(introduction...)

Voluntary HIV counselling and testing in pregnancy

Testing of antenatal women

Pregnant women have been the target of many seroprevalence studies, as they provide an accessible cohort for HIV testing and a stable sampling frame^{19,23,22,310,311}. While valuable information has been obtained on trends in the epidemic, the practice of testing in pregnancy has been criticized in the past, as one which stigmatizes women and which has not led to implementation of appropriate health strategies^312,313.

With increasing knowledge about HIV and about mother-to-child transmission in particular, the focus has moved from the possible public health benefits of testing in pregnancy to the potential benefits for the individual woman^314,315. This has re-emphasized the need for the provision of appropriate facilities for testing and counselling^{126,277,316,317,318,319,320,321,322,323,324}. Voluntary testing of pregnant women is recommended and offered in many countries^{17,325,326,327}. The introduction of testing programmes has increased the number of identified HIV positive women in many centres³²⁸. Despite this, identification of infected women may not be optimal if women do not access antenatal care, or where counselling and testing services are inadequate^{262,327,329,330,331,332,333}.

Wherever possible, voluntary counselling and testing should be available to any pregnant woman who requests it and offered to all in areas of moderate or high prevalence. Routine testing of pregnant women without consent or without access to counselling is, however, an unacceptable practice and the disadvantages may negate any benefit obtained from knowing the HIV status of the women. These include a reluctance to utilize maternity services through fear of discrimination, denial of a positive diagnosis and stigmatization. Recent discussion about, and recommendations for mandatory testing of pregnant women or newborns have led to concern about the autonomy and rights of women^315,329.

There are, however, a number of potential benefits to women of voluntary HIV testing prior to or during pregnancy. This is the case even in the absence of expensive interventions such as long-course antiretroviral therapy. These benefits include:

1 Where a woman is found to be infected, this knowledge can facilitate early counselling and treatment.

2 A diagnosis in the mother allows appropriate treatment and follow-up of her child.

3 Knowledge of her HIV status enables the woman to take decisions on continuation of the pregnancy and on future fertility.

4 Testing allows an opportunity to implement strategies to attempt to prevent transmission to the child.

5 Knowledge of HIV status enables the woman to take precautions to help prevent transmission to sexual partners.

6 Women diagnosed as HIV positive can tell their sexual partners and enable partners to be counselled and tested.

7 If the test result is negative, women can be guided in appropriate HIV prevention measures and risk reduction behaviour.

Balanced against these advantages are the possible disadvantages of HIV testing in pregnancy. These will vary from community to community, but reports have described an increase in the risk of violence against women; the possibility that the woman may be stigmatized within her community and by health workers; higher levels of anxiety and psychological sequelae; and concerns about the additional work load for maternity services^{334,335,336,337}. Several studies have described the reluctance of some women to return for their test results³³⁷,³³⁸'³³⁹. In Nairobi, 5.9% of HIV-positive women reported violence related to the HIV test result. After changing to a policy of giving results out only on request, only 35% of women who had agreed to testing returned to ask for results³³⁷. In Kigali, 63.9% of positive women and 71.3% of HIV-negative women returned for test results and the only variable found to be associated with failure to return for counselling was a positive HIV test³³⁸.

Women should be encouraged to bring their sexual partner(s) for counselling and testing wherever possible. However, very few testing services have managed to achieve much success in this regard^336,338. The best predictor of return for counselling by women in one US study was the time spent in counselling women and the counsellor's skills³³⁹. Voluntary counselling and testing (VCT) services for couples, preconceptual counselling and testing services not linked to antenatal care may increase testing uptake. However, it must be emphasized that, unless people have real choices for action once they have their test results (i.e. access to affordable services such as mother-to-child transmission preventive interventions, and care and support services), there is no good reason to take a test (see: Counselling and voluntary HIV testing for pregnant women in high HIV prevalence countries: Guidance for service providers (UNAIDS, May 1999))

A qualified person should take the blood specimen for an HIV test, using "universal precautions" against accidental transmission in all cases. These must include the safe disposal of needles and syringes. The type of tests used will depend upon local seroprevalence, policy and available facilities. In most cases blood specimens will be sent to the appropriate laboratory, but in some areas, dry blood spot testing may be an acceptable alternative. The first line test for HIV-antibodies is an enzyme-linked immuno-absorbent assay (ELISA) test, or a rapid test algorithm. Depending on local conditions, a confirmatory test with a second ELISA or rapid test using a different test kit, or a Western Blot should be performed. Any testing strategy must be undertaken with appropriate laboratory quality assessment³⁴⁰,³⁴¹.

