HIV testing during pregnancy in sub-Saharan Africa

Globally, 2 million children live with HIV, and 370,000 more children are infected every year; three-quarters of these new infections occur in sub-Saharan Africa [1]. A total of 90% of children with HIV acquired the infection by mother-to-child transmission (MTCT), either during the antepartum, intrapartum or postpartum period [2]. In one study, the probability of transmission was 23% in utero, 65% intrapartum or early postpartum, and 12% in late postpartum [3]. With appropriate treatment and intervention the risk of a child becoming infected can be reduced from approximately 25% to less than 2% [4].

It is estimated that only 18% of all HIV-positive women are tested during pregnancy and of those tested, 80% receive antiretroviral prophylaxis [1]. This suggests that the lack of testing may be hindering efforts to increase prevention coverage for pregnant women in need. Reasons for the low coverage of HIV testing include inadequate resources, stigma and discrimination, attitudes and skills of healthcare providers, and the strategy used for HIV testing [5].

There has been substantial evolution in antenatal HIV testing approaches overtime. The different approaches constitute a spectrum where at one end there is voluntary counseling and testing, and at the other end there is mandatory (compulsory) testing. In between these two extremes, we have routine counseling and testing. In an effort to increase coverage, the global strategy has shifted from voluntary to routine counseling and testing. Mandatory testing is yet to receive widespread acceptance, if ever.

Ethical considerations around HIV testing for pregnant women

There are two main reasons for HIV testing during pregnancy: to prevent MTCT of HIV and to provide treatment to women with indications for antiretroviral therapy. However, there is evidence that HIV testing can lead to violence against women, stigmatization of women within their community and by health workers, and emotional and psychological sequelae [6,7]. Debates surrounding the testing of HIV during pregnancy have been based on the ethical principles of beneficence and autonomy.

If the individual’s autonomy is respected, then a woman should have the right to refuse a HIV test. In practice, women are frequently unaware of this right. For example, in a study in Botswana, where HIV testing is routinely offered to pregnant women, 68% of participants believed that they could not refuse the test [8]. The right to refuse a HIV test can only be guaranteed if women are aware that they could refuse and are empowered to do so. In sub-Saharan Africa, culture dictates that people do not question medical advice from providers. In addition, there is often an imbalance in the power relationship between the provider and clients, especially women, which makes rational decision-making almost impossible. The reasons why women may fail to oppose medical recommendations include the high social status of the health professionals, gender inequality and the fear that providers might negatively impact on healthcare provision [9].

The principle of beneficence has been used to argue for and against HIV testing during pregnancy. The case against HIV testing is strong where resources are not available to provide appropriate interventions to prevent MTCT and to treat HIV-infected women. Under such conditions, the harm of testing outweighs the benefits. However, where resources are available and the HIV prevalence is high, the argument favors HIV testing. Under such conditions, some authors reported that it is ethically plausible to institute mandatory HIV testing [10,11]. However, the denial of opportunity to consent to an HIV test directly infringes on individual right of autonomy and dignity and can affect utilization of healthcare services.

Voluntary HIV counseling & testing during pregnancy

An early strategy for HIV testing during pregnancy focused on voluntary counseling and testing (VCT). In the VCT approach, all pregnant women are given a brief education on HIV testing, either individually or as a group, after which they opt-in for HIV counseling and testing. Therefore, VCT is sometimes known as an ‘opt-in’ approach to distinguish it from the ‘opt-out’ approach in which HIV testing is considered routine, but a woman can choose to decline [9].

The key components of VCT include pretest counseling, HIV testing and post-test counseling for all women, irrespective of their test results. VCT is based on three main principles often known as the three Cs: consent, counseling and confidentiality. The aim of pretest counseling is to provide information on the clinical and prevention benefits of testing, the right to refuse, the follow-up services that will be offered and the importance of sharing results with a partner [12]. The purpose of post-test counseling is to inform the client of the HIV test results, deal with feelings and concerns arising from test results and refer the client for follow-up care and counseling [13].

The VCT approach has the advantage that, when properly implemented, there is respect of individual autonomy, privacy, confidentiality, informed consent and dignity. However, this approach has been unable to increase antenatal HIV testing coverage to desirable levels in many countries in sub-Saharan Africa. Therefore, in recent years, there has been a global move from VCT to routine HIV testing, which has the potential to increase coverage.

Routine HIV testing & counseling during pregnancy

Until 2000, routine testing of pregnant women was discouraged because of its potential negative consequences, such as reluctance to utilize maternity services and stigmatization [13–15]. In routine testing, women are informed that HIV testing will be provided as part of an essential package of standard antenatal care; they have the option to decline or opt-out if they choose. Women have the right to refuse HIV testing without affecting their access to other services.

