Approaches for scaling up human immunodeficiency virus testing and counseling in prevention of mother-to-child human immunodeficiency virus transmission settings in resource-limited countries

Provider-Initiated Testing and Counseling 

Current global recommendations from the World Health Organization (WHO) and UNAIDS advocate for provider-initiated testing and counseling with the right to refuse (opt-out) within PMTCT settings (antenatal, labor and delivery, and postdelivery settings).14, 15 With provider-initiated testing and counseling, health care workers or providers recommend HIV testing as part of the standard package of services provided routinely to all clients. The client must specifically opt-out or refuse the test if she does not want to know her HIV status.14, 15 There is no need for a separate written consent for HIV testing; consent is almost always verbal. This is a shift from the historical practice of client-initiated (opt-in) testing, or voluntary counseling and testing, in which the client specifically requests an HIV test and usually provides written consent. The rationale for provider-initiated testing and counseling is that it normalizes HIV testing in medical settings, increases the number of people who know their HIV status, and improves PMTCT program impact.14, 33

International and national policies increasingly endorse provider-initiated testing and counseling within the context of pregnancy. Various articles in the past have referred to the provider-initiated testing and counseling with right to refuse as an opt-out strategy and client-initiated testing and counseling as an opt-in strategy, but for the purpose of this paper, we will use provider- and client-initiated testing and counseling when referring to these strategies. New WHO guidelines, to be released in early 2007, will further advocate for provider-initiated testing and counseling within various medical settings including PMTCT, sexually transmitted infection and tuberculosis clinics. As shown in the Table, data from both developed countries16, 34, 35, 36 and resource-limited countries17, 18 have shown an increase in the uptake of testing and counseling when the provider-initiated testing and counseling approach is implemented.

TABLE. Comparison of HIV-testing uptake before and after implementation of provider-initiated testing and counseling during prenatal care

	Study/location	Client-initiated testing and counseling	Provider-initiated testing and counseling	P
	2005, Van’t Hoog et al18 Large provincial hospital, Kenya	2278/4142 (55%) (12 months)	2799/4089 (68%) (12 months)	<.001
	2004, Centers for Disease Control and Prevention17Multisite study, Francistown, Botswana	381/506 (75%) 3 months in 2003	314/347 (90%) 4 months in 2004	<.001
	National Data Botswana [Botswana national PMTCT program, unpublished data] From all 24 health districts Personal communication, Tracy Creek	67%, 2003	92%, 2005	—
	2001, Stringer et al35 University of Alabama Hospitals, Birmingham, Alabama	2561/3415 (75%) 12 months, 1998-1999	3324/ 3778 (88%) 12 months 1999-2000	<.001
	1999, Simpson et al36 United Kingdom	35%	88%	—
	2006, Sherr et al34 Three London hospitals, United Kingdom	2309/2710 (85%), 2002	774/850 (91%) 2004	<.0001

Country Experiences Implementing Provider-Initiated Testing and Counseling 

Data from developed countries such as the United States and Canada show that HIV testing rates were generally higher in states or provinces that used provider-initiated testing and counseling than in those that used client-initiated testing—71-98%, compared with 25-83%.16 These findings resulted in a change in U.S. policy to provider-initiated testing for women in prenatal care.37, 38 In 2006, the U.S. government released new guidelines that recommend HIV screening for all patients in all health care settings after the patient is notified that testing will be performed, unless the patient declines (referred to as opt-out screening).39 Universal screening in health care settings was recommended despite the low national prevalence of HIV infection in the United States (less than 1%) because strategies that incorporated universal screening such as those among pregnant women and blood donors had resulted in increased testing and near elimination of perinatal transmission and transfusion-associated HIV infection. In addition, providers in busy health care settings often lack the time necessary to conduct risk assessments and might perceive counseling requirements as a barrier to testing. Furthermore, earlier diagnosis could lead to earlier treatment of HIV infection and potential reduction of risk behaviors by HIV-infected individuals.39

