Horizons | Research Summary| HIV Voluntary Counseling and Testing: An Essential Component in Preventing Mother-to-Child Transmission of HIV

RESEARCH SUMMARY

December 2003

HIV Voluntary Counseling and Testing:
An Essential Component in Preventing Mother-to-Child Transmission

Key Findings (continued)

Coverage of VCT within PMTCT programs is increasing.

As shown in Figure 1, more than 22,000 women sought antenatal care as new clients at the three sites in Kenya and Zambia where the cohort study was implemented during the approximately 27-month-long study period. Slightly more than 13,000 women (61 percent) received individual pre-test HIV counseling, where women had a chance to learn more about the advantages and disadvantages of HIV testing and ask questions in a confidential setting. Overall, 7,280 women, or less than one-third, of new antenatal care clients went on to have an HIV test.

Figure 1. Service utilization by site

Broad averages mask significant differences in the coverage of PMTCT counseling across the 11 countries involved in the evaluation of UN-supported PMTCT pilot projects. The percent of women who come to clinics for antenatal care and receive individual HIV pre-test counseling ranges from less than 25 percent in Zambia (across the six pilot sites) to more than 90 percent in Burundi and Rwanda. An examination of the time trend in service statistics since the introduction of pilot programs shows that for many countries there has been a significant increase in the proportion of women who are offered pre-test counseling. This was the case in such countries as India, Kenya, and Uganda, where, by the end of the evaluation period, antenatal clinics were counseling more than 90 percent of clients.

Client use of services declines substantially during the VCT process.

Uptake of HIV counseling services is negatively affected by staff shortages and the organization of service delivery, which influences both the supply and demand for HIV counseling. Probably the single most important hurdle to providing pre-test counseling is a shortage of staff. Good counseling takes time, which is in short supply at many busy clinics where workers already provide antenatal, well-child, and family planning services. At some sites, lack of privacy, long waits, or rules that require clients to return another day for counseling further discourage women from being counseled. As demonstrated by the sites that have made pre-test counseling routine, adaptations to the staffing and organization of service delivery can achieve high levels of coverage. Successful strategies have included hiring additional medical staff, utilizing professional or lay counselors, reassigning some MCH staff to become dedicated counselors, and reorganizing staff work hours.

Photo credit: Melissa May/ Population Council

The percentage of women who accept an HIV test after counseling ranges between 64 and 83 percent in the 11 countries with UN-supported pilot sites. The quality of counseling is undoubtedly one key factor motivating women to take the HIV test. Another variable is whether the blood drawn for the HIV test is part of the collection of blood drawn for syphilis and other routine antenatal tests or whether a second blood draw, for example, a finger prick, is required for the HIV test.

Many programs in the evaluation used a testing algorithm that required women to come back on another day to receive their results. Findings show that women do not receive their results for a variety of reasons: results may not be ready when women return, women change their minds or were never sure about the benefit of taking the test and thus do not return for results, women do not return for additional antenatal care visits, and women’s partners are opposed to testing. Programs do not routinely report the proportion of women who collect their test results, but the operations research studies in Kenya and Zambia suggest that, on average, 20 to 50 percent of women do not get their results, though there is large variation depending on the setting. For example, in a large urban health center in Lusaka, Zambia, which used rapid tests but often did not have results available the same day as the test, only 37 percent of women collected their test results; by contrast, at a rural clinic in Zambia, where the counselors offered antenatal care through outreach services at health posts and performed rapid HIV tests that were completed as part of their one-day visit, almost all clients received their results.

Pregnant women value information received through HIV counseling and testing.

Interviews with clients reveal that overall, HIV counseling and testing during antenatal care provide information to clients that is tailored to their concerns and context about their own risk, the health of their partner and children, and their relationship with their partner. Although sometimes the information is confusing or incomplete, in most cases women found the discussions to be empowering because they learn they are not helpless. Many women at PMTCT sites in Zambia felt, as these clients did, that the information was useful and positive:

“… I got information I did not know.”

“I liked the advice on whether I should be tested or not.”

“I liked the message about MTCT to avoid infecting my baby.”

Another advantage noted by respondents was that women no longer have to fearfully guess about their status but can instead choose to have an HIV test. Women pointed out that a negative result is an enormous relief and that a positive result is delivered in the context of services to help them have a healthy baby as well as information about living positively with HIV. As one woman said:

“I now know even if I was HIV-positive I could still live a normal life unlike when I only knew HIV is death.”

