and 45% during opt-in. Linkage to treatment and care for prevention of vertical transmission was reported on six studies, and results ranged between 12·9-77·2%.

CONCLUSION

The findings show that irrespective of human immunodeficiency virus epidemiological scenarios, routine testing gave more women opportunity to learn their human immunodeficiency virus status and take measures for prevention of mother-to-child transmission of human immunodeficiency virus. Future studies should focus on identifying strategies to improving linkages to treatment and care for prevention of vertical transmission.

RELEVANCE TO CLINICAL PRACTICE

Understanding the contributions of Routine opt-out testing in antenatal clinic would help practitioners adopt the novel testing model for more mothers to learn their human immunodeficiency virus status for prevention of mother-to-child transmission.

Sustaining the future of HIV counselling to reach 90-90-90: a regional country analysis

Introduction

Counselling services are recommended by the World Health Organization and have been partially adopted by national HIV guidelines. In settings with a high HIV burden, patient education and counselling is often performed by lay workers, mainly supported with international funding. There are few examples where ministries of health have been able to absorb lay counsellors into their health systems or otherwise sustain their work. We document the role of lay cadres involved in HIV testing and counselling and adherence support and discuss approaches to sustainability.

Methods

We focused on a purposive sample of eight sub-Saharan African countries where Médecins Sans Frontières supports HIV programmes: Guinea, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe. We reviewed both published and grey literature, including national policies and donor proposals, and interviewed key informants, including relevant government staff, donors and non-governmental organizations.

Results and discussion

Lay counsellors play a critical role in scaling up HIV services and addressing gaps in the HIV testing and treatment cascade by providing HIV testing and counselling and adherence support at both the facility and community levels. Countries have taken various steps in recognizing lay counsellors, including harmonizing training, job descriptions and support structures. However, formal integration of this cadre into national health systems is limited, as lay counsellors are usually not included in national strategies or budgeting.

Conclusions

The current trend of reduced donor support for lay counsellors, combined with lack of national prioritization, threatens the sustainability of this cadre and thereby quality HIV service delivery.

Lost opportunities to identify and treat HIV-positive patients: results from a baseline assessment of provider-initiated HIV testing and counselling (PITC) in Malawi

OBJECTIVE

To assess implementation of provider-initiated testing and counselling (PITC) for HIV in Malawi.

METHODS

A review of PITC practices within 118 departments in 12 Ministry of Health (MoH) facilities across Malawi was conducted. Information on PITC practices was collected via a health facility survey. Data describing patient visits and HIV tests were abstracted from routinely collected programme data.

RESULTS

Reported PITC practices were highly variable. Most providers practiced symptom-based PITC. Antenatal clinics and maternity wards reported widespread use of routine opt-out PITC. In 2014, there was approximately 1 HIV test for every 15 clinic visits. HIV status was ascertained in 94.3% (5293/5615) of patients at tuberculosis clinics, 92.6% (30,675/33,142) of patients at antenatal clinics and 49.4% (6871/13,914) of patients at sexually transmitted infection clinics. Reported challenges to delivering PITC included test kit shortages (71/71 providers), insufficient physical space (58/71) and inadequate number of HIV counsellors (32/71) while providers from inpatient units cited the inability to test on weekends.

CONCLUSIONS

Various models of PITC currently exist at MoH facilities in Malawi. Only antenatal and maternity clinics demonstrated high rates of routine opt-out PITC. The low ratio of facility visits to HIV tests suggests missed opportunities for HIV testing. However, the high proportion of patients at TB and antenatal clinics with known HIV status suggests that routine PITC is feasible. These results underscore the need to develop clear, standardised PITC policy and protocols, and to address obstacles of limited health commodities, infrastructure and human resources.

Factors Associated with Ever Being HIV-Tested in Zimbabwe: An Extended Analysis of the Zimbabwe Demographic and Health Survey (2010-2011)

INTRODUCTION

Zimbabwe has a high human immunodeficiency virus (HIV) burden. It is therefore important to scale up HIV-testing and counseling (HTC) as a gateway to HIV prevention, treatment and care.

OBJECTIVE

To determine factors associated with being HIV-tested among adult men and women in Zimbabwe.