With increasingly sensitive and specific simple and "rapid" tests becoming available, on-site testing may become more feasible (see The importance of simple/rapid assays in HIV testing. WHO/UNAIDS recommendations; WER 1998, 73, 321-328). Recent reports of the use of "same-day" rapid test results in a rural hospital in a resource-poor setting and in an urban STI clinic have suggested that this is an acceptable and appropriate intervention³⁴²,³⁴³. Preliminary reports of the use of dual rapid tests for same day diagnosis in antenatal clinics suggest that this is an appropriate and acceptable way to provide testing in this setting. The major advantage is that early results enable more women to access antenatal strategies for the prevention of mother-to-child transmission.

Counselling before and after HIV testing in pregnancy

Pre- and post-test counselling are essential elements of the management of HIV in pregnancy. Pre-test counselling enables women and men to make informed decisions about an HIV test. Post-test counselling is an integral part of the management of the HIV-positive person, and provides an important opportunity for risk-reduction messages for those found to be HIV-negative.

Pre-test counselling

HIV testing should be accompanied by the provision of pre-test information and by informed consent to the test by the woman (see Table 5). Pre-test counselling implies explanation of both the test and the illness to the woman in a non-directive manner, and answering any questions prior to the performance of the test. The woman should be given time to decide on the test and, if unsure, should be counselled to take more time to think about the test and return at a later stage. Information about HIV testing can be incorporated into the health education and promotion activities of antenatal clinics and need not be too time consuming within maternity services³¹⁹. Various models have been tried, including group counselling, video education, incorporating information on HIV into the first visit interview by midwives and the use of lay counsellors^344,345. An appropriate model should be developed for the circumstances of each service, based on the prevalence and the level of prior awareness of the women in the community.

Table 5 : Pre-test counselling
[Based on guidelines from the Johannesburg Community AIDS Centre]

Post-test counselling

The essential elements of post test counselling for HIV positive women are illustrated in Table 6. Counselling implies more than merely giving a positive result, and continued care and advice will be necessary as part of the management throughout the pregnancy and beyond^344,346,347. The choice of appropriate counsellor will depend upon the circumstance of the practice or health service: counsellors ideally should have personal qualities, which equip them for the job, but many of the skills can be acquired during training. Wherever possible, counselling should be provided in the woman's home language and within the same cultural background. The involvement of peer counsellors - women who are themselves HIV-infected, who are able to counsel and to share their own experiences, fears and successes may be very valuable and should be encouraged. The integration of peer counsellors and support groups into the work of health services can be a very valuable addition to the available services.

Table 6 : Post-test counselling
[Based on guidelines from the Johannesburg Community AIDS Centre]

The delay between taking the test and giving the result should be as short as possible, as the woman may be very concerned about the test and the implications of the result. Women who test positive should be encouraged to bring their male partner(s) for counselling and testing wherever possible.

Post-test counselling should also be provided for HIV-negative women, with a focus on providing information to enable them to avoid infection. This could be provided on a group basis, or by individual health workers, depending on the circumstances.

Counselling about pregnancy-related issues

There are several issues to be addressed when counselling HIV positive pregnant women, in addition to the general issues related to HIV infection. These include information about the interactions of HIV and pregnancy, options of termination of pregnancy, discussion about disclosure to the male partner, the risk of mother-to-child transmission and possible interventions to prevent this, other treatment options, infant feeding and HIV and future fertility. Some of these pregnancy-related issues are detailed in Table 7.

Table 7 : Issues in counselling HIV-positive pregnant women

HIV-infected women should be given appropriate information to make informed decisions about the continuation of their pregnancy and future fertility³⁴⁸. Termination of pregnancy should be offered to HIV positive women; where this is legal. It should be clear to health care workers that offering termination should never be coercive and that all women, irrespective of their HIV status, have the right to determine the course of their reproductive life. Although there are some reports of increased rates of termination in HIV positive women, the majority of women will elect to continue with the pregnancy^{249,349,350,351}. Knowledge of HIV infection had little effect on reproductive trends and the decision on future children in a number of studies^{248,352,353,354} although this has been seen more in developing countries than developed countries. However, a family planning intervention in Rwanda, providing access to and information about contraceptives, showed a reduction in subsequent pregnancies which was greater than in HIV-negative women³⁵⁵, and other studies have shown a reduction in the number of pregnancies in HIV positive women^{349,356,357,358}.