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Low uptake of HIV testing during antenatal care: a population-based study from eastern Uganda

Larsson, Elin Ca; Waiswa, Petera,b,c; Thorson, Annaa; Tomson, Görana,d; Peterson, Stefana,b; Pariyo, Georgeb; Ekström, Anna Miaa

doi: 10.1097/QAD.0b013e32832eff81

aDivision of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Sweden

bMakerere University School of Public Health, Kampala, Uganda

cIganga District Health Department, Iganga, Uganda

dMedical Management Centre (MMC), Karolinska Institutet, Stockholm, Sweden.

Received 31 March, 2009

Revised 25 May, 2009

Accepted 3 June, 2009

In 2003, 10% of pregnant women in Uganda were tested for HIV [1]. Three years later, the proportion of HIV-tested pregnant women who received their test results had only increased to 21%, despite high antenatal care (ANC) attendance of 94% and information campaigns [2]. To increase the uptake of HIV testing and reduce mother-to-child transmission (MTCT) of HIV, an opt-out testing policy was introduced in Uganda in 2006, stating that all pregnant women routinely should be offered/referred for HIV testing during ANC [3]. Previous health-facility-based studies of routine HIV testing at ANC from sub-Saharan Africa including Uganda have shown uptake up to 80% [4–8].

This population-based study from rural, eastern Uganda examines the uptake and determinants for HIV testing among pregnant women in Iganga/Mayuge Demographic Surveillance Site (DSS), where field assistants regularly collect data from all households on vital events and other variables in a population of 67 200 inhabitants. The demographic surveillance area (DSA) is served by one hospital, eight public-health centers, three nongovernmental organization clinics, and multiple private health facilities; all provide ANC and four provide HIV testing. The adult HIV prevalence is 6.4%. An interviewer-mediated questionnaire study regarding women's experiences of ANC, HIV testing, delivery practices, and healthcare postpartum during their last pregnancy was conducted in March–August 2007. All women in the DSA with a live baby aged 1–4 months (n = 403) were interviewed, and the 97% responding to the question of HIV testing were included in this analysis. Information on sociodemographic and socioeconomic (principal components analysis of household assets) was drawn from the DSS database and linked to the interview data. STATA 10 (Stata Corporation, College Station, Texas, USA) was used to calculate chi-squares for the association between independent variables and the outcome ‘HIV tested’. Apart from age, only variables with a P value of less than 0.1 were included in the multivariate analysis and removed with a backwards-stepwise method to calculate adjusted prevalence ratios (aPRs). We analyzed several proxy measures for quality of ANC and included the most robust variable, receiving malaria prophylaxis, in the multivariate models. Data on whether an ANC facility provided testing on site was available for a subset of women (n = 170). The study was ethically approved by the Makerere University School of Public Health Institutional Review Board and Uganda National Council of Science and Technology.

The respondents' were 26.4 years on average and most had primary school education, were married/cohabitating, and had given birth before. The ANC attendance rate was higher than the Ugandan average, 96%. Most women reported two to three ANC visits during their last pregnancy, but only 58.5% had been tested for HIV. The likelihood of being HIV tested was higher among primi-parous women, the least poor, and those who received higher quality ANC (Table 1). Twice as many women, who went to ANC facilities with HIV testing services on site, were tested (71%) as compared to only 35% at ANC facilities that had to refer for testing. Hence, if no referral was needed, the likelihood of testing increased by 41% [aPR 1.41; 95% confidence interval (CI) 1.28–1.47] adjusting for age, parity, quality of ANC, and socio-economic status.

Table 1

Table 1

It is disappointing that despite an opt-out policy and even higher ANC attendance than the Ugandan average, less than 60% of pregnant women were HIV tested. It is unlikely that multiparous women's lower propensity to test can be justified by HIV testing during earlier pregnancies, and regardless, the Ugandan policy encourages repeated testing at every pregnancy.

Referral for HIV testing seems ineffective, and poor referral outcomes have been demonstrated previously in Uganda [9]. The fact that the poorest women were at highest risk of not being tested is another example of the law of inverse care; that is, the availability of good medical care tends to vary inversely with need [10].

Uptake of HIV testing during pregnancy is related to both individual factors, for example, knowledge and poverty, and to health system factors, for example, availability of services and good quality care [11,12]. Interviews with pregnant women indicate that choosing an ANC facility without testing services might be a conscious choice to avoid testing (forthcoming publication).

Health facility-based studies from sub-Saharan Africa appear to have overestimated the uptake of opt-out HIV testing during ANC [4–8,13]. Thus, population-based approaches may be more accurate for assessment of policy change impact.

To increase the coverage of HIV testing among pregnant women especially for the poorest and multiparous women, intensified counseling at health facilities and referral follow-up are needed, and HIV testing services should be made available at as many ANC facilities as possible.

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This research is part of the project Effects of Antiretrovirals for HIV on African health systems, Maternal and Child Health (ARVMAC), was in part supported by the European Community's FP6 funding. This publication reflects only the author's views. The European Community is not liable for any use that may be made of the information herein. The ARVMAC consortium includes the following seven partner institutions: Karolinska Institutet (Co-coordinating Institute), Stockholm, Sweden; Centre de Recherche en Sante de Nouna, Kossi, Burkina Faso; Ifakara Health Institute, Dar es Salaam, Tanzania; Institute of Tropical Medicine, Antwerp, Belgium; Makerere University School of Public Health, Kampala, Uganda; Swiss Tropical Institute, Basel, Switzerland; University of Heidelberg, Hygiene Institute, Department of Tropical Hygiene and Public Health, Heidelberg, Germany (

This study was also supported under a Sida/SAREC – Makerere University – Karolinska Institutet research collaboration and also by funds provided by Save the Children USA through a Grant from the Bill & Melinda Gates Foundation for the Saving Newborn Lives Project. We thank the study participants, research assistants, and Iganga/Mayuge Demographic Surveillance Site, and acknowledge useful comments on the article from Anastasia Pharris.

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