METHODS

Secondary analysis was done using data from 7,313 women and 6,584 men who completed interviewer-administered questionnaires and provided blood specimens for HIV testing during the Zimbabwe Demographic and Health Survey (ZDHS) 2010-11. Factors associated with ever being HIV-tested were determined using multivariate logistic regression.

RESULTS

HIV-testing was higher among women compared to men (61% versus 39%). HIV-infected respondents were more likely to be tested compared to those who were HIV-negative for both men [adjusted odds ratio (AOR) = 1.53; 95% confidence interval (CI) (1.27-1.84)] and women [AOR = 1.42; 95% CI (1.20-1.69)]. However, only 55% and 74% of these HIV-infected men and women respectively had ever been tested. Among women, visiting antenatal care (ANC) [AOR = 5.48, 95% CI (4.08-7.36)] was the most significant predictor of being tested whilst a novel finding for men was higher odds of testing among those reporting a sexually transmitted infection (STI) in the past 12 months [AOR = 1.86, 95%CI (1.26-2.74)]. Among men, the odds of ever being tested increased with age ≥ 20 years, particularly those 45-49 years [AOR = 4.21; 95% CI (2.74-6.48)] whilst for women testing was highest among those aged 25-29 years [AOR = 2.01; 95% CI (1.63-2.48)]. Other significant factors for both sexes were increasing education level, higher wealth status and currently/formerly being in union.

CONCLUSIONS

There remains a high proportion of undiagnosed HIV-infected persons and hence there is a need for innovative strategies aimed at increasing HIV-testing, particularly for men and in lower-income and lower-educated populations. Promotion of STI services can be an important gateway for testing more men whilst ANC still remains an important option for HIV-testing among pregnant women.

Acceptability of provider-initiated HIV testing as an intervention for prevention of mother to child transmission of HIV and associated factors among pregnant women attending at Public Health Facilities in Assosa town, Northwest Ethiopia

BACKGROUND

Despite more efforts for prevention of mother to child HIV transmission, still there are problems with provider-initiated HIV testing. This study was done to assess the acceptance rate of provider-initiated HIV testing among antenatal care attendants and its associated factors.

METHODS

Institutions based cross sectional study with a sample size of 398 was conducted from February to March 2014 in two health facilities in Assosa town. Proportional allocation of the sample size of health facilities followed by systematic sampling method was done; data were collected using an interviewer administered questionnaire. Bivariate and multivariate regression analysis was employed using SPSS version 20.

RESULTS

A total of 386 pregnant women participated with response rate 97 % and 312 (80.8 %) of them accepted provider-initiated HIV testing. The odds of acceptance of provider-initiated HIV testing was higher among rural residents (AOR 4.04; 95 % CI 1.24-13.11) than urban. It was also higher among students (AOR 6.00; 95 % CI 1.45-24.75), merchants (AOR 4.43; 95 % CI 1.18-16.68) and employed women (AOR 2.15; 95 % CI 1.08-4.30) than housewives. Pregnant women who had no stigmatized attitude towards people living with HIV/AIDS were more likely to accept testing (AOR 3.54; 95 % CI 1.23-10.16) than who had a strong stigmatized attitude. In addition, those who planned to disclose their test results from their husbands were higher odd of acceptance (AOR 14.85; 95 % CI 4.60-47.94) than who secreted.

CONCLUSION

Acceptance of provider-initiated HIV testing among pregnant women attending for antenatal care services was relatively high. Mothers from urban residence, occupational satus being housewives, stigmatization and not having a plan to disclose the status of test results were negatively affect the acceptance of provider-initiated HIV testing. During counselling sessions, antenatal care providers should focus on barriers of provider-initiated HIV testing such as residence, occupational status, stigmatized attitudes and disclosure status of results of HIV tests.

Ethical issues surrounding the provider initiated opt--Out prenatal HIV screening practice in Sub-Saharan Africa: a literature review

Background

Prevention of mother to child transmission of HIV remains a key public health priority in most developing countries. The provider Initiated Opt – Out Prenatal HIV Screening Approach, recommended by the World Health Organization (WHO) lately has been adopted and translated into policy in most Sub – Saharan African countries. To better ascertain the ethical reasons for or against the use of this approach, we carried out a literature review of the ethics literature.

