HIV-1 testing in pregnancy: acceptability and correlates of return for test results

Mother-to-child transmission of HIV-1 is a major public health concern; particularly in sub-Saharan Africa where 90% of the 1.2 million infected children live ^[1]. The use of antiretroviral agents and the avoidance of breast-feeding can prevent mother-to-child transmission of HIV-1 ^[2,3]. However, these interventions require the identification of HIV-1- infected women during pregnancy.

Studies in Europe and North America ^[4,5] suggest that women who perceive themselves as at risk of HIV-1 are more likely to accept HIV-1 testing. In African studies, women who are HIV-1 seropositive are less likely to return for test results than those who are seronegative ^[6,7]. It is likely that in settings where HIV infection is stigmatized and treatment is not readily available HIV-1 testing appeals less to those who perceive themselves to be at a high risk.

To implement strategies for the prevention of perinatal HIV-1 transmission, it is necessary to optimize the process of voluntary counselling and testing for HIV-1 during pregnancy.

We conducted a study to evaluate HIV-1 testing acceptability and return for test results in two Nairobi city council antenatal clinics. Pregnant women attending the clinics received pre-test counselling and were offered HIV-1 testing at the time of routine syphilis and haemoglobin level testing. After blood was drawn, a questionnaire was administered on sociodemographic and obstetric characteristics.

Only two out of 399 women offered HIV-1 testing declined testing (an acceptance rate of 99.8%). Fifty (12.6%) of the 397 women tested were HIV-1 positive. A history of previous pregnancy [odds ratio (OR) 2.9, 95% confidence interval (CI) 1.5, 11.3], miscarriage (OR 2.9, 95% CI 1.4, 6.1), and sexually transmitted disease (OR 5.0, 95% CI 2.1, 11.3) were associated with being HIV-1 positive. A total of 379 (99.5%) of the women said HIV testing should be offered to all antenatal mothers.

A total of 276 (69%) of the women returned to collect their results. Women who collected their results were similar to those who did not with respect to age, education, marital status, socioeconomic status and occupation. Women who did not return to collect their results were more likely to be HIV-1 positive (OR 2.0, 95% CI 1.1, 3.3) and to have had a previous pregnancy (OR 1.7, 95% CI 1.0, 2.5) (Table 1).

Table 1

We found that women readily accepted HIV-1 testing, and most women actually felt that HIV-1 testing should be routinely offered in the antenatal clinic. Although women agreed to HIV-1 testing at the time that it was offered, we found that 31% did not return to obtain their results. This was perhaps a more polite way for them to decline HIV-1 testing. Allowing women to choose to obtain results may be an important way to maintain their autonomy. The fact that 44% of HIV-1-positive women did not return for test results has significant implications for the implementation of strategies that require the identification of HIV-1-infected women to prevent perinatal HIV-1 transmission. At the time of this study in 1994, there were no effective options to prevent perinatal HIV-1 transmission, and testing may be more acceptable with effective interventions available. Childcare commitments may explain why some women fail to return for test results because women who have had previous pregnancies were less likely to return for test results.

Pretest counselling should include the importance of checking on test results and assurance about fears women may have regarding testing.

James Kiarie

Ruth Nduati

Kamau Koigi

Janet Musia

Grace John