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Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe
Global Health Sciences Literature Digest
Published February 25, 2008
Journal Article

Chandisarewa W, Stranix-Chibanda L, Chirapa E, Miller A, Simoyi M, Mahomva A, et al. Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. Bull World Health Organ 2007 Nov;85(11):843-50.

Objective

To assess the impact of routine antenatal HIV testing in preventing mother-to-child transmission (PMTCT) of HIV in urban Zimbabwe.

Study Design

A pre-post intervention study. During the pre-intervention period (October 2004 to March 2005), women received standard patient-initiated "opt-in" counseling and testing. A routine, provider-initiated "opt-out" approach with right of refusal was implemented June 2005 to November 2005.

Setting

Four antenatal care clinics in Chitungwiza, a socioeconomically disadvantaged community 25 km south of Harare, Zimbabwe. Harare has a population of 1.5 million, and antenatal HIV sero-prevalence in urban clinics has been estimated to be 21.3%. (1) Reported acceptance rates of voluntary counseling and testing among clients of the antenatal care clinic in Zimbabwe have ranged from 20% to 63%.(2,3)

Participants

During the 6-month pre-intervention period, 4,872 women presented to the antenatal care clinic and attended pre-test counseling and group education. During the 6-month opt-out period, 4,551 women participated.

Intervention

Before implementing the routine HIV testing policy, a voluntary counseling and testing instrument was used to assess the adequacy of staffing levels, adherence to PMTCT protocols, availability of health education materials, availability of test kits and medical consumables, adherence to staff roles and responsibilities, and general aspects of site operations. A counselor reflection form and an exit survey form for voluntary counseling and testing clients were used to guide implementation of the routine HIV testing policy. Community mobilization activities for improving public awareness of the routine HIV testing policy were carried out by community outreach counselors. A drama skit was developed and presented at health worker in-service training workshops and at community advisory board meetings for critiques and comments before presentation to clients. The community counselors performed the skit on a rotational basis at the four clinics for new clients and also in the community and at colleges, churches and industrial facilities. Before implementation of the routine HIV testing policy, clinic staff members at the four sites attended a 2-day training session conducted by the PMTCT program staff in which the new strategy, including data collection and interview techniques, was discussed in detail. Under the new system, existing PMTCT clinic counselors held 15-minute group education and discussion sessions with pregnant women, using a structured flip chart as a discussion guide. The discussion focused on HIV transmission, PMTCT, single dose nevirapine (sdNVP) prophylaxis and routine HIV testing for all mothers, specifying their right to refuse. Women who did not want any one of the routine antenatal tests were referred for individual pre-test counseling. Women who arrived for a clinic visit when no group was conducted received the same education individually via pre-test counseling. Women who did not refuse and who gave verbal informed consent had blood drawn individually by clinic nurses for rapid, onsite HIV testing in addition to routine syphilis, blood group and hemoglobin level testing. Maternal HIV status was determined onsite using two rapid tests in parallel on each blood sample, with a third test as a tie-breaker. Women received their test results the same day during extensive individual post-test counseling, which focused on PMTCT interventions for HIV-infected women; enrollment into support groups; counseling for exclusive breastfeeding for 6 months, according to WHO and national guidelines; sdNVP prophylaxis; and mother-infant follow-up. To assess the acceptability of the routine HIV testing policy, a 15-item, self-administered exit questionnaire in Shona, the local language, was provided to 2,011 women during the initial 3 months of implementation after completion of their first visit to the antenatal care clinic. To determine the negative effects related to routine HIV testing, 221 women who had participated in routine HIV testing were interviewed individually, regardless of HIV status, during the fifth month of study implementation by counselors blinded to their sero-status.

Primary Outcomes

The primary outcomes were acceptance rates of HIV testing acceptance and post-test return and acceptance of PMTCT interventions and follow-up.

Results

Of the 4,551 pregnant women who presented to the antenatal care clinic during the first 6 months of opt-out, provider-initiated routine HIV testing, 4,547 (99.9%) were tested for HIV compared with 3,058 (65%) of 4,700 pregnant women who presented during the last 6 months of pre-intervention, opt-in, client-initiated testing (p<0.001). No negative effects on clinic attendance, collection of test results, post-test counseling rates or uptake of PMTCT interventions were noted. Correspondingly, more women were identified with HIV infection during routine antenatal testing (n=926, 20.4% sero-prevalence, vs. 513 during opt-in testing, 16.8% sero-prevalence, p<0.001). Overall, 4,538 of 4547 (99.8%) women collected their test results during the routine HIV testing period compared with 2,964 of 3058 (96.7%) during the opt-in testing period (p<0.001). Significantly more HIV-infected women during the routine testing period than during the opt-in period received post-test counseling and collected test results (908 vs. 487, p<0.001). Likewise, there was a corresponding increase in deliveries by known HIV-infected women in the four clinics (256 vs. 186, p≤0.001), resulting in more mother-infant pairs receiving sdNVP prophylaxis during routine testing (256 vs 185 during opt-in testing). In addition, more HIV-infected women during routine testing than opt-in testing enrolled in the mentorship program led by community counselors (526 vs. 257, p=0.064), joined psychosocial support groups (80 vs. 42, p=0.681), and followed up with their infants at the clinics (105 vs. 49, p=0.002). Of the 4,547 women who underwent routine HIV testing and were encouraged to bring their partners for free voluntary counseling and testing, only 308 of their partners (6.8%) opted for HIV testing, and of the men tested, 307 (99.7%) returned to collect their results and receive post-test counseling; of these, 49 (16%) were found to be infected with HIV.

