Antenatal Care - Testing and Counseling

Gaps in Research

1.: Further interventions are needed to incorporate violence prevention, screening and counseling services into PMTCT testing and counseling.
2.: Additional efforts are needed to improve information and counseling about HIV during ANC to ensure that pregnant women and their sexual partners have adequate information.
3.: Additional efforts are needed to ensure confidentiality in testing.
4.: Increased support is needed for HIV serostatus disclosure, particularly at key times such as delivery, infant weaning, and at the resumption of sexual activity.
5.: Further interventions are needed to provide couples counseling and testing to reduce seroconversion during pregnancy.
6.: Multiple strategies are needed to promote male involvement in ways that meet pregnant women’s needs.
7.: Further interventions are needed to reduce barriers to HIV testing.
8.: Improved record keeping on HIV counseling, serostatus, and treatment is needed to improve referrals and linkages with other health care services.
9.: HIV testing must be linked to access to treatment.
10.: Criminalization of HIV transmission may lead pregnant women to not seek testing and care.
11.: In some settings, repeat testing of HIV-negative women during pregnancy is warranted.

1. Further interventions are needed to incorporate violence prevention, screening and counseling services into PMTCT testing and counseling. [See also Addressing Violence Against Women] Studies found high rates of violence, sexual coercion and abuse among HIV-positive pregnant women, particularly when accessing HIV testing or during disclosure.

Gap noted, for example, in Uganda (Were and Hasunira, 2010); Nigeria (Ezechi et al., 2009); Zimbabwe (Shetty et al., 2008a); Kenya (Kiarie et al., 2006; Gaillard et al., 2002:) and South Africa (Dunkle et al., 2004).

2. Additional efforts are needed to improve information and counseling about HIV during ANC to ensure that pregnant women and their sexual partners have adequate information. Studies found significant numbers of pregnant women received HIV tests with no counseling and reported that HIV testing was a mandatory part of their antenatal care. Studies also found that HIV-positive women feared transmitting HIV to their babies through casual contact. Studies found some providers assured women that treatment guaranteed that there would be no vertical transmission. In addition, studies found that some couples erroneously believed that sex during pregnancy causes miscarriages. Studies have also found that women who have tested HIV-negative at their first antenatal visit had seroconverted to HIV-positive by 12 months following delivery.

Gap noted, for example, in South Africa (Moodley et al., 2011; Griessel et al., 2010); India (Sinha et al., 2008; Van Hollen, 2007; Rogers et al., 2006; Firth et al., 2010); Democratic Republic of Congo (Mulongo et al., 2010); Uganda (Were and Hasunira, 2010); Ethiopia (Ismail and Ali, 2009); Tanzania (Falnes et al., 2011); Nigeria (Adeleke et al., 2009); Brazil (Ramos et al., 2009); Vietnam (Nguyen et al., 2008f; Brickley et al., 2008); Kazakhstan (Sandgren et al., 2008); Kenya (Delva et al., 2006); Thailand (Teeraratkul et al., 2005); India, Thailand, Philippines and Indonesia (Paxton et al., 2004a); Nigeria (Moses et al., 2009; Onah et al., 2002) and globally in resource-limited settings (Baek and Rutenberg, 2010).

3. Additional efforts are needed to ensure confidentiality in testing. Studies found that women were tested without their consent and that providers did not protect women’s confidentiality.

Gap noted, for example, in Ukraine (Finnerty et al., 2010); Uganda (Were and Hasunira, 2010); South Africa (Peltzer et al., 2010); Vietnam (Hardon et al., 2009; Oosterhoff et al., 2008a) and Turkey (Ersoy and Akpinar, 2008).

4. Increased support is needed for HIV serostatus disclosure, particularly at key times such as delivery, infant weaning, and at the resumption of sexual activity. Studies found that disclosure to partners was low and women reported needing additional support to disclose.

Gap noted, for example, in Côte d’Ivoire (Tonwe-Gold et al., 2009; Brou et al., 2007).

5. Further interventions are needed to provide couples counseling and testing to reduce seroconversion during pregnancy. Studies found that inadequate numbers of couples are counseled on safer sex during pregnancy and that despite national guidelines, repeat testing during pregnancy is not routinely done. Studies also found that inadequate spaces for men in antenatal care as well as gender norms that discouraged men from accompanying women to antenatal care discouraged couples testing.

Gap noted, for example, in Uganda (Byamugisha et al., 2010c); South Africa (Peltzer et al., 2009; Moodley et al., 2009); Zimbabwe (Tavengwa et al., 2007) and in southern Africa (Rutenberg et al., 2001).

6. Multiple strategies are needed to promote male involvement in ways that meet pregnant women’s needs. Studies found that some women found their partners’ involvement controlling and/or violent and other women wanted more autonomy in health decision-making. Studies also found men lacked information on vertical transmission and felt excluded from PMTCT programs. Other studies found that women indicated that they could not discuss their HIV serostatus with their husbands.

Gap noted, for example, in South Africa (Maman et al., 2011); sub-Saharan Africa (Auvinen et al., 2010); Thailand (Youngwanichsetha et al., 2010) and Uganda (Medley et al., 2009b; Mbonye et al., 2010).

7. Further interventions are needed to reduce barriers to HIV testing. Studies found that fear of partner notification, risk of domestic violence, the unreliability of rapid HIV tests, test availability, long waiting times at the clinic, costs for transport, lack of childcare and the need for partner consent were barriers to HIV testing. The impact of rapid testing during labor and delivery for HIV-positive women has yet to be assessed and HIV test results were not provided prior to delivery.

Gap noted, for example, in a global review of PMTCT (Pai and Klein, 2009); Ecuador (Dearborn et al., 2010); Uganda (Homsy et al., 2007 cited in Pai and Klein, 2009) and Brazil (Oliveira et al., 2010b).

8. Improved record keeping on HIV counseling, serostatus, and treatment is needed to improve referrals and linkages with other health care services. A study found that record keeping of HIV staging and CD4 counts was inadequate.

Gap noted, for example, in a review of maternal care practices in Africa (Rollins and Mphatswe, 2008).

9. HIV testing must be linked to access to treatment.

Gap noted, for example, in Ecuador (Dearborn et al., 2010); Vietnam (Nam et al., 2010); Uganda (Dahl et al., 2008).

10. Criminalization of HIV transmission may lead pregnant women to not seek testing and care. A study in Ukraine with pregnant women found that providers told women who tested HIV-positive that they carry criminal liability and others did not access care. A global review found that in some countries, vertical transmission is criminalized.

Gap noted, for example, globally (Csete et al., 2009); and in Ukraine (Finnerty et al., 2010).

11. In some settings, repeat testing of HIV-negative women during pregnancy is warranted. One study found that acute infection resulted in high rates of vertical transmission. Another study found that of 750 consecutive pregnant women, with an HIV prevalence of 37.3%, 0.9% of women were acutely infected and thus at a high risk of vertical transmission. HIV RNA assays to detect acute infection are very costly (US$1,313) and have not been used routinely in resource-limited settings.