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Successful introduction of routine opt-out HIV testing in antenatal care in Botswana
Global Health Sciences Literature Digest
Published April 17, 2009
Journal Article

Creek TL, Ntumy R, Seipone K, et al. Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. JAIDS 2007;45:102-7.

In Context

HIV prevalence in Botswana is among the highest in the world. It was estimated to be 37.4% among women attending antenatal clinics (ANCs) in Botswana in 2003.(1) HIV testing, followed by a short course of antiretroviral therapy (ART) for HIV-infected women has been demonstrated to substantially reduce the risk of perinatal HIV transmission(2) and is available at no cost to women in Botswana. Despite its availability, and the high proportion of pregnant women who have had at least one ANC visit, the number of women testing for HIV has been low. Voluntary HIV counseling and testing, which requires trained counselors and affirmative consent from women, has been available in Botswana since the mid-1990s, but a variety of factors have contributed to poor uptake of testing. Opt-out routine HIV testing, as is used for nearly all diagnostic tests, was implemented in Francistown, Botswana in 2004.


To compare HIV testing rates, PMTCT intervention rates, and ANC attendance before and after the introduction of routine testing in ANCs


Four antenatal clinics in Francistown, Botswana

Study Design

Cross-sectional, observational study


Women attending antenatal clinics


HIV testing rates, use of prevention of mother-to child-transmission (PMTCT), and attendance rates before and after the introduction of opt-out testing


Four ANCs were included. At these sites, ANC services were modified such that all women attended a group counseling education session that included a review of the tests that would be conducted (hemoglobin, HIV, syphilis, glucose, and blood pressure) and the information that any test may be refused by the patient. Women who declined all tests were referred to a counselor to discuss their decision. Country-specific testing protocols were followed, including off-site ELISA testing for women at <28 weeks gestation and off-site rapid testing for women at >28 weeks. Results were available in one month for women in their second trimester and one week for women in their third trimester. For women whose test results showed HIV infection, post-test counseling included written and verbal information and referrals for ART.

Data obtained from these clinics during the five months (September 2003-January 2004) before implementation of routine, opt-out testing was the control condition; and the first eight months of opt-out testing (February 2004-September 2004) was the intervention group.

Beginning in July 2004, interviews from women who attended the clinic after February 2004 were obtained. Women were asked about their knowledge of PMTCT and their HIV testing experiences, choices, and outcomes. Similar interviews had been conducted among women at these clinics in 2003, and the responses from this earlier survey were used as the comparison group. A total of 50 women participated in the survey of opt-out testing.

Data were also obtained from logbooks at the regional hospital in Francistown and national level PMTCT programs. These data were used to assess the similarity between testing in Francistown and in the nation.


A total of 492 women were seen at ANCs during the voluntary period and 964 during the routine testing period. HIV testing increased from 76% to 95%, and receipt of results increased from 72% to 82% between the voluntary and routine, opt-out testing periods. Clinic attendance did not change during these periods. Use of PMTCT among women testing during the voluntary period was the same as those tested during routine testing. Test results from women tested with the rapid test were returned in an average of 27 days when voluntary testing was in place and 10 days once routine testing was implemented. Similarly, ELISA tests were returned to the clinic in an average of 21 days during the voluntary testing period and 18 days once routine testing was used. The average time between testing and receiving results was 53 days during the voluntary testing period and 38 days during the routine testing period (P=0.16). HIV prevalence among tested women was 47% in the voluntary period and 43% in the routine period (P=0.16).

Survey responses showed that women who were tested routinely scored higher on questions measuring knowledge of HIV and PMTCT than did women using voluntary testing. Routinely tested women compared with women tested voluntarily also disclosed their HIV status to their families at a higher rate. The proportion of women who experienced domestic violence following disclosure was low overall and did not differ between the two groups.

Routine testing resulted in greater uptake of PMTCT services nationally and at the regional hospital.


Routine HIV testing resulted in a greater proportion of women at ANCs testing and receiving PMTCT services without evidence of adverse effects.

Quality Rating

This was a very well-conducted study. The use of the same clinics before and after implementation of routine testing provided a representative sample of women in the intervention and control´┐Ż groups who resided in Francistown. Outcomes were clearly identified and measured. Results from other settings may differ.

Programmatic Implications

The change from the voluntary counseling and testing model to HIV testing under routine conditions has been slow but once implemented, met with better uptake of HIV testing and ART.(3) Continued efforts to integrate HIV testing and treatment into mainstream medical care is warranted.


  1. Botswana National AIDS Coordinating Agency (NACA). 2003 Second Generation HIV/AIDS Surveillance Technical Report. Gaborone, Botswana: NACA; 2003. Abstract not available.
  2. Nolan ML, Greenberg AD, Fowler MG. A review of clinical trials to prevent mother-to-child HIV-1 transmission in Africa and inform rational intervention strategies. AIDS 2002;16:1991-9.
  3. Welty TK, Bultery MB,Welty ER, et al. Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon. J Acquir Immune Defic Syndr 2005;40:486-93.Ole-Nguyaine S, Crump JA, Kibiki GS, et al. HIV-associated morbidity, mortality and diagnostic testing opportunities among inpatients at a referral hospital in northern Tanzania. Ann Trop Med Parasitol 2004;98:171-9.