1. Introduction

For many years, little was known about preventing transmission of HIV infection from mother to child. Recently, however, many advances have been made in developing effective and affordable interventions that reduce the likelihood that a woman will pass HIV on to her baby.

The two most important interventions - the provision of antiretroviral drugs and the avoidance of breastfeeding - only apply to HIV-positive women. Both therefore require that a woman know whether she is infected by HIV. And yet in the developing countries, where 95% of mother-to-child infections take place, there are very few counselling and testing services that allow a woman to find out her HIV status.

HIV counselling and testing in relation to pregnancy and other reproductive health services may prove a valuable entry point for provision of counselling and voluntary testing to the wider community of healthy and asymptomatic women and their partners. Some reproductive health settings such as STD clinics, paediatric services and family planning clinics may provide an opportunity to offer testing to potential mothers and fathers of further children, while antenatal services will allow testing to be offered to women already pregnant and their partners.

Counselling and voluntary testing for HIV have benefits beyond the prevention of transmission from mother to child. Counselling services have been slow to gain acceptance in many countries, especially where HIV is heavily stigmatized and access to services and support for the HIV-infected is limited. Indeed, HIV testing has often been used as a diagnostic tool to confirm symptomatic AIDS. But a growing number of studies attests to the value of counselling and voluntary HIV testing in largely healthy populations. These services have been shown to contribute to an increase in safe behaviour at the individual level, and are likely also to reduce the ignorance, fear and stigma associated with HIV infection in the population at large.

Few countries have actively promoted counselling services and few have yet developed clear national guidelines on the provision of counselling and voluntary HIV testing in reproductive health service settings. However, service provision does not grind to a halt just because there are no clear guidelines. That means that facility managers have to make difficult decisions without guidelines, and often with incomplete information. This document aims to provide guidance on the counselling and HIV testing for managers of antenatal clinics and other pregnancy-related services, whether they are public, private or non-profit. It may also be used as a basis for discussions in developing a national policy in this increasingly important area.

The document gives an overview of the magnitude of the problem of HIV transmission from mother to child. It then focuses on the benefits of counselling and voluntary HIV testing in the context of pregnancy, and discusses the content of such counselling. Operational issues and potential difficulties in setting up and maintaining such a service are explored.