Mother-to-child transmission (MTCT) of HIV is a serious public health problem, especially in sub-Saharan Africa, where 86% of the world's 2.2 million infected children live. Most of the HIV infections in children are caused by perinatal transmission.1 The use of potent antiretroviral (ARV) drugs, cesarian delivery, and avoidance of breast-feeding has reduced MTCT of HIV to less than 2% in the developed world.2,3 In resource-constrained settings, the use of short ARV regimens and advice on infant-feeding methods have been shown to reduce MTCT of HIV transmission by 37% to 50%.4-7 However, to access these interventions, HIV-infected pregnant women need to know their HIV status. Voluntary counseling and testing for HIV in pregnant women is therefore a public health priority, given the proven effect of these perinatal interventions.
High acceptance rates for HIV testing (range, 69%- 99%) among pregnant women have been shown in previous studies conducted in resource-poor settings.8-11 However, 10% to 42% of those women who were tested did not return for HIV posttest counseling and results.9-13 HIV-positive status, education, low income, a younger age, little knowledge of prevention of MTCT of HIV, disapproval by partner, fear of discrimination, and domestic violence were predictors of failure to return for HIV posttest results.9,11,13,14 However, most of these studies were conducted when ARVs for perinatal prevention were not widely available and the operational voluntary counseling and testing services for HIV in prenatal care were few. ARV drugs for prevention of MTCT and for treatment of HIV-infected people to prolong life are becoming increasingly available in resource-poor settings. It is therefore expected that more pregnant women will accept testing and intervention. It is thus important to know the profile of women who do not return for results after having accepted testing in an era when HIV treatment and care is increasingly available.
In Tanzania, 58% of the 1.8 million people living with HIV are women.15 Until recently, prevention of MTCT (PMTCT) programs were limited to national and referral hospitals.8,9 The Ministry of Health, however, is extending PMTCT services to all government health facilities offering prenatal, delivery, and postnatal care. More than 90% of pregnant women in Tanzania receive routine antenatal care at government primary health care (PHC) facilities.8 In this article, we present the results of a study conducted to determine the predictors for failure to return for HIV posttest results among pregnant women attending PHC clinics in Moshi urban district, Tanzania. This information will assist health managers in planning for the upgrade and further extension of services to other PHC facilities.
Study Design and Subjects
This was part of a prospective cohort study that enrolled women in the third trimester of pregnancy and followed them up to 18 months after delivery, in a program for the prevention of MTCT of HIV. The study was conducted in the 2 largest government PHC clinics, Majengo and Pasua, located in Moshi urban district, Kilimanjaro region in Northern Tanzania. These 2 community clinics were selected because they are both the largest and represent the largest geographic area, giving the best possible random selection among 60,000 women of reproductive age.
All pregnant women attending the clinics for routine care, who were in their third trimester and residing in Moshi urban district, were eligible to participate. They were informed about the study and its aims, and were invited to participate between June 2002 and March 2004. Trained research nurses conducted individual pretest counseling of every woman and provided information about HIV and PMTCT. The women were assured that the information they provided and the test results would be treated confidentially, and that participation in the study was voluntary. They could withdraw from participation or follow-up at any time and this would not affect their prenatal care or access to other services at the clinic. Ten women refused to participate after the pretest session, whereas 2654 women agreed to participate. Women wishing to participate in the study gave their informed consent in writing. For illiterate women, the right thumbprint was taken as a signature. Sociodemographic data, economic information, sexual behavior, obstetric history, knowledge of HIV, knowledge of perinatal transmission, and their partner's sociodemographic profile and behavior factors were collected during a face-to-face interview using a structured pretested questionnaire. The interviews were conducted in Kiswahili, the national language. Venous blood was drawn for diagnosis of HIV and syphilis. The women were assigned numeric identifiers, and all the questionnaires, appointment cards, and laboratory samples were labeled with matching numbers to maintain confidentiality.
The women were asked to return specifically for their HIV test results after 1 week. The numeric identifier was required for the return consultation and was the only identification of participating clients. No other service required the identifier, thus guaranteeing that those presenting the identifier were requesting for their HIV or sexually transmitted infections (STIs) test results. Posttest counseling was done individually with each woman and, when possible, by the same nurse who conducted the pretest counseling. HIV-positive women were given an NVP tablet, with full instructions on how to take the medication at the onset of labor. They were also instructed to bring the infants for administration of NVP syrup within 3 days after delivery. Issues regarding infant-feeding methods were discussed in detail; mixed feeding was discouraged. HIV-negative women were encouraged to undergo a retest after 3 months and advised about the importance of exclusive breast-feeding. Syphilis-positive women were treated with a single intramuscular dose of 2.4 million units of benzathine penicillin. They were encouraged to inform their partners and bring them for counseling, testing, and treatment where required. All the services were free of charge for both the women andtheir partners. Ethical clearance for the study was given by the Tanzanian Ministry of Health and by the Norwegian Ethical Committee.