The lessons learned from developed countries in implementing provider-initiated testing and counseling have been adapted and used in resource-poor settings. Increases in HIV testing uptake have been reported in several African settings in which provider-initiated testing and counseling has been implemented. For example, Botswana implemented provider-initiated testing and counseling in 2004,17 following a declaration by the President for universal testing in medical settings. An evaluation of the early impact of routinely recommended testing on HIV-test acceptance and the rates of return for care in prenatal settings in Botswana’s second largest city showed that acceptance of testing increased from 75.3% to 90.5% (Table); there was no difference in the percentage of tested women who did not receive results (29.4% client initiated vs 33.0% provider initiated, P = .29), and there was no change in the number of women seeking prenatal care. National data show that uptake of testing and counseling in prenatal settings in Botswana has similarly increased to more than 90%.17 Although the experience in other settings have shown that not all women will return for test results,40 the increased emphasis on rapid HIV testing with same-day results will increase the number of women who know their HIV status.14, 15

Despite the evidence, a number of resource-limited countries with generalized HIV epidemics (HIV prevalence greater than 1%) have either not adopted or fully implemented this approach. Even where it is the policy, field experience in Africa indicates that testing still needs to be greatly expanded to increase coverage and ensure wide provision of appropriate interventions.41 There are also concerns that women may feel coerced into accepting testing and may not return for their test results and other PMTCT interventions if they accept testing in a provider-initiated program.40, 42 Despite these concerns, the provider-initiated testing and counseling approach has been found to be acceptable21, 32 and does not appear to deter women from returning for their results.17

Group Pretest Education 

Many PMTCT programs now provide HIV pretest information to groups of clients (rather than individually) and incorporate the information into general health talks.17, 19, 20, 21 The group pretest session helps to reduce the burden on providers25 and allows more time for the individual posttest counseling session during which the client is provided with the result and, if HIV positive, information about PMTCT interventions and HIV-related treatment and care.14, 15, 21 During the group pretest session, provider-initiated testing and counseling can be easily offered as part of routine services while ensuring that confidentiality, consent (with a choice to opt out), and counseling (provided during individual posttest sessions) are maintained.14, 15, 19, 20 The same basic information provided in individual sessions is offered during the group session, although the individual session does offer an opportunity to discuss more in-depth personal issues.

Using Rapid HIV Testing with Same-Day Results 

Use of rapid HIV testing is recommended by the WHO43 to increase uptake of HIV testing and counseling and is now widely available, and the testing method of choice in many African countries.44, 45 Rapid HIV testing has several advantages: It is simple to perform, is highly sensitive and specific, cost effective, simplifies logistics, minimizes recording errors, and offers the opportunity for same-day results.46, 47, 48, 49, 50

Rapid HIV testing takes 10-20 minutes to perform so that clients can be given their results on the same day. This is extremely important because many women in resource-limited countries may make only 1 prenatal visit or may present late in pregnancy for their first visit.51 Same-day results on the first prenatal visit ensures that clients have the opportunity to know their HIV status as part of prenatal care and to receive PMTCT interventions and referrals.33, 50 A study in Uganda found that rapid testing with same-day results increased notification rates, compared with standard enzyme-linked immunosorbent assay (ELISA) testing among pregnant HIV-positive women (96% vs 65%).22 Rapid tests also play an important role in labor and delivery settings in which eligibility for PMTCT interventions may depend on the quick return of test results.

Because whole blood or oral fluids are used for rapid testing, nonlaboratory personnel can be trained to collect and test specimens.43 Specialized laboratory facilities are not required, and testing can be conducted in front of clients, increasing confidence in results and reducing clerical errors.41, 43 The sensitivity and specificity of rapid HIV testing are similar to ELISA.22, 46, 47, 48 Rapid testing has also been shown to be cost effective when compared with ELlSA and Western blot.49 However, support is needed to establish and maintain the quality of rapid testing through the establishment of both internal and external quality assurance systems, including regular training and supervision of health care staff.

Testing and Counseling at Labor and Delivery or Immediately After Delivery 

Many women in resource-limited countries present at labor and delivery (L&D) with unknown HIV status.10, 18, 29, 52 In some settings, these women may be at higher risk of HIV than those tested during prenatal care.52 Rapid testing and counseling at L&D or immediately after delivery enables women that might have been missed during prenatal care to also know their HIV status and access PMTCT interventions. Testing in these settings also allows access to treatment and care for the HIV-infected mother and other family members. The provision of routine testing and counseling in L&D and postpartum wards for women not tested during the antenatal periods is a crucial safety net for maximizing PMTCT programs and has been found to increase uptake of PMTCT services.53, 54, 55 This approach is endorsed by the WHO and other international and national agencies.15, 37, 38, 43

