Rapid Testing May Not Improve Uptake of HIV Testing and Same Day Results in a Rural South African Community: A Cohort Study of 12,000 Women

000 Women. PLoS ONE 3(10): e3501. doi:10.1371/journal.pone.0003501 Rapid Testing May Not Improve Uptake of HIV Testing and Same Day Results in a Rural South African Community: A Cohort Study of 12,000 Women Ntombizodumo B. Mkwanazi 0 Deven Patel 0 Marie-Louise Newell 0 Nigel C. Rollins 0 A. Coutsoudis 0 H. M. Coovadia 0 R. M. Bland 0 Seth C. Kalichman, University of Connecticut, United States of America 0 1 Africa Centre for Health and Population Studies, University of KwaZulu-Natal , Durban , South Africa , 2 Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London , London , United Kingdom , 3 Department of Paediatrics and Child Health, University of KwaZulu-Natal , Durban , South Africa , 4 Centre for HIV/AIDS Networking, University of KwaZulu-Natal , Durban , South Africa , 5 Division of Developmental Medicine, University of Glasgow , Glasgow , United Kingdom Background: Rapid testing of pregnant women aims to increase uptake of HIV testing and results and thus optimize care. We report on the acceptability of HIV counselling and testing, and uptake of results, before and after the introduction of rapid testing in this area. Methods and Principal Findings: HIV counsellors offered counselling and testing to women attending 8 antenatal clinics, prior to enrolment into a study examining infant feeding and postnatal HIV transmission. From August 2001 to April 2003, blood was sent for HIV ELISA testing in line with the Prevention of Mother-to-Child Transmission (PMTCT) programme in the district. From May 2003 to September 2004 women were offered a rapid HIV test as part of the PMTCT programme, but also continued to have ELISA testing for study purposes. Of 12,323 women counselled, 5,879 attended clinic prior to May 2003, and 6,444 after May 2003 when rapid testing was introduced; of whom 4,324 (74.6%) and 4,810 (74.6%) agreed to have an HIV test respectively. Of the 4,810 women who had a rapid HIV test, only 166 (3.4%) requested to receive their results on the same day as testing, the remainder opted to return for results at a later appointment. Women with secondary school education were less likely to agree to testing than those with no education (AOR 0.648, p,0.001), as were women aged 2135 (AOR 0.762, p,0.001) and .35 years (AOR 0.756, p,0.01) compared to those ,20 years. Conclusions: Contrary to other reports, few women who had rapid tests accepted their HIV results the same day. Finding strategies to increase the proportion of pregnant women knowing their HIV results is critical so that appropriate care can be given. - Pregnant women need to know their HIV status to receive optimal care during pregnancy, delivery and postnatally[1,2,3]. Antenatal rapid testing aims to increase efficiency at clinics by avoiding transportation of samples to laboratories; increase the proportion of women receiving same-day results; and ensure that women booking late in pregnancy obtain HIV results prior to delivery[4]. However, despite the widespread introduction of programmes to prevent mother-to-child transmission (MTCT) of HIV, many women decline HIV testing for reasons that are not fully understood[1,5,6,7,8,9,10,11], and women who are tested do not always wish to know their results. Reports of increased uptake of HIV results with Rapid Tests (and immediate results)[12] appear counter-intuitive, and may reflect compliant behaviour rather than valid consent. We report on the acceptability of HIV testing and returning for results, in a cohort of pregnant women from a rural area of South Africa with one of the highest HIV prevalences in the world[13,14]. The women were part of a large study examining the risks of postnatal HIV transmission associated with different modes of infant feeding[15,16], which started enrolment at the same time as a Prevention of Mother-to-Child Transmission (PMTCT) programme was implemented in the area. The findings reported represent an operational setting, and the paper evaluates an evolving programme and discusses what the results might mean. Pregnant women attending 8 clinics in rural KwaZulu-Natal were offered HIV voluntary counselling and testing prior to enrolment into a cohort study investigating infant feeding and geographical location. A demographic surveillance system operates in the same area, established in the year 2000[20]. In 2003 population-based HIV testing through annual surveys was started in the surveillance area and shows some of the highest populationbased infection rates ever documented world-wide; prevalence of 51% (95% CI 4755%) amongst women aged 2529 and 44% (95% CI 3849%) in men aged 3034[20]. Of the 25,901 people resident in the area and eligible for inclusion in the populationbased HIV survey (women aged 1549 years and men aged 1554 years), 19,867 (77%) were contacted for HIV testing, of whom 11,551 (58%) consented to be tested[20]. However, less than 5% of those tested returned for their results (personal communication, Till Barnighausen, Africa Centre). Whilst the latter results are from a population surveillance system and not a clinic setting providing voluntary counselling and testing, they do provide greater contextual information with which to interpret the results presented in this manuscript. This study was approved by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal, Durban, South Africa. Overall, 12,323 pregnant women received HIV counselling; their socio-demographic characteristics are shown in Table 1. Figure 1 shows the proportion of women who accepted testing and those who returned for results. Overall 74% (9,134/12,323) of women accepted testing, of whom 9 did not want their results. In a logistic regression model including maternal education, age and parity, women with secondary school education were less likely to accept testing than those with no education (AOR 0.648; 95% CI 0.540.79; p,0.001). Compared to women below 20 years, those aged 2135 years were less likely to accept testing (AOR 0.762; Women counselled N = 12,323 HIV transmission[15]. Local government clinics are organized to render antenatal care, with HIV counselling and testing, on specific days of the week. To cope with large client numbers, a 3stage group counselling process was employed at all the clinics in the area (14 fixed government clinics at the time of the study). Stage 1 (20 minutes) Group Education Clinic assistants conducted a group education session to all women (1060 per session) waiting at the antenatal clinic. Topics covered included: general HIV/AIDS information, definition of disease, transmission modes, mother-to-child transmission issues, advantages and disadvantages of testing, interpretation of positive, negative and indeterminate results. Stage 2 (15 minutes) Group Counselling HIV counsellors conducted small group counselling with five to six women in a private room. They addressed issues of confidentiality, personal risk assessment (...truncated)