Across Africa in 2005, <10% of an estimated 13.5 million HIV-infected women accessed HIV counseling and testing (HCT) and <10% of pregnant women received antiretroviral (ARV) prophylaxis for the prevention of mother-to-child transmission of HIV (PMTCT).1,2 Studies on the acceptance of HIV testing in PMTCT settings have found that low HIV risk perception and stigma were often associated with not testing.3-6 Most The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the Centers for Disease Prevention and Control. *Based on an estimated 2006 African population of 900 million, 55% of whom are women, 30% of whom are of reproductive age and sexually active.of these studies were conducted in settings offering traditional (opt-in) rather than universal (opt-out) HCT, however. The introduction of routine opt-out HCT at antenatal care (ANC) clinics using rapid tests with same-day results has been shown to greatly increase the uptake of PMTCT services.7-9 Although the proportion of women opting out of routine HCT is relatively low, in Africa, each percentage point of women not testing represents nearly 1.5 million women,* of whom an average of 7% (>100,000 women) can be expected to be infected with HIV.1,10,11 Thus, as routine HCT becomes the standard entry point to PMTCT programs, understanding the reasons why some women decline the service is increasingly important.
Tororo District Hospital (TDH) is a 200-bed government referral hospital servicing a catchment population of approximately 1 million people in eastern Uganda. In August 2004, TDH introduced opt-out HCT in the ANC clinic, whereby PMTCT education and HIV testing were provided routinely for all pregnant women unless they declined testing. In December 2004, a similar routine opt-out HCT service was established in the maternity ward for women presenting with undocumented HIV status.
Between October 2004 and June 2005, a sequential sample of 137 pregnant or postdelivery women who declined HCT in the ANC clinic or the maternity ward were asked to answer a short questionnaire about their main reason for opting out. Women provided consent for participation after being assured of anonymity of the information collected. Those who declined to participate were not asked any further questions. Participants were interviewed in their own language by a trained midwife counselor. Respondents' age, parity, occupation, marital status, educational level, household size, and head of household status were recorded in addition to their main reason for declining to test. Questions related to opting out of testing were asked in an open-ended fashion, and the answers were coded.
All variables with a P value <0.05 in bivariate analyses were included in the multivariate model, and only those that remained significant using a backward elimination method were kept in the final model. Logistic regression was used to identify significant associations between reporting the need for partner consent as a reason for opting out and sociodemographic characteristics.
Between October 2004 and June 2005, 6.4% (218 of 3392) of pregnant women without a recent documented HIV test opted out of HCT in the ANC clinic, and 7% (25 of 354) of women in the maternity ward without a recent documented HIV test opted out. Five (3.6%) of 137 women declined to respond to the questionnaire. The 132 women interviewed for this evaluation represented 54% (132 of 243) of all women opting out of HCT during that period.
As shown in Table 1, 69% of women interviewed were ≤25 years of age (range: 15-42 years), 90% were married or cohabiting with a partner, 20% had no formal education, 51% had received some primary education, 84% were homemakers or peasants, 59% were nulliparous or primiparous, and 87% had their spouse or partner as the head of the household. There was no difference in age or parity distribution among these women and those who received HCT: the median and mean ages were 23 and 23.6 years (SD = 5.95), respectively, for women who opted out as compared to 23 and 24.5 years (SD = 5.89), respectively, for women who opted in. Median parity was 1 in both groups.