Methods

Papers published in English and French Languages between 1990 and 2015 from the following data bases were searched: Pubmed, Cochrane literature, Embase, Cinhal, Web of Science and Google Scholar. After screening from 302 identified relevant articles, 21 articles were retained for the critical review.

Discussion

Most authors considered this approach ethically justifiable due to its potential benefits to the mother, foetus and society (Beneficence). The breaching of respect for autonomy was considered acceptable on the grounds of libertarian paternalism. Most authors considered the Opt - Out approach to be less stigmatizing than the Opt - In. The main arguments against the Opt - Out approach were: non respect of patient autonomy, informed consent becoming a meaningless concept and the HIV test becoming compulsory, risk of losing trust in health care providers, neglect of social and psychological implications of doing an HIV test, risk of aggravation of stigma if all tested patients are not properly cared for and neglect of sociocultural peculiarities.

Conclusions

The Opt – Out approach could be counterproductive in case gender sensitive issues within the various sociocultural representations are neglected, and actions to offer holistic care to all women who shall potentially test positive for HIV were not effectively ascertained. The Provider Initiated Opt – Out Prenatal HIV Screening option remains ethically acceptable, but deserves caution, active monitoring and evaluation within the translation of this approach into to practice.

Women's willingness to be tested for human immunodeficiency virus during pregnancy: A review

Mother-to-child-transmission of human immunodeficiency virus (HIV) is a primary cause of pediatric infections with HIV. Many of these infections involve women who were not tested early enough in pregnancy, or who did not receive prevention services. HIV testing of pregnant women is considered to be one of the key strategies for preventing mother-to-child-transmission of HIV, but HIV testing rates among pregnant women in various countries remain suboptimal. Understanding the factors relating to women's willingness to be tested for HIV during pregnancy is critical for developing strategies to increase HIV testing rates among pregnant women. Extensive research points to various factors relating to women's willingness to be tested for HIV during pregnancy, and various recommendations aimed at improving testing rates among pregnant women have been suggested based on the research. In light of the goals set by the United Nations to reduce the rate of infants infected with HIV, it is necessary to summarize what is currently known regarding factors related to women's willingness to be tested for HIV during pregnancy. The purpose of this review is therefore to examine factors related to women's willingness to be tested for HIV during pregnancy, and to summarize recommendations for practice and further research.

Applying Choice Architecture Principles to Understand HIV Testing: Findings From Malawi and Zimbabwe

Improvements spearheaded by the World Health Organization in antenatal HIV counseling in sub-Saharan Africa from 2004 to 2011 have seen a parallel increase in HIV testing. We sought to determine the extent to which the use of choice architecture principles (one that introduces an opt-out option as the default) affect uptake of HIV testing, above and beyond individual-level attitudes and cognitions. Demographic and Health Survey data collected between 2004 and 2011 from Zimbabwe (N = 1,330) and Malawi (N = 4,043)--countries where over 10% of adults have HIV--were analyzed. We explored the influence of demographic variables, modes of knowledge about HIV, stigma against people living with HIV, attitudes about spousal abuse, and whether or not HIV testing had been offered during antenatal visits. Results demonstrated that, taking into account secular trends in higher testing rates, structural-level support was the strongest predictor of HIV testing above and beyond individual-level attitudes and cognitions.

Evaluating the effect of HIV prevention strategies on uptake of HIV counselling and testing among male most-at-risk-populations in Nigeria; a cross-sectional analysis

OBJECTIVE

The aim of this study was to evaluate the effects of three strategies in increasing uptake of HIV counselling and testing (HCT) among male most-at-risk-population (M-MARPs) using programmatic data.

DESIGN

HIV prevention strategies were evaluated in a cross-sectional analysis.

METHODS

Three HCT strategies were implemented between July 2009 and July 2012 among men who have sex with men (MSM) and people who inject drugs (PWIDs) in four states in Nigeria. The first strategy (S1), involved key opinion leaders (KOLs) who referred M-MARPs to health facilities for HCT. The second strategy (S2) involved KOLs referring M-MARPs to nearby mobile HCT teams while the third (S3) involved mobile M-MARPs peers conducting the HCT. χ(2) statistics were used to test for differences in the distribution of categorical variables across groups while logistic regression was used to measure the effect of the different strategies while controlling for confounding factors.

