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 frame19,23,22,310,311. 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 strategies312,313.
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
woman314,315. This has re-emphasized the need for the provision of
appropriate facilities for testing and
counselling126,277,316,317,318,319,320,321,322,323,324. Voluntary
testing of pregnant women is recommended and offered in many
countries17,325,326,327. 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 inadequate262,327,329,330,331,332,333.
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
women315,329.
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 services334,335,336,337.
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 regard336,338. 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.
