Is 'Opt-Out HIV Testing' a real option among pregnant women in rural districts in Kenya?

Opondo Awiti Ujiji,Gilbert Wangalwa,Gaetano Marrone,David Wamalwa,Birgitta Rubenson,Festus Ilako,Anna Mia Ekström

doi:10.1186/1471-2458-11-151

Opondo Awiti Ujiji, Gilbert Wangalwa + Show 5 more

Open Access

https://doi.org/10.1186/1471-2458-11-151

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Abstract

BackgroundAn 'opt-out' policy of routine HIV counseling and testing (HCT) is being implemented across sub-Saharan Africa to expand prevention of mother-to-child transmission (PMTCT). Although the underlying assumption is that pregnant women in rural Africa are able to voluntarily consent to HIV testing, little is known about the reality and whether 'opt-out' HCT leads to higher completion rates of PMTCT. Factors associated with consent to HIV testing under the 'opt-out' approach were investigated through a large cross-sectional study in Kenya.MethodsObservations during HIV pre-test information sessions were followed by a cross-sectional survey of 900 pregnant women in three public district hospitals carrying out PMTCT in the Busia district. Women on their first antenatal care (ANC) visit during the current pregnancy were interviewed after giving blood for HIV testing but before learning their test results. Descriptive statistics and multivariate regression analysis were performed.ResultsOf the 900 women participating, 97% tested for HIV. Lack of testing kits was the only reason for women not being tested, i.e. nobody declined HIV testing. Despite the fact that 96% had more than four earlier pregnancies and 37% had been tested for HIV at ANC previously, only 17% of the women surveyed knew that testing was optional. Only 20% of those surveyed felt they could make an informed decision to decline HIV testing. Making an informed decision to decline HIV testing was associated with knowing that testing was optional (OR = 5.44, 95%CI 3.44-8.59), not having a stable relationship with the child's father (OR = 1.76, 95%CI 1.02-3.03), and not having discussed HIV testing with a partner before the ANC visit (OR = 2.64 95%CI 1.79-3.86).ConclusionHigh coverage of HIV testing appears to be achieved at the cost of pregnant women not understanding that testing is optional. Good quality HIV pre-test information is central to ensure that pregnant women understand and accept the reasons for testing and will thus come back to collect their test results, an important prerequisite for completing PMTCT for those who test HIV-positive.

Highlights

An ‘opt-out’ policy of routine HIV counseling and testing (HCT) is being implemented across subSaharan Africa to expand prevention of mother-to-child transmission (PMTCT)
With the current approach, high coverage of HIV testing at antenatal care (ANC) may be achieved at the cost of women not understanding that testing is optional and at the risk of low uptake and completion of PMTCT which is a major problem in this area, where between 30%-40% of all pregnant women enrolled in ANC programs are estimated to not come back for their test results, and documented in other parts of sub-Saharan Africa (SSA) [16,17]
Good quality HIV pre-test counseling is central for making pregnant women understand and accept the reasons for testing and encourage consent to HIV testing, an important prerequisite for the consequent completion of the PMTCT program by those who are HIV infected

Summary

Introduction

An ‘opt-out’ policy of routine HIV counseling and testing (HCT) is being implemented across subSaharan Africa to expand prevention of mother-to-child transmission (PMTCT). The current guidelines were designed to increase coverage of testing and identify patients in need of antiretroviral therapy (ART) In the former ‘opt in’ HIV strategy, the initiative to be tested was with the individual, not with the health care services, and individual pre-test counseling followed by informed consent was required before testing. Proponents of “opt out” assert that the provider-initiated consent process is crucial to achieve high coverage of HIV testing and prevention of motherto-child transmissions (PMTCT) while it still protects autonomy [8]. It helps the ‘streamlining’ of HIV into ‘normal care’ thereby decreasing the stigma [8,9]

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