RESULTS

A total of 1988, 14 726 and 14 895 M-MARPs were offered HCT through S1, S2 and S3 strategies, respectively. Overall, S3 (13%) identified the highest proportion of HIV-positive M-MARPs compared with S1 (9%) and S2 (3%), p≤0.001. Also S3 (13%) identified the highest proportion of new HIV diagnosis compared with S1 (8%) and S2 (3%), respectively, p≤0.001. When controlled for age, marital status and occupation, MSM reached via S3 were 9 times (AOR: 9.21; 95% CI 5.57 to 15.23) more likely to uptake HCT when compared with S1 while PWIDs were 21 times (AOR: 20.90; 95% CI 17.33 to 25.21) more likely to uptake to HCT compared with those reached via S1.

CONCLUSIONS

Peer-led HCT delivered by S3 had the highest impact on the total number of M-MARPs reached and in identifying HIV-positive M-MARPs and new testers. Training M-MARPs peers to provide HCT is a high impact approach in delivering HCT to M-MARPs.

Poor-quality health services and lack of programme support leads to low uptake of HIV testing in rural Mozambique

Mozambique has one of the world's highest burdens of HIV infection. Despite the increase in HIV-testing services throughout the country, the uptake has been low. To identify barriers to HIV testing we conducted a study in six rural districts in Zambézia Province. We recruited a total of 124 men and women from the community through purposeful sampling to participate in gender-specific focus group discussions about barriers to HIV testing. The participants noted three main barriers to HIV testing: 1) poor conduct by clinicians, including intentional disclosure of patients' HIV status to other community members; 2) unintentional disclosure of patients' HIV status through clinical practices; and, 3) a widespread fatalistic belief that HIV infection will result in death, particularly given poor access to adequate food. Improving quality and confidentiality within clinical service delivery, coupled with the introduction of food-supplement programmes should increase people's willingness to test and remain in care for HIV disease.

[Epidemiological distribution of HIV infection among pregnant women in the ten regions of Cameroon and strategic implications for prevention programs]

Introduction

Le Cameroun se situe dans un contexte d’épidémie généralisée du VIH. La sous-population des femmes enceintes, facilement accessible au sein de la population générale, représente une cible probante pour mener la surveillance du VIH et estimer l’évolution épidémiologique. L'objectif de notre étude était d’évaluer la distribution épidémiologique du VIH chez les femmes enceintes.

Méthodes

Étude transversale menée en 2012 chez 6521 femmes enceintes (49,3% âgées de 15-24 ans) en première consultation prénatale (CPN1) dans 60 sites des 10 régions Camerounaises. L'algorithme en série a été utilisé pour le sérodiagnostic du VIH.

Résultats

La prévalence du VIH était de 7,8% (508/6521), avec une différence non significative (p = 0,297) entre milieu rural (7,4%) et milieu urbain (8,1%). En zone rurale, cette prévalence variait de 0,7% à l'Extrême-Nord à 11,8% au Sud. Cependant, en zone urbaine elle variait de 4% à l'Ouest à 11,1% au Sud-Ouest. Suivant l’âge, la prévalence était plus élevée (11,3%) chez les femmes de 35-39 ans. Suivant le niveau de scolarisation, la prévalence du VIH était plus faible (4,4%) chez celles non-scolarisées, et plus élevée (9,3%) chez celles ayant un niveau primaire. Selon la profession, l'infection était plus élevée chez les coiffeuses (15,5%), secrétaires (14,8%), commerçantes (12,9%) et institutrices/enseignantes (10,8%).

Conclusion

La prévalence du VIH reste élevée chez les femmes enceintes au Cameroun, sans distinction entre milieux rural et urbain. Les stratégies de prévention devraient s'orienter préférentiellement chez les femmes enceintes âgées, celles du niveau d'instruction primaire, et celles du secteur des petites et moyennes entreprises.

