HIV Test in Pregnancy
The principal purpose of testing a woman for HIV during pregnancy is to prevent any possible infection being passed on to her unborn child. Mother to Child Transmission (MTCT) can occur during pregnancy, during labour and birth or through breastfeeding. However, with appropriate treatment and intervention, the chances of a child becoming infected can be reduced from around 25% to less than 2%.
These days, in areas where antiretroviral therapy is available, testing in pregnancy also allows for the mother’s infection to be identified and treated. This will enable her to remain healthy enough to care for her baby and see her child grow up.
For many women, pregnancy will be the only time in their young adult lives when they access healthcare services on a regular basis. It therefore presents an excellent opportunity not only to screen for HIV, but also to educate and advise about the dangers of the virus.
In most developed nations, HIV tests are either routinely offered as part of antenatal care or are offered to pregnant women thought to be at high risk of exposure to HIV. This has helped to reduce rates of mother-to-child transmission dramatically.
There are two different forms of routine testing: opt-out and opt-in.
In an increasing number of countries, routine testing is now offered on an "opt-out" basis. That means that all women receive an HIV test, unless they specifically state that they do not want one. Before testing, all women are given information about what HIV is, what the test is for and how it will be carried out. Any woman that receives a positive result will then be counselled and given appropriate treatment if necessary. Studies in developed countries have shown that when pregnant women are offered a routine HIV test with counselling, around 85–95% agree to have one.
With opt-in testing, a woman may be informed that a test is available, but they will only be given one if they specifically request it. Generally this means that only women who are worried about HIV (perhaps because they fit into a "high-risk group") will agree to be tested. Opt-in testing is generally considered less effective than opt-out. Many women believe that they simply don’t need the test, or fear that the midwife or doctor will make assumptions about their levels of "risky" behaviour if they agree to it. This means uptake tends to be much lower.
In some countries (particularly those with limited resources), HIV testing is not routinely offered as part of national prenatal care programmes at all. However, internationally funded MTCT programs are now being set up in many developing countries, and HIV testing in pregnancy is on the rise.
What actually happens when a woman goes for testing in Moldova?
In Moldova, HIV testing is carried out at the first meeting with the family doctor, or obstetrician, gynaecologist, neo-natologist, at around the 10–12th week of pregnancy. Opt-out voluntary HIV testing policy is applied, meaning that the woman can refuse to be tested for HIV and still receive natal care. Blood will be taken, and this blood will then be screened for HIV, usually at the same time that a full blood count is taken and rubella antibodies, hepatitis B and syphilis infection are tested for. Information or a leaflet will usually be given, explaining exactly what is being tested for and why. Post-test counselling will be offered to all women when they receive their test result, regardless of whether it is positive or negative.
If there is no record of the woman being tested throughout the pregnancy period and she only comes in to the natal care facility for delivery, a rapid HIV test will be carried out in order to ensure that the safety of the child.
What options other than voluntary testing are there?
On a sliding scale of the level of intervention women face during pregnancy, routine opt-out testing is generally considered to be somewhere in the middle. It is common, acceptable to most and it works, without infringing on a woman’s rights. At either end of this scale however, you have two vastly contrasting strategies. One is the option of no intervention at all, which can lead to high levels of MTCT, and a large population of HIV+ children. The other is the controversial choice of mandatory testing.
Mandatory testing is different from voluntary testing because the mother has no choice over whether she gets tested or not. She is bound by law to be tested and no consent is required.
Testing in pregnancy in high prevalence areas
Routine voluntary testing in pregnancy is advisable anywhere, but for developing countries at the heart of the AIDS epidemic, it is an essential step in preventing MTCT and the onward spread of HIV. Non-governmental organisations and charities have long been helping to run complete programmes to prevent mother to child transmission in developing countries, but their work is often restricted to small areas or individual hospitals. Government-implemented nationwide screening programmes are therefore necessary to provide universal coverage. Until recently, the uptake of routine voluntary testing in resource-poor countries was low, but progress is now being made.
Antenatal screening can be difficult to implement in resource poor settings for a number of reasons:
Monetary constraints can mean that it is simply not financially viable to provide tests for every pregnant woman
Stigma and discrimination can be severe in certain areas, and many women fear people will discover their status if they take a test.
Lack of education can make doctors and midwives more wary of women with HIV, particularly if standard universal precautions (such as surgical gloves) are not available during delivery. This can in turn make women reluctant to find out their status in case they are treated differently or are refused care.
Lack of drugs, specialist care or breast milk formula to actually prevent MTCT can lead to the belief that testing for HIV is a waste of time.
However, when fully informed of the benefits of testing, many women in high prevalence areas are more than willing to receive a test. A study carried out in Zimbabwe in 2005 for example, found that out of 285 women, 55% had actually been tested for HIV in pregnancy, but 80% would be willing to take the test. This led the investigators to recommend that "opt-out" voluntary testing should be introduced across the country.
Note: This information is cross-posted and slightly adapted from AVERT.org in order to emphasize some aspects refering particulary to Moldova. For more details, visual adds, updated information and primary sources, please visit AVERT.org web page.