Within 6 hours of collection, blood was centrifuged on-site, and serum was tested for HIV by using 2 rapid tests, Determine HIV-1/2 (Abbott Laboratories, Abbott Park, IL) and Capillus HIV-1/HIV-2 (Trinity Biotech, Co Wicklow, Ireland). HIV was diagnosed when both test results were positive. In case of discordance between the 2 tests, a third test, the enzyme-linked immunosorbent assay test, Vironostika HIV Uni-Form II (Organon Teknika, Boxtel, Netherlands), was used. Active syphilis was diagnosed by positive results of both a rapid plasma regain test (Becton Dickinson, Cockeysville, MD) and a specific test, Determine Syphilis TP (Abbott Laboratories).
Data were analyzed using SPSS statistical software (SPSS, Inc, Chicago, IL). Statistical comparison between groups was made using χ2 test and Fisher exact test, when appropriate. Odds ratios (ORs) were calculated with 95% confidence intervals (CIs) to measure the strength of association. Multiple logistic regression analysis was performed to identify independent factors associated with failure to return for HIV test results. A cutoff value of P < 0.20 in the univariate analysis was used as the criteria to include variables in the multivariate models. The level of significance was set at P = 0.05.
Ten of the 2664 women offered HIV counseling declined testing, producing an acceptance rate of 99.6%. The reasons for declining testing were as follows: (1) not being ready to face the HIV test results, (2) need to consult their partners, and (3) perception of not being at risk because they were born-again Christians. For the 2654 participating women, the mean age was 24.6 years (SD, 5.4 years; range, 14-43 years) and mean parity was 1.2 (range, 0-9). The majority were married (61%) or cohabiting (30%), had completed 7 years of primary education (86%), were not formally employed (95%), and had an income of less than 30,000 Tanzanian shillings (≈US $30) per month (94%). Only 9.6% of the women had been tested for HIV before.
A total of 182 women (6.9%) failed to return for the HIV posttest counseling and results. Women aged 20 to 24years were more likely to return for test results than those younger than 20 years or those aged 25 years or older. In theunivariate analysis (Table 1), women were significantly less likely to return for results if they (1) were Christian (P < 0.001), (2) attended Majengo clinic (P < 0.0001), (3) consumed alcohol (P < 0.0001), or (4) were in gestation for 29weeks or longer (P = 0.003). Knowledge of at least one mode of vertical transmission for HIV was high (86%); knowledge of HIV transmission and prevention methods was also high. However, these factors did not predict failure to return for test results. No association was found between failure to return and education, income, marital status, parity, number of sexual partners, risk perception, or report of genital symptoms at interview.
Table 2 depicts the predictors of failure to return for HIV test results in relation to the male partner's characteristics. There was a tendency of increased failure to collect the HIV test results with increasing partner's age (e.g., 8.0% of women with partners aged 35-71 years did not return for their test results, compared with those with partners aged <25 years [5.6%]). Furthermore, as the age difference between couples increased, so was the likelihood of failure to return for test results: 2.5% when the woman was older; 4.4% when they were of the same age; 6.3% or 7.3% when partner was older by 1 to 4 years or by 5 years or more, respectively. Women with partners who did not come for counseling and testing (P < 0.0001), were frequent travelers (P < 0.001), consumed alcohol (P < 0.001), or verbally or physically abused them (P = 0.02) were more likely not to return for HIV test results. Eighty-nine percent of the women reported having discussed one or more reproductive health issues (condoms [30%], family planning [63%], sexual satisfaction [65%], or HIV [82%]) with their partner and were more likely to return for test results than the others.
In multivariate analysis, failure to bring the partner for testing remained significantly associated with failure to return for HIV posttest results (AOR, 12.63; 95% CI, 3.10-51.39). Other independent predictors for failure to return for HIV test results were the site of recruitment, occasional alcohol consumption, age of 25 to 29 years, gestation age of 29 weeks or longer, alcohol intake by the male partner, male partner who frequently travels, and never having discussed reproductive health issues with their partners.
Sixteen (8.7%) of the 184 HIV-positive women and 166 (6.7%) of the HIV-negative women did not return for test results. One hundred thirty of 168 HIV-positive women who returned received NVP and 103 infants received NVP syrup. Two of the 23 women with syphilis did not return for test results. Nineteen (90%) of 21 women received treatment, and 7 of the partners came for treatment. HIV or syphilis seropositivity did not predict failure to return for test results.
Failure to return for HIV test results is a major obstacle in both HIV prevention and perinatal intervention programs. Knowing one's HIV status is important for both HIV-positive and HIV-negative pregnant women. For those who are HIV positive, early identification and treatment is crucial to prevent transmission to the infant; it also facilitates early discussion of infant-feeding issues, prevention of transmission to others, future pregnancy choices, and delaying of clinical progression. For HIV-negative women, appropriate counseling should help to impart knowledge of prevention and promote behavior change so that they can aspire to remain uninfected.16 It is therefore important to know which factors are associated with failure to return for posttest results so that these can be addressed effectively during counseling.