Male involvement for the prevention of mother-to-child HIV transmission: A brief review of initiatives in East, West, and Central Africa

Current trends in HIV/AIDS research in sub-Saharan Africa (SSA) highlight socially and culturally sensitive interventions that mobilize community members and resources for universal access to HIV prevention, treatment, and care services. These factors are particularly important when addressing the complex social and cultural nature of implementing services for prevention of mother-to-child transmission of HIV (PMTCT). Across the globe approximately 34 % fewer children were infected with HIV through the perinatal or breastfeeding route in 2011 (est. 330,000) than in 2001 (est. 500,000), but ongoing mother-to-child HIV transmission is concentrated in sub-Saharan Africa, where fully 90 % of 2011 cases are estimated to have occurred. Recent literature suggests that PMTCT in Africa is optimized when interventions engage and empower community members, including male partners, to support program implementation and confront the social, cultural and economic barriers that facilitate continued vertical transmission of HIV. In resource-limited settings the feasibility and sustainability of PMTCT programs require innovative approaches to strengthening male engagement by leveraging lessons learned from successful initiatives in SSA. This review presents an overview of studies assessing barriers and facilitators of male participation in PMTCT and new interventions designed to increase male engagement in East, West, and Central Africa from 2000-2013, and examines the inclusion of men in PMTCT programs through the lens of community and facility activities that promote the engagement and involvement of both men and women in transformative PMTCT initiatives.

Correlates of suboptimal entry into early infant diagnosis in rural north central Nigeria

BACKGROUND

Despite an estimated 59,000 incident pediatric HIV infections in 2012 in Nigeria, rates of early infant diagnosis (EID) of HIV service uptake remain low. We evaluated maternal factors independently associated with EID uptake in rural North Central Nigeria.

METHODS

We performed a cohort study using HIV/AIDS program data of HIV-infected pregnant women enrolled into HIV care/treatment on or before December 31, 2012 (n = 712). We modeled the probability of initiation of EID using multivariable logistic regression.

RESULTS

Three hundred fifty-seven HIV-infected pregnant women enrolled their infants in EID across the 4 study sites. Women who enrolled their infants in EID vs. those who did not were similar across age, occupation, referral source, and select laboratory variables. Clinic of enrollment and date of enrollment were strong predictors for EID entry (P < 0.001). Women enrolled more recently were less likely to have their infants undergo EID than those enrolled at the beginning of the project (January 2011 vs. January 2010, adjusted odds ratio = 0.35, 95% confidence interval: 0.22 to 0.56; January 2012 vs. January 2010, adjusted odds ratio = 0.30, 95% confidence interval: 0.14 to 0.61). Women who received care in the more urban setting of Umaru Yar Adua Hospital were more likely to have their infants enrolled in EID than those who received care in the other 3 clinics.

CONCLUSIONS

HIV-infected women in our prevention of mother-to-child HIV transmission program were more likely to bring in their infants for EID if they were enrolled in a more urbanized clinic location, and if they presented during an earlier phase of the program. The need for more intensive family engagement and program quality improvement is apparent, especially in rural settings.

Intimate partner violence after disclosure of HIV test results among pregnant women in Harare, Zimbabwe

Background

HIV status disclosure is a central strategy in HIV prevention and treatment but in high prevalence settings women test disproportionately and most often during pregnancy. This study reports intimate partner violence (IPV) following disclosure of HIV test results by pregnant women.

Methods

In this cross sectional study we interviewed 1951 postnatal women who tested positive and negative for HIV about IPV experiences following HIV test disclosure, using an adapted WHO questionnaire. Multivariate regression models assessed factors associated with IPV after disclosure and controlled for factors such as previous IPV and other known behavioural factors associated with IPV.

Results

Over 93% (1817) disclosed the HIV results to their partners (96.5% HIV− vs. 89.3% HIV+, p<0.0001). Overall HIV prevalence was 15.3%, (95%CI:13.7–16.9), 35.2% among non-disclosers and 14.3% among disclosers. Overall 32.8% reported IPV (40.5% HIV+; 31.5% HIV− women, p = 0.004). HIV status was associated with IPV (partially adjusted 1.43: (95%CI:1.00–2.05 as well as reporting negative reactions by male partners immediately after disclosure (adjusted OR 5.83, 95%CI:4.31–7.80). Factors associated with IPV were gender inequity, past IPV, risky sexual behaviours and living with relatives. IPV after HIV disclosure in pregnancy is high but lower than and is strongly related with IPV before pregnancy (adjusted OR 6.18, 95%CI: 3.84–9.93).