Information and counseling promote couple communication about HIV and PMTCT.

In Lusaka, pregnant women hear about and discuss HIV issues, including PMTCT, through various mechanisms, including a group talk for clients waiting for ANC services, and during pre- and post-test counseling. Findings from this site indicate that women who have gone through the education, counseling, and testing process as part of the PMTCT program are increasingly broaching sensitive HIV-related topics with their partner. As shown in Figure 2, the proportion of women who discussed sexually transmitted infections, PMTCT, and VCT rose significantly following exposure to the PMTCT program (p < .05), with the greatest increases seen in discussion of PMTCT and VCT.

Figure 2. Percent of women (n = 419) discussing HIV topics with their partners before and after participation in the Lusaka PMTCT program

Serostatus disclosure is high, although HIV-positive women are significantly less likely to disclose than HIV-negative women.

Discussing the HIV testing experience and sharing results with a partner is a key step to eliciting support and involvement. More than 70 percent of respondents in Lusaka shared their test result with their partner (this was measured between two weeks and five months after the HIV test). Data from Kenya show similar results. After being counseled and tested as part of the PMTCT program, more than half of women (58 percent in Karatina and 64 percent in Homa Bay) shared their HIV result with their partner. Overall, 81 percent, 74 percent, and 69 percent of women in Lusaka, Karatina, and Homa Bay, respectively, shared their HIV test result with someone (partner, family member, friend, etc.). As seen in Table 1, disclosure varied with HIV status, with HIV-positive women significantly less likely to disclose to anyone than HIV-negative women (p < .05).

Table 1 Percent disclosing HIV test results

The proportion of women disclosing their HIV status to partners and others within these cohorts is notably higher than the figures described in the literature on PMTCT in sub-Saharan Africa that draws heavily on studies of clinical trials. It may be that women in routine PMTCT services receive more support for disclosure during their counseling sessions than women participating in trials focusing on the efficacy of preventive antiretroviral therapies.

The study found both positive and negative outcomes of serostatus disclosure to partners.

Disclosure of an HIV test result to a partner can be an important step for HIV-positive women in accessing care and support, because women can then more openly seek medical care and support services. HIV-negative women can also benefit by disclosing to partners that they’ve had an HIV test and sharing the topics discussed during counseling, since this can be an entry point to enlisting support for behavioral changes that reduce infection risk. Disclosure can also have a positive effect on personal relationships, for both HIV-positive and HIV-negative women. For example, as seen in Figure 3, in the two to three months after HIV testing during pregnancy, women in Lusaka who disclosed to their partner were significantly more likely than women who did not disclose to report that they had experienced a strengthening in their relationship in the previous three months (p < .05 ). Although the proportion of HIV-negative women who disclosed and reported a strengthened relationship was greater than the figure for HIV-positive women, this difference was not statistically significant.

Figure 3. Percentage of women experiencing stronger relationship in last 3 months, by whether disclosure had been made to partner

Yet the benefits that women may receive from sharing HIV test results with their partners need to be balanced against the potential risks that an individual woman may face when she discloses that she had an HIV test and what her HIV status is. Two negative outcomes of disclosure were investigated among the Zambian and Kenyan cohorts: physical abuse and the break-up of the marriage.

Figure 4 shows the proportion of women at one week postpartum who had disclosed their HIV status to their partners and experienced physical abuse in the last three months, compared to the proportion of women who did not disclose their HIV status but had also experienced physical abuse. Both groups are compared to a control group of postpartum women who reported physical abuse in their last pregnancy, which served as a proxy measure for the underlying levels of physical abuse in pregnancy across the three sites. The findings are not consistent across the three sites. There is no statistically significant effect of disclosure on physical abuse in Lusaka. Study participants at the Karatina site are substantially less likely than the comparison group to have experienced physical violence in the preceding three months, regardless of partner disclosure. In contrast, in Homa Bay, women who disclosed their serostatus were more likely to experience physical abuse in the preceding three months, compared to women who did not disclose their HIV status and to the baseline group. The differences in proportions found in Karatina and Homa Bay are statistically significant (p < .05).

Figure 4. Percentage of women experiencing physical abuse in last 3 months, by whether disclosure had been made to partner

During the three months preceding the interview, marriage break-up occurred in less than 5 percent of marriages for women in the study across the three sites. Women who did not disclose their serostatus were significantly more likely to have experienced a break-up of their marriage in the last three months at all three sites. Without further study, it is impossible to determine why marriages among women who did not disclose their HIV status broke up.

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