Group PreTest Counseling A Strategy to Increase HIV Rapid Test Uptake Among Pregnant Women Attending

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REPÚBLICA DE MOÇAMBIQUE MINISTÉRIO DA SAÚDE
Group Pre-Test Counseling A Strategy to
Increase HIV Rapid Test UptakeAmong Pregnant
Women Attending Antenatal Clinics (ANC) Isabelle
Yersin, Fatima Oliveira-Tsiouris, Judite Langa,
Josue Lima, Jessica Justman, Wafaa M El-Sadr
International Center for AIDS Care and Treatment
Programs (ICAP) at Columbia University Mailman
School of Public Health Health
INTRODUCTION
RESULTS
In the short time since the implementation of the
group pre-test counseling method, the proportion
of women offered pre-test counseling has
increased. The percent of women attending their
first prenatal visit who accessed HIV TC
services increased from 42 in February of 2005
to 85 by the end of April 2006. Acceptance of
testing among women attending group pre-test
counseling increased but it varied by site,
reaching 99.9 in an urban area in Maputo City
(2716 counseled and 2715 tested), 85 in a
semi-urban provincial capital in Nampula (1462
counseled and 1224 tested) and 67 in Marrere, a
rural area (450 counseled and 303
tested). Available trained staff and private
space are important factors of increased HIV
testing acceptance rates, but more is needed to
achieve higher acceptance of TC. The group
sessions reduced the total time spent conducting
counseling by half an hour, enabling more women
per day to receive TC services. The group method
clearly increases awareness and willingness to be
tested.
In order for women to take advantage of
strategies aimed at preventing maternal to child
transmission (MTCT) of HIV, they must know their
HIV serologic status. Prevention of MTCT (PMTCT)
programs have been introduced in Mozambique and
are moving from successful pilot projects to a
national program. Increasing evidence suggests
that availability of information on Testing and
Counseling (TC) reduces reported risk behaviors,
increases awareness and willingness of women to
be tested. Nonetheless, fear of stigma,
discrimination toward women, misperceptions and
myths surrounding HIV infection are known to
represent enormous obstacles to HIV testing
acceptance in PMTCT programs. Furthermore, severe
staffing shortages, untrained staff in HIV TC,
and lack of adequate space to guarantee privacy
and confidentiality have been additional barriers
to the uptake of PMTCT services. The Mozambique
national policy recommends that MCH nurses
perform individual TC for pregnant women
attending their first antenatal consultation
(ANC). Our aim was the improvement of pretest
counseling to reduce the amount of time a woman
waits for test results, to reduce the risk of
failure of the woman to return for results and
thus to increase the effectiveness of HIV
screening. Examining strategies to increase
uptake of HIV TC among pregnant women is
extremely important in the context of scaling up
PMTCT programs in high-prevalence areas. . .

• Current PMTCT coverage in Mozambique
• To date, only 8.3 (83/1000) of antenatal
  clinics (ANC) offer PMTCT services.
• In 2005, among approximately 750,000
• women who delivered only 19.5
• (146,253) had access to PMTCT services.
• Among women attending the
• ANC for their first appointment, 67
• (146,253/218,724) received CT in 2005.
• Data from MISAU 2005 annual report

METHODS
Two PMTCT model centers have been established to
enhance the Ministry of Healths national PMTCT
scale-up efforts. The centers have implemented
new systems to ensure increased coverage of
services for women attending their first
pre-natal visits, normalizing HIV testing by
integrating it into ANC care while establishing
supportive services for HIV pregnant women and
their families as well as strengthening the
referral system to offer care and treatment to
all HIV infected pregnant women and their exposed
children. HIV testing and counseling is
systematically offered to all pregnant women
attending the two ANC clinics. Group pre-test
counseling sessions are performed by MCH nurses
trained in comprehensive ANC/PMTCT services.
Women are offered rapid HIV testing as a routine
service during their ANC consultation and the
test is processed in front of them, immediately
followed by post test counseling once test
results are obtained.
DISCUSSIONS

• Current challenges
• Reliance on lay counselors to perform group
  counseling sessions to address lack of staff
• Quality of counseling (pre and post-test
  counseling)
• Differences in acceptance rates between urban
  and rural settings could be related to womens
  fear of stigmatization and lack of decisional
  power to be tested for HIV without husband
  authorization

• Overview of PMTCT interventions at
• Model Centers
• Group Pre test Counseling
• Introduction of a one stop strategy into ANC
  (Routine ANC care includes individualized
  testing post-test counseling, CD4 testing of
  all HIV women, referral to care and treatment,
  Immunizations)
• Comprehensive ANC/PMTCT registers enabling
  longitudinal patient tracking
• Comprehensive PMTCT training of all MCH nurses
  at health facility
• Mother/Child support groups
• TC of partners and couples counseling
• On site task force multidisciplinary meeting

• Current priority efforts
• Training of health staff in interactive group
  counseling skills and methods
• Enhancing site capacity and infrastructure to
  ensure that privacy is ensured
• Expanding PMTCT services to peripheral Health
  Centers around model centers to further increase
  access to PMTCT services

CONCLUSIONS

• Key areas of focus during Group Pre-Test
  Counseling
• Basics of HIV transmission, risk and MTCT
• Testing process
• The range of care available to pregnant women
  who test positive
• The preventive measures for their baby
• Discordance and promoting partners testing and
  involvement in care
• Disclosure and issue of stigma
• Promoting participation in supportive mother
  groups
• Encouraging questions and answers during the
  session

Group pre-test counseling sessions in the setting
of routine ANC services simplify the HIV TC
procedure, maximize the scant human resources
available for counseling and increase the uptake
of HIV TC by pregnant women. Group pre-test
counseling has shown to have an impact on the
number of women who access HIV testing services
which could lead to increased use of available
PMTCT services and reduced vertical transmission.
Further evaluation is needed to investigate the
role of private consultation space for antenatal
care/counseling and testing, the availability of
sufficient numbers of trained staff, and the
effect of group pre-test counseling on reducing
stigma and encouraging women to accept HIV
testing.
ACKNOWLEDGEMENTS
The PMTCT Model Center Project is supported by
the Presidents Emergency Relief Program We
acknowledge the Mozambique Ministry of Health,
program participants and program staff for their
support.