Of the 2,624 women who opted for routine HIV testing during the first 3 months of the study and who answered the questionnaire at the end of their first clinic visit, 2,011 (76.6%) completed the exit survey. The overall response was positive, with clients generally satisfied with the quality of the counseling; for instance, 98% said that the information they were given by the community counselors had adequately prepared them for the testing result.

In a follow-up survey, 221 women who opted for routine testing were sampled and interviewed individually, regardless of their HIV status, to determine any negative social effects from routine HIV testing. The women's mean age was 24 years, with most women married (90%), educated through secondary school (82%) and employed (67%). Of the 221 women interviewed, 219 (99%) were tested for HIV at the first antenatal visit; 109 women (49%) were HIV-infected. The most frequent reasons the women gave for accepting the HIV test were protection of their children and concern for their own health. All women found the information provided by community counselors adequate to make informed decisions about routine HIV testing. Of the 221 women interviewed, 89% (197) had disclosed their sero-status to their husbands, only 7% of whom were tested for HIV infection. Of these, one hundred eighty-one (92%) women did not experience violence and the relationship with their partners continued. Fourteen HIV-infected and 2 HIV-uninfected women (8%) experienced disclosure-related violence, including pushing, slapping and kicking, but reported no injuries related to firearms, knives or burning. In four couples (2%) the relationship ended due to divorce (1 couple), separation (1), and abandonment by the male partner (2). Of the 221 women interviewed, 11% (24) had not disclosed their sero-status to anyone because of fear of violence, divorce and stigma. Overall, 89% (197 of 221) of women viewed routine HIV testing during pregnancy as an empowering tool to exercise their rights and responsibilities and to make informed decisions about PMTCT and infant feeding.

Conclusion

The authors conclude that routine HIV testing is feasible for the clinics and acceptable to almost all women and can lead to significant improvement in the acceptance of PMTCT services. In addition, HIV-infected women who participated in routine testing reported relatively low levels of spousal abuse and other adverse social consequences.

Quality Rating

There is no widely accepted quality assessment scale for similar pre- and post-intervention designs, and this study has certain limitations: 1) the almost 100% acceptance rate of antenatal HIV testing at the clinics may not be attainable in other sites with less motivated clinic staff or if results are not immediately available; 2) findings are limited in terms of overall generalization and effect, as only 25% of HIV-infected women identified in the city of Chitungwiza actually deliver in clinics. Most women deliver in other urban or rural facilities or at home; and 3) the study design makes it difficult to attribute the findings to the intervention or to differences in the study population.

In Context

Routine HIV testing is rare in sub-Saharan Africa; however, results from this study are consistent with recent reports showing that routine antenatal HIV testing is acceptable and can significantly increase HIV testing rates. (4,5)

Programmatic Implications

The results of this study suggest that routine HIV testing in areas of high HIV prevalence can have a significant public health effect on perinatal transmission of HIV. Attention to the right of refusal, however, is critical in ensuring individual rights, especially in settings marked by poverty, illiteracy, gender inequalities, weak healthcare infrastructure and poor access to antiretroviral treatment. Importantly, compared to opt-in testing, routine HIV testing in this study did not lead to reductions in the number of women attending antenatal care clinics or of women receiving test results. On-site testing and improved community awareness and group education about the importance of routine antenatal HIV testing is likely responsible for these findings and should be implemented wherever possible. The relatively low levels of partner abuse are also reassuring; however, the low rate of partner testing is of concern and indicates the need for further attention and study. Finally, the intervention employed in this study was very resource intensive and may not be feasible in other settings. The effective use of community members for counseling, however, is a scalable strategy that addresses the shortage of healthcare workers in most developing settings.

References

  1. Zimbabwe Ministry of Health. National survey of HIV and syphilis prevalence among women attending antenatal clinics in Zimbabwe, 2004. Harare: Zimbabwe Ministry of Health; 2005. (No abstract available.)
  2. Shetty AK, Mhazo M, Moyo S, von Lieven A, Mateta P, Katzenstein DA, et al. The feasibility of voluntary counseling and HIV testing for pregnant women using community volunteers in Zimbabwe. Int J STD AIDS 2005;16(11):755-9.
  3. Stranix-Chibanda L, Chibanda D, Chingono A, Montgomery E, Wells J, Maldonado Y, et al. Screening for psychological morbidity in HIV-infected and HIV-uninfected pregnant women using community counselors in Zimbabwe. J Int Assoc Physicians AIDS Care 2005 Dec;4 (4):83-8.
  4. Kiarie J, Nduati R, Koigi K, Musea J, John G. HIV-1 testing in pregnancy: acceptability and correlates of return for test results. AIDS 2000 Jul 7;14(10):1468-70. (No abstract available.)
  5. Centers for Disease Control and Prevention (CDC). Introduction of routine HIV testing in prenatal care - Botswana, 2004. MMWR Morb Mortal Wkly Rep 2004 Nov 26;53:1083-6.