Opt-out HIV testing during antenatal care: experiences of pregnant women in rural Uganda

Abstract

Two years after the introduction of provider-initiated, opt-out HIV counselling and testing during antenatal care (ANC) in Uganda, HIV testing uptake is still low. This study was carried out to explore pregnant women's experiences of, and views on, the policies for opt-out, and couple HIV testing, and to understand how the policy implementation could be improved in order to increase access to prevention of mother-to-child-transmission (PMTCT) services. The study was conducted at three ANC health facilities at different levels of care in rural eastern Uganda. Data were collected through sit-in observations during ANC and 18 semi-structured interviews with pregnant women receiving ANC, and thereafter analysed using latent content analysis. Pregnant women who received ANC from facilities that provided HIV testing on-site perceived HIV testing as compulsory without actually fully realizing the benefits of HIV testing and PMTCT. No referral for HIV testing or information about testing was given at ANC facilities that lacked HIV testing on-site. A major challenge of couple HIV testing was that pregnant women were made responsible for recruiting their spouses for testing, a precarious dilemma for many women who tried to fulfil health workers' requests without having the power to do so. In order to increase uptake of PMTCT services, the pre-test counselling in groups that precedes the provider-initiated HIV testing should be adjusted to inform women about the benefits of PMTCT. Further, if testing is perceived as compulsory it could potentially deter some women from seeking ANC services. In order to increase HIV testing of male partners new strategies are needed, for example peer-sensitization and male clinics. Moreover, to achieve the desired outcomes of the PMTCT programme, monitoring and evaluation should be built into the programme.

From caution to urgency: the evolution of HIV testing and counselling in Africa

“…37 In our review, evidence from four studies, the majority involving small groups of pregnant women, indicated that patients were not always aware they had the right to decline HTC in antenatal clinics, perhaps because of the power balance between patients and health-care providers. 29,31 However, studies in other regions suggest that women may find the routine offer of HTC acceptable because it "normalizes" the process of HTC. 38 Our review has several limitations.…”

“…Women that had been offered HTC in an ANC and accepted the offer (i) 22.2% stated that refusing the offer of a test was an option and believed that women could still receive services if they opted out of testing; (ii) the majority who underwent HIV testing stated they were not given the option of refusing in the ANC; (iii) HTC was considered a precondition for receiving care Larsson, 2011 29 …”

A Qualitative Study of Barriers to Effectiveness of Interventions to Prevent Mother-to-Child Transmission of HIV in Arba Minch, Ethiopia

“…The importance of family support for women living with HIV can never be overestimated especially when husbands and mothers-in-law in particular have traditionally played key roles in the care and maintenance of expectant mothers. As studies have highlighted, there exists huge potential for improving the effectiveness of PMTCT programs when people living with HIV have the support of their families [13,17,[28][29][30][31][32][33].…”

Antenatal Care and Couples’ HIV Testing in Rural Northern Uganda: A Gender Relations Analysis

“…While male involvement is key to couples' testing and can provide important benefits, Larsson et al (2012) highlighted significant challenges for implementation of couples' testing. The pressures on relationships arising from testing can be serious: "Women who test for HIV without their partner's knowledge or consent and turn out to be HIV positive have difficulty disclosing and face a number of potential negative reactions from their partners, including blame, and abandonment" (Medley, Mugerwa, Kennedy, & Sweat, 2012, p. 361).…”