Similar to the VCT approach, there is pretest counseling, HIV testing and post-test counseling. Group pretest counseling is provided for all women attending antenatal care. Women are given the option to have individual counseling in addition to the group counseling if they desire. After the pretest counseling, women who do not want HIV testing can opt-out. The post-test counseling is generally time-consuming as it has to be conducted at individual level and information tailored according to the individual HIV serostatus. Routine HIV testing is currently used in many sub-Saharan African countries, including Kenya, South Africa, Swaziland, Zambia and Zimbabwe [101]. The details of how routine HIV testing is conducted and the degree to which emphasis is given on consent, counseling and confidentiality vary from country to country.

This approach has been shown to increase coverage and decrease stigma associated with HIV testing in many countries in sub-Saharan Africa. However, it has been criticized for lack of emphasis on informed consent, as the concept of ‘routine’ testing sometimes misleads providers to believe that there is no need for consent. Lack of informed consent has been associated with fear, disbelief, shock and embarrassment on an individual learning their HIV status [14,16].

Provider-initiated HIV testing & counseling

Provider-initiated HIV testing and counseling (PITC) is a type of routine HIV testing that has recently been endorsed by the WHO and the The Joint United Nations Programme on HIV and AIDS (UNAIDS). In August 2006, in an effort to provide some direction and guidance on routine HIV testing, the WHO and UNAIDS issued a joint statement in which they promoted PITC [9]. According to the WHO/UNAIDS, PITC is a strategy that is not limited to antenatal HIV testing but should be offered to all adults in health facilities irrespective of their reason of seeking services [4]. Both organizations recognize that, in light of resource constraints, prioritization of sites for implementation of PITC will be required. Therefore, the WHO and UNAIDS currently recommend that antenatal, childbirth and postpartum services be one priority location for implementing PITC in countries with generalized epidemics [4]. Some sub-Saharan African countries, such as Tanzania, have taken up this new strategy [101].

Issues that will need to be properly discussed and addressed at the national level as more countries adopt this strategy include pretest counseling, informed consent, post-test counseling, referrals and access to appropriate services, confidentiality, stigma and discrimination, and ensuring an enabling environment including policy and resources [9]. Failure to properly address these issues could lead to the failure of PITC programs.

Rapid HIV testing during labor

The traditional method of preventing MTCT of HIV is testing during pregnancy [17,18]. In settings where many women give birth with unknown HIV status, either because of low antenatal attendance or otherwise, HIV testing during labor provides the last window of opportunity before delivery for interventions to reduce MTCT of HIV [12].

Although rapid testing can ensure that HIV-positive pregnant women receive treatment quickly, there are questions over how ethical it is. A prerequisite for informed consent is proper counseling. The argument against HIV testing during labor is that proper counseling cannot be guaranteed during labor and that some women will be unable to cope emotionally with positive results during labor.

In practice, however, rapid HIV testing during labor has been successful in many settings [12]. Results of studies in sub-Saharan Africa have been very encouraging, with acceptability rates for HIV testing ranging from 73 to 97% [12,19,20]. Therefore, current international recommendations are that rapid HIV testing be conducted during labor [4].

In a systematic review, Pai et al. found that the overall sensitivity and specificity of blood-based rapid tests was high compared with oral tests and that a two-step strategy was superior to a single-test strategy in labor and delivery settings [19]. The two-step strategy (i.e., parallel or serial testing) is, therefore, recommended for HIV testing. While parallel testing avoids indeterminate results produced by serial testing, it is significantly more costly [21].

Mandatory HIV testing during pregnancy

The continued search for ways to increase the proportion of women tested for HIV during pregnancy led to the proposal of mandatory HIV testing by some authors. In 2006, Clark called for mandatory HIV testing in Botswana where HIV prevalence rates are the highest in the African continent [10]. Schuklenk and Kleinsmidt, in 2007, proposed to pilot mandatory HIV testing of pregnant women during antenatal care in areas with high HIV prevalence rates [11]. While mandatory testing is ethically plausible, particularly when coupled with guaranteed access to treatment and care, the moment to employ this strategy is yet to come [16]. A mandatory HIV testing program could deter women from seeking antenatal care, increase unsafe sexual behaviour after pregnancy and outstretch an already overburdened health system with limited resources [22,23]. In sub-Saharan Africa, many barriers remain for pregnant women in terms of access to HIV treatment and care. As long as these barriers persist, mandatory testing cannot be justified.

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.