Frequency of pregnant women who accept HIV screening using rapid detection test and factors associated with acceptance

Abstract

To assess the frequency of pregnant women who accept HIV screening using rapid detection test and factors associated with acceptance we undertook a cross-sectional study conducted