Conclusion

The study demonstrates the interconnectedness of IPV, HIV status and its disclosure with IPV which was a common experience post disclosure of both an HIV positive and HIV negative result. Health services must give attention to the gendered nature and consequences of HIV disclosure such as enskilling women on how to determine and respond to the risks associated with disclosure. Efforts to involve men in antenatal care must also be strengthened.

Utilization of PMTCT services and associated factors among pregnant women attending antenatal clinics in Addis Ababa, Ethiopia

BACKGROUND

Mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) remains the major source of HIV infection in young children. Targeting pregnant women attending antenatal clinics provide a unique opportunity for implementing prevention of mother-to-child transmission (PMTCT) programmes against HIV infection of newborn babies. This study aimed to investigate factors associated with the acceptability and utilization of PMTCT of HIV.

METHODS

An institution based cross-sectional study was conducted in April 2010 using exit interviews with 843 pregnant women attending antenatal care (ANC) clinics of 10 health centers and two hospitals in Addis Ababa, Ethiopia. Trained nurses administered structured questionnaires to collect data on socio-demographic characteristics, knowledge about MTCT, practice of HIV testing and satisfaction with the antenatal care services. Six focus group discussions among pregnant women and 22 in-depth interviews with service providers complemented the quantitative data.

RESULTS

About 94% of the pregnant women visited the health facility for ANC check-up. Only 18% and 9% of respondents attended the facility for HIV counselling and testing (HCT) and receiving antiretroviral prophylaxis, respectively. About 90% knew that a mother with HIV can pass the virus to her child, and MTCT through breast milk was commonly cited by most women (72.4%) than transmission during pregnancy (49.7%) or delivery (49.5%). About 94% of them reported that they were tested for HIV in the current pregnancy and 60% replied that their partners were also tested for HIV. About 80% of the respondents reported adequacy of privacy and confidentiality during counseling (90.8% at hospitals and 78.6% at health centers), but 16% wished to have a different counselor. Absence of counselors, poor counselling, lack of awareness and knowledge about HCT, lack of interest and psychological unpreparedness were the main reasons cited for not undergoing HIV testing during the current pregnancy.

CONCLUSIONS

HIV testing among ANC attendees and knowledge about MTCT of HIV was quite high. Efforts should be made to improve the quality and coverage of HCT services and mitigate the barriers preventing mothers from seeking HIV testing. Further research should be conducted to evaluate the uptake of antiretroviral prophylaxis among HIV-positive pregnant women attending ANC clinics.

A comparison of linkage to HIV care after provider-initiated HIV testing and counselling (PITC) versus voluntary HIV counselling and testing (VCT) for patients with sexually transmitted infections in Cape Town, South Africa

BACKGROUND

We examined linkage to care for patients with sexually transmitted infection who were diagnosed HIV-positive via the provider-initiated HIV testing and counselling (PITC) approach, as compared to the voluntary counselling and testing (VCT) approach, as little is known about the impact of expanded testing strategies on linkage to care.

METHODS

In a controlled trial on PITC (Cape Town, 2007), we compared HIV follow-up care for a nested cohort of 930 HIV-positive patients. We cross-referenced HIV testing and laboratory records to determine access to CD4 and viral load testing as primary outcomes. Secondary outcomes were HIV immune status and time taken to be linked to HIV care. Logistic regression was performed to analyse the difference between arms.

RESULTS

There was no difference in the main outcomes of patients with a record of CD4 testing (69.9% in the intervention, 65.2% in control sites, OR 0.82 (CI: 0.44-1.51; p = 0.526) and viral load testing (14.9% intervention versus 10.9% control arm; OR 0.69 (CI: 0.42-1.12; p = 0.131). In the intervention arm, ART-eligible patients (based on low CD4 test result), accessed viral load testing approximately 2.5 months sooner than those in the control arm (214 days vs. 288 days, HR: 0.417, 95% CI: 0.221-0.784; p = 0.007).

CONCLUSION

The PITC intervention did not improve linkage to CD4 testing, but shortened the time to viral load testing for ART-eligible patients. Major gaps found in follow-up care across both arms, indicate the need for more effective linkage-to-HIV care strategies.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN93692532.