The Mother Infant Rapid Intervention at Delivery (MIRIAD) study53 evaluated the feasibility of offering rapid testing to women of unknown HIV status at L&D in 16 hospitals in the United States. MIRIAD found that rapid testing and counseling is acceptable and feasible and that the rapid tests deliver accurate and timely test results. Based on this study, the United States now recommends routine HIV testing and counseling at L&D to women with unknown status.37, 38

A few studies in large provincial hospitals in resource-limited countries such as Uganda and Kenya found that testing and counseling at L&D and immediately after delivery is acceptable and feasible and increases HIV testing uptake.29, 55, 56 However, concerns have been expressed that women may be pressured to give consent, may not understand the testing and counseling process at the time of labor, or may feel coerced to test for HIV.57 On the contrary, an evaluation to determine whether participants in the MIRIAD study actually understood from the consent process that they could opt out of HIV testing and counseling found that approximately 70% of participants were able to state in their own words the benefits of testing. Over 80% accepted rapid HIV testing and knew they had the right to opt out, indicating that they were not being forced or coerced.53, 58 It is important, however, to ensure that providers are trained to conduct the pretest session, offer the test, and ensure consent without unduly pressuring the patient. This may be particularly important when working in settings in which patients may not feel free to question their health care provider.32

Rescreening Women Who Test HIV Negative During the Prenatal Period 

Recent studies show high rates of seroconversion among women who test negative early in pregnancy in some sub-Saharan African settings.59 Depending on local HIV incidence, consideration should be given to retesting HIV-negative women in the third trimester or during labor. Recent evidence also indicates that HIV rescreening late in pregnancy in high-prevalence, resource-limited settings is a cost-effective strategy for reducing MTCT.60 These findings illustrate the need for stronger posttest counseling messages that include risk reduction and encourages partner testing, and they highlight the benefits of retesting later in pregnancy, especially in high-prevalence settings.

Human Resource Capacity 

Despite the above approaches, the human resource crisis facing many African countries may affect the capacity to scale up HIV testing and counseling.21 Innovative strategies can be implemented to support staff, typically nurses who are tasked with testing and counseling in PMTCT settings.21, 24, 25, 26, 27 The paper by Sripipatana et al in this supplement clearly outlines the need to utilize lay counselors such as traditional birth attendants, mothers living with HIV infection, community health care workers, and off-duty workers to provide PMTCT services including HIV testing and counseling. People in other fields can also be rapidly trained as counselors to help to alleviate the human resources crisis. For example, in Botswana, high school graduates serve as counselors after receiving a 4-week HIV-counseling training.17

Ongoing training and utilization of job aids such as videos, algorithms, protocols, and flip charts with text messages and action steps will help these various cadres of staff to provide quality and standardized HIV testing and counseling services.61 The Centers for Disease Control and Prevention (CDC) in collaboration with the WHO, United Nations Children’s Fund, and the United States Agency for International Development have developed the Testing and Counseling for PMTCT Support Tools, which provide educational materials, job aids, and training resources to support the integration of testing and counseling into prenatal, L&D, and postdelivery settings as well as linking PMTCT services with care, treatment, and community services. These tools are available online, can be used as an orientation package for new providers, and are being adapted in several countries including Mozambique, Cambodia, Nigeria, Kenya, and Botswana.61

Male Partner Involvement and Couples Counseling 

One major factor that prevents some women from accepting testing is the need to seek their partner’s consent or assent.29, 30, 31, 62, 63 More than 50% of pregnant women who refused HIV testing in a PMTCT setting in Uganda reported the need for their partner’s assent or presence before they could test.29 Studies have shown that when male partners are involved or couples counseling is provided, HIV testing uptake is higher and women are more likely to implement PMTCT and treatment and care interventions.29, 31, 62, 63, 64 Involving men has been one of the most difficult strategies to implement, yet there have been some successful efforts. One study in Tanzania showed a 30% increase in male partner counseling when men were sent a letter of invitation to participate in PMTCT programs.64 Studies in Uganda and Kenya have shown that routine offer of testing and counseling to male partners as part of couples counseling during labor or immediately after delivery is highly acceptable and has resulted in higher rates of HIV testing.5, 29 In Swaziland, lower infant transmission rates were recorded when the male partner was involved and participated in support group activities for people living with or affected by HIV.65

Additionally, utilization of PMTCT interventions, including the receipt of antiretrovirals, avoidance of breast-feeding, and condom use, have also been reported to be higher when couples are counseled together, emphasizing the need to further support couples counseling within PMTCT settings.29, 62 Other strategies include extending clinic hours so that men can visit in late afternoon or reducing wait times for men or couples who visit MCH clinics. A combination of these strategies is needed to increase testing uptake and involve the male partner.