In this study, 93% of the pregnant women returned for their HIV posttest results. The rate of failure to return for posttest results (7%) is much lower than that observed among pregnant women in Dar es Salaam (32%), Nairobi (31%), and West Africa (18.2%).9-11 Individual counseling, confidentiality, and increased availability of ARV drugs might have all contributed to the desire to know one's serostatus.17 The observed high rate of acceptance of HIV testing and the return for test results should encourage health workers to consistently offer counseling and testing to pregnant women. This will help reach many women of reproductive age, given that 90% or more of them have never undergone a test before.
Gestation age of 29 weeks or longer was the only obstetrical factor related to failure to return for test results. The probability of failure to return increased with increasing gestation age.11 Because we recruited women in the last trimester (gestation age, 28-36 weeks), some may have delivered before their appointed time for the results or were too tired to make the journey back to the clinic for the test results. Testing at first booking, using rapid assays, and giving the results on the same day may be a better way to avoid losing the chance to give test results to some women. In addition, a special approach is needed for women who are first seen during labor to maximize the benefits of perinatal interventions.
Alcohol consumption by the women themselves or their male partner was a strong predictor of failure to return for test results (AOR, 1.6 for women and 1.8 for men). Unexpectedly, occasional drinkers were more likely to fail to return for test results than daily drinkers. The pattern of drinking in East Africa tends to be binging. Typically, people drink more on payday with an increase of sexual risk-taking under the influence of alcohol (eg, having multiple partners and having unprotected sex).18,19 Cubbins et al20 found that the use of alcohol, at least monthly, in rural Zimbabwe was associated with reduced likelihood to collect test results or be treated for sexually transmitted infections (STIs), and with increased risk for HIV, HSV-2, and syphilis. In this study, women who consumed alcohol, compared with nondrinkers, had higher rates of HIV (9.5% vs. 5.8%, respectively; P = 0.001), had more casual partners in the past 12 months (6.2% vs. 3.6%, respectively; P = 0.002), and had a greater number of lifetime partners (≥2 lifetime partners, 57.3% vs. 37.8%, respectively; P < 0.001). Alcohol is emerging as an important risk factor for failure to return for test results and for HIV/STIs in low-economy settings.18,19 This group should be especially targeted during pretest counseling and in health education programs.
Male partner factors were strong predictors of failure to return for test results in this study, especially the failure to bring the partner for counseling and testing. Many women (90%) named their partner as the first person they would wish to share the HIV/STI results with; however, only 328 (12%) managed to bring them for testing. In addition, women who had never discussed reproductive health issues or were verbally or physically abused by their partner were more likely to fail to return for the test results.11 Most of the participating women were young, had children at an early age, had little education, and had very little income or none. As a result, most were dependent on men; thus, men are the main decision-makers. Therefore, some women may have failed to return for the test results because of fear of loss of security, domestic violence, ordivorce.9,11
We also observed that greater difference in age between partners and increased partner age were associated not only with a greater tendency for failure to return for the test results, but also for HIV infection and verbal or physical abuse. This further illustrates women's lack of control in relationships. Therefore, the involvement of men is vital for the success in HIV perinatal interventions. For example, HIV-infected women need to take ARV medication and they need to bring the infants for medication shortly after delivery. Decisions on infant-feeding issues need to be undertaken to reduce transmission. Condom use is another topic where women need to involve their partners. All these important factors need the support and cooperation of the partner. It is not enough for the woman to know her HIV status if she is powerless to follow the advice given. Couple counseling should thus be prioritized in prenatal care, where partners are given counseling and testing together, instead of targeting the women alone. In Kenya, HIV-positive women who received couple counseling were 3 times more likely to take NVP at delivery and 5 times more likely to avoid breast-feeding.21 Innovative methods that target men outside the hospital environment (e.g., at work) are required.
This study had several limitations. Our subjects received prenatal care at government primary health clinics. This may have excluded women who chose private health care or those whose pregnancies were complicated and were referred to district or referral hospital. It might also have excluded pregnant women whose first contact with health care is during delivery. Counselor characteristics, time spent in counseling, and waiting time, which had an effect on return rates in other studies,11,13 were not registered in this study. Despite the limitations, we feel that the recruited women fairly represent the women of reproductive age in the area because of the very high rate of attendance (>95%).8
In conclusion, although testing was highly acceptable, 7% of the women did not return for the results. Testing at first booking and giving results on the same day may increase the number of women receiving the results. However, the involvement of male partners is paramount in making the interventions work. Specially designed couple-counseling programs should be given priority, given the overcrowded, male-unfriendly prenatal care atmosphere. Alcohol should be addressed as a risk in community education programs. Tanzania is extending its PMTCT program. Thus, there is a need to improve community awareness and knowledge of the availability of HIV perinatal interventions. Furthermore, inasmuch as HIV counseling, testing, and treating infected women is new in the prenatal setting in most PHC clinics, there will be a need for frequent in-service training of health workers as management and guidelines change.
The authors thank the Tanzanian Ministry of Health and the regional and district medical officers for allowing the study to be conducted. We also thank the team of nurses and laboratory staff at Majengo and Pasua clinics for their hard work and commitment, the mothers who participated, and Robert K. Stallman for the review of the article. The study was funded by a grant from the Letten Saugstads Foundation.
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