Determinants of HIV testing among Nigerian couples: a multilevel modelling approach

In this article we analyse the determinants of HIV testing among Nigerian couples using Demographic and Health Survey data set (2008). This study is motivated by the fact that although there is a strong willingness from the Nigerian Government to examine new HIV preventions approaches such as Pre-Exposure Prophylaxis for HIV (PrEP) and Treatment as Prevention (TasP) for HIV serodiscordant couples, the implementation of such policies would require the HIV status of each partner in the couple to be known. This is far to be achieved in the Nigerian context since in Nigeria only 6% of couples know their HIV status. In order to identify potential policies that are needed to increase HIV testing uptake, we use a three-level random intercept logistic model to separately explore the determinants of knowing HIV status among female and male partners. The use of the multilevel modelling allows including the unobserved heterogeneity at the village and state level that may affect HIV testing behaviours. Our results indicate that education, wealth, stigma, HIV knowledge and perceived risk are predictors of HIV testing among both partners while routine provider initiated testing appears to be very effective to increase HIV testing among women. The introduction of financial incentives as well as an increase in routine testing and home-based testing may be needed for large scale increase in HIV testing prior to the implementation of new HIV prevention technologies among discordant couples.

Reporting of context and implementation in studies of global health interventions: a pilot study

BACKGROUND

There is an increasing push for 'evidence-based' decision making in global health policy circles. However, at present there are no agreed upon standards or guidelines for how to evaluate evidence in global health. Recent evaluations of existing evidence frameworks that could serve such a purpose have identified details of program context and project implementation as missing components needed to inform policy. We performed a pilot study to assess the current state of reporting of context and implementation in studies of global health interventions.

METHODS

We identified three existing criteria sets for implementation reporting and selected from them 10 criteria potentially relevant to the needs of policy makers in global health contexts. We applied these 10 criteria to 15 articles included in the evidence base for three global health interventions chosen to represent a diverse set of advocated global health programs or interventions: household water chlorination, prevention of mother-to-child transmission of HIV, and lay community health workers to reduce child mortality. We used a good-fair-poor/none scale for the ratings.

RESULTS

The proportion of criteria for which reporting was poor/none ranged from 11% to 54% with an average of 30%. Eight articles had 'good' or 'fair' documentation for greater than 75% of criteria, while five articles had 'poor or none' documentation for 50% of criteria or more. Examples of good reporting were identified.

CONCLUSIONS

Reporting of context and implementation information in studies of global health interventions is mostly fair or poor, and highly variable. The idiosyncratic variability in reporting indicates that global health investigators need more guidance about what aspects of context and implementation to measure and how to report them. This lack of context and implementation information is a major gap in the evidence needed by global health policy makers to reach decisions.

Group Problem-Solving Therapy for Postnatal Depression among HIV-Positive and HIV-Negative Mothers in Zimbabwe

Postnatal depression (PND) is a major problem in low- and middle-income countries (LMICs). A total of 210 postpartum mothers attending primary care urban clinics were screened for PND at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS) and Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition; DSM-IV) criteria for major depression. The HIV prevalence was 14.8%. Of the 210 enrolled postpartum mothers, 64 (33%) met DSM IV criteria for depression. Using trained peer counselors, mothers with PND (n = 58) were randomly assigned to either group problem-solving therapy (PST, n = 30) or amitriptyline (n = 28). Of the 58 mothers with PND, 49 (85%) completed 6 weeks of group PST (n = 27) or pharmacotherapy (n = 22). At baseline, the mean EPDS score for participants randomized to group PST was 17.3 (standard deviation [SD] 3.7), while the group randomized to amitriptyline had a mean EPDS score of 17.9 (SD 3.9; P = .581). At 6 weeks postintervention, the drop in mean EPDS score was greater in the PST group (8.22, SD 3.6) compared to the amitriptyline group (10.7, SD 2.7; P = .0097). Group PST using peer counselors is feasible, acceptable, and more effective compared to pharmacotherapy in the treatment of PND. Group PST could be integrated into maternal and child health clinics and preventing mother-to-child transmission of HIV programs in LMICs.