The main reason given for not accepting HCT was the need for a partner's consent or presence before testing, accounting for 51% (67 of 131) of all women interviewed (see Table 1). Other reasons included fearing the test result (knowing one's status) or disclosure of the test result to one's partner (15%), needing more time to make a decision (9%), and having reportedly been recently tested (11%). Responses did not differ significantly among women interviewed in the ANC or maternity ward. In bivariate analysis, invoking the need for one's partner's consent was associated with being married (odds ratio [OR] = 15.0, 95% confidence interval [CI]: 1.89 to 119.1), having one's spouse or partner as head of the household (OR = 5.39, 95% CI: 1.45 to 20.0), a household size <5 persons (OR = 2.29, 95% CI: 1.06 to 4.95), having had none or a partial primary education (OR = 2.29, 95% CI: 1.11 to 4.74), and age (OR = 0.93, 95% CI: 0.87 to 0.99). In multivariate analysis, only age (fitted as a continuous variable) and marital status remained significantly associated with women reporting partner consent as a primary reason for opting out (age: OR = 0.90, 95% CI: 0.84 to 0.96; marital status: OR = 23.1, 95% CI: 2.72 to 194.7).
During the 9 months after the introduction of routine opt-out HCT in this hospital, <7% of pregnant women opted out of the service. The age distribution of these women did not differ from those who opted to get tested. Among women who opted out, younger married women were more likely to report the need for their partner's assent to get tested. A similar finding was made among women attending an ANC clinic in Brazil.12 This is in contrast to the low HIV risk perception and stigma previously found to be associated with opting out of VCT programs.3-6 A possible explanation might be that the community surrounding TDH has benefited from a sustained home- and facility-based HIV prevention, care, and treatment intervention since 2001,13 and thus has high awareness and less stigma about HIV/AIDS.
Most women opting out were married and 25 years of age or younger. Thus, others factors not explicitly explored in this study could have better differentiated these women from those who opted in, such as domestic violence, which may be implicit to the need for partner consent or to the fear of disclosure. This is not supported by most studies about HCT and disclosure in sub-Saharan Africa, however.14 In any case, our results indicate that partner involvement and disclosure may influence the uptake of and adherence to HIV care and prevention interventions. This may be particularly relevant for young women who have limited access to education and whose partners control reproductive choices and resource allocations within the family, as is the case in many parts of sub-Saharan Africa.10,11,14,15 In such contexts, it may be important to offer younger married ANC clients enhanced counseling support to empower them to convince their partner to get tested and counseled together with them. Counselors can also assist couple members to disclose their serostatus to each other.14 At TDH, attempts to increase male attendance at the ANC clinic have been largely unsuccessful, and male attendance has remained at less than 5%.9 However, we found that many more men accompany their partners to the maternity ward, and accept being tested around the time of labor and delivery.9 Moreover, as in many health centers in Uganda, in TDH, VCT and PMTCT clinics operate in parallel, with widely divergent male attendance rates. Another strategy involving men that we are thus pursuing is to ask men systematically attending the VCT clinic if they have a pregnant wife or partner attending the ANC clinic, and if so, to offer them posttest counseling together.
Given the high prevalence of HIV serodiscordance among couples in Uganda and Africa and the prevention and care benefits of disclosure,16-20 pregnant women need to be empowered to appreciate the importance of PMTCT for themselves and their family, to learn their HIV serostatus as early as possible in their pregnancy, and to involve their male partners actively in PMTCT.
The authors thank the clients, in-charges, and staff of the TDH Mother and Child Health Unit for their cooperation in collecting data for this study. They are indebted to Drs. Mary Glenn Fowler and Rebecca Bunnell for their useful comments and edits. This program is supported by the Centers for Disease Control and Prevention through the Emergency Plan for AIDS Relief.
Jaco Homsy, MD, MPH*†
Rachel King, MPH†
Samuel S. Malamba, MSc†
Christine Opio, RN, RM†
Alice Okallany, RN, RM‡
Julius N. Kalamya, MBChB, MPH†
John H. Obonyo, MBChB, MPH‡
Jonathan Mermin, MD, MPH§
*Institute for Global Health University of California, San Francisco San Francisco, CA †Centers for Disease Prevention and Control (CDC)-Uganda Global AIDS Program National Center for HIV, STD, and TB Prevention CDC
‡Tororo District Hospital Tororo, Uganda
§CDC-Kenya Coordinating Office for Global Health CDC Nairobi, Kenya
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