Concern has been raised that women who disclose to their partners, whether through couples counseling or other circumstances, have an increased likelihood of adverse social outcomes such as abandonment or violence. A recent study in Zambia showed that this is not always the case because adverse social events were reported regardless of disclosure or counseling status. The rate of adverse social events were similar in women who received couples counseling, women who disclosed after individual testing, and women who did not disclose their HIV status.30 Although adverse social events of up to 4-16% have been reported after disclosure in sub-Saharan African settings, the experience from multiple African countries have shown that more women actually experienced beneficial outcomes and support after disclosing their HIV status to their partner.66 However, it will be extremely important to establish support mechanisms for the women who may experience negative outcomes,66 and additional data from resource-poor settings would help to further understand the depth of social adverse events following HIV testing and disclosure.

Community Involvement 

Scaling up testing and counseling within PMTCT settings is influenced by not only policies, staffing, and infrastructure but also the community. Community norms, ideas, and support for a particular program or activity can influence a woman’s decision to test for HIV. However, experience with involving the community is limited. One such experience is from a comprehensive rural PMTCT program in Zimbabwe. Community activities included informational meetings about testing and counseling for PMTCT and provision of educational materials for community members.32 This program was successful in increasing testing uptake, and community education was seen as a contributor to increasing awareness of HIV and PMTCT services and to decreasing the stigma surrounding HIV.32

For women in rural settings or those who do not have easy access to health centers, testing and counseling for PMTCT can be integrated into community prenatal and immunization outreach services. Other innovative practices involving the community include mobile testing and counseling services provided in Uganda and the traveler tester and counselor program in Kenya41 in which counselors use bicycles to reach remote settings to provide HIV testing and counseling services. These strategies can target pregnant women and can offer testing and referral for other PMTCT interventions. Models for increasing community involvement such as communication strategies to increase knowledge and awareness of HIV and PMTCT services are needed to reduce stigma and to increase the acceptability of testing and PMTCT interventions.31, 32

Conclusion 

Testing and counseling in prenatal, L&D, and postdelivery settings is an important gateway to providing PMTCT and treatment and care services to women and their families. Uptake of HIV testing and counseling can be greatly increased with provider-initiated testing and counseling, group pretest counseling sessions, and rapid HIV testing with same-day results. These services should be integrated into every component of reproductive health and MCH services. Finally, international and national policies that promote use of provider-initiated testing and counseling and rapid HIV testing should be widely adopted to further encourage scale-up of HIV testing and counseling in PMTCT settings.

Training health care providers in key elements of HIV testing and counseling and distributing work to appropriately trained lay providers can help alleviate the human resources crisis faced in many resource-limited countries as discussed elsewhere in this supplement (Sripipatana et al). Tools such as flip charts, wall charts, videos, and written information can assist lay personnel in conducting standardized testing and counseling activities. Male partner involvement should also be encouraged because men can affect women’s decisions to be tested and treated for HIV infection. Involving male partners will increase uptake of HIV testing and PMTCT interventions and will serve as a critical step in involving the family in HIV care. The community should also be involved in program planning and implementation to help reduce stigma and discrimination and to improve community awareness of HIV and PMTCT services beyond MCH settings.

Finally, scale-up of HIV testing and counseling should be accompanied by scale-up of other PMTCT interventions including provision of antiretroviral prophylaxis or treatment, modified obstetric practices, infant feeding counseling, and support for women who test positive as well as prevention counseling and intervention for women who test negative. Continued efforts must also be made to ensure that HIV-positive women have access to other prevention interventions such as cotrimoxazole prophylaxis; counseling to prevent transmission to HIV-negative partners (ie, secondary prevention); linkages or referral for early infant diagnosis; partner referral; and treatment, care, and support for women, their infants, and their families. This will ensure that testing and counseling within PMTCT and MCH settings can serve as points of entry to comprehensive HIV care for entire families.