Provider-initiated HIV testing and counseling in low- and middle-income countries: a systematic review

Provider-initiated HIV testing and counseling (PITC) has expanded since 2007 WHO guidelines were established. We conducted a systematic review of PITC in low- and middle-income countries. Peer-reviewed studies were included if they measured pre-post or multi-arm outcomes. Two coders abstracted data using standardized forms. Nineteen studies were included, all from sub-Saharan Africa (N = 15) or Asia (N = 4). Studies were conducted in clinics for antenatal/family planning/child health (N = 12), tuberculosis (N = 4), outpatient (N = 1), sexually transmitted diseases (N = 1), and methadone maintenance (N = 1). HIV testing uptake increased after PITC. Condom use also increased following PITC in most studies; nevirapine uptake and other outcomes were mixed. Few negative outcomes were identified. Findings support PITC as an important intervention to increase HIV testing. PITC's impact on other outcomes is mixed, but does not appear to be worse than voluntary counseling and testing. PITC should continue to be expanded and rigorously evaluated across settings and outcomes.

Pregnant women's experiences of routine counselling and testing for HIV in Eastern Uganda: a qualitative study

Background

Routine HIV counselling and testing as part of antenatal care has been institutionalized in Uganda as an entry point for pregnant women into the prevention of mother-to-child transmission of HIV (PMTCT) programme. Understanding how women experience this mode of HIV testing is important to generate ideas on how to strengthen the PMTCT programme. We explored pregnant HIV positive and negative women’s experiences of routine counselling and testing in Mbale District, Eastern Uganda and formulated suggestions for improving service delivery.

Methods

This was a qualitative study conducted at Mbale Regional Referral Hospital in Eastern Uganda between January and May 2010. Data were collected using in-depth interviews with 30 pregnant women (15 HIV positive and 15 HIV negative) attending an antenatal clinic, six key informant interviews with health workers providing antenatal care and observations. Data were analyzed using a content thematic approach.

Results

Prior to attending their current ANC visit, most women knew that the hospital provided HIV counselling and testing services as part of antenatal care (ANC). HIV testing was perceived as compulsory for all women attending ANC at the hospital but beneficial, for mothers, especially those who test HIV positive and their unborn babies. Most HIV positive women were satisfied with the immediate counselling they received from health workers, but identified the need to provide follow up counselling and support after the test, as areas for improvement. However, most HIV negative women mentioned that they were given inadequate attention during post-test counselling. This left them with unanswered questions and, for some, doubts about the negative test results.

Conclusions

In this setting, routine HIV counselling and testing services are known and acceptable to mothers. There is need to strengthen post-test and follow up counselling for both HIV positive and negative women in order to maximize opportunities for primary and post exposure HIV prevention. Partnerships and linkages with people living with HIV, especially those in existing support groups such as those at The AIDS Support Organization (TASO), may help to strengthen counselling and support for pregnant women. For effective HIV prevention, women who test HIV negative should be supported to remain negative.

Acceptability of routine offer of HIV Testing (opt-out approach) among pregnant women in the Wa municipality

BACKGROUND

With the introduction of the opt out HIV testing policy in Ghana, the HIV test is offered routinely to all pregnant women unless they decline testing.

OBJECTIVE

To assess acceptability of the routine offer of HIV testing antenatal clinic (ANC) clients in the Wa municipality, Ghana.

DESIGN

Cross-sectional study of 270 randomly selected ANC attendees.

RESULTS

More than 90% of respondents were in favour of the opt-out policy. The most commonly cited reasons were that it would help pregnant women know their status and facilitate prevention of mother to child transmission of HIV (PMTCT). About 60% of respondents had tested for HIV in the current pregnancy with more than 90% reporting that the test was offered them in a manner in which they could have refused the test. HIV testing in the current pregnancy was associated with having heard of the opt-out policy (p <0.001) and awareness that the test was offered at the facility (p < 0.001), but there was no relationship with educational level. Out of the 112 clients who had not had HIV test in the current pregnancy, 61.8% claimed the test had not been offered to them while 82.4% expressed willingness to have the test done if offered.

CONCLUSION

The opt-out HIV testing policy is acceptable to the pregnant women surveyed in the Wa municipality. A well laid out process to ensure that all pregnant women are routinely offered HIV testing at the ANC may help minimize missed opportunities for utilizing PMTCT services.