Introduction.

An estimated 17,000 children in Uganda were infected with HIV through mother-to-child transmission (MTCT) in 2009, despite a stable HIV prevalence of 7.5% among women of reproductive age (15–49 years) and high (94%) uptake of antenatal care (ANC) [1], [2]. HIV testing is the first and crucial step in prevention of MTCT (PMTCT); however, only 63% of pregnant Ugandan women were tested in 2010 [3]. A reduction in MTCT rate from roughly 40% to around 1% is possible through the provision of prophylactic therapy with three antiretroviral medicines (ARVs) administered to HIV infected women before, during and after delivery, cesarean section, and provision of prophylactic ARVs to newborns and replacement infant feeding [4].

In low-income countries with limited access to combination ARV regimens or the capacity to provide cesarean section and replacement feeding, the rate of MTCT can still be reduced to around 5%, provided that women are tested, enrolled in and complete the PMTCT program [5]–[7].

Long waiting times at health facilities and lack of comprehensive information about HIV and PMTCT, spousal disapproval and stigma, are generally suggested as barriers to the uptake and completion of PMTCT [8]–[11]. The World Health Organization (WHO) recommends that countries with generalized HIV epidemics implement opt-out or provider-initiated HIV testing during ANC to increase likelihood of HIV testing among pregnant women [12]. Health facility-based studies have indicated an increase in HIV testing rates during pregnancy and thus support utilization of these recommendations [13]–[18]. Accordingly, the Ugandan national policy guidelines for PMTCT recommends that all pregnant women are counseled and tested for HIV during ANC, provided they do not actively opt-out, or referred for testing if onsite services are not available [19]. Additionally, but so far with limited success in practice, joint couple HIV testing including the pregnant woman and her spouse has also been introduced in Uganda, hoping to expand the coverage of HIV testing and to reduce barriers to accessing PMTCT services [20]–[24].

Despite these efforts at the national level, evidence on the effectiveness of policy implementation at population-level is still lacking. This study examines barriers to HIV testing in the context of the national opt-out HIV testing policy and assesses population-based coverage of HIV testing during pregnancy in a prospective cohort of pregnant women identified through a health and demographic surveillance site in Uganda.

Abstract.

The aim was to assess population-level HIV-testing uptake among pregnant women, key for access to prevention-of mother to child transmission (PMTCT) services, and to identify risk factors for not being HIV tested,

The study was conducted May 2008–May 2010 in the Iganga/Mayuge Health and Demographic Surveillance Site (HDSS), Eastern Uganda, during regular surveillance of 68,000 individuals. All women identified to be pregnant May–July 2008 (n = 881) were interviewed about pregnancy-related issues and linked to the HDSS database for socio-demographic data. Women were followed-up via antenatal care (ANC) register reviews at the health facilities to collect data related to ANC services received, including HIV testing. Adjusted relative risk (aRR), and 95% confidence intervals (CI) for not being HIV tested were calculated using multivariable binomial regression among the 544 women who remained after record review.

Despite high ANC attendance (96%), the coverage of HIV testing was 64%. Only 6% of pregnant women who sought ANC at a facility without HIV testing services were referred for testing and only 20% received counseling regarding HIV. At ANC facilities with HIV testing services, 85% were tested. Only 4% of the women tested had been couple tested for HIV. Living more than three kilometers away from a health facility with HIV testing services was associated with not being tested both among the poorest (aRR,CI; 1.44,1.02–2.04) and the least poor women (aRR,CI;1.72,1.12–2.63).

The lack of onsite HIV testing services and distant ANC facilities lead to missed opportunities for PMTCT, especially for the poorest women. Referral systems for HIV testing need to be improved and testing should be expanded to lower level health facilities. This is in order to ensure that the policy of HIV testing during pregnancy is implemented more effectively and that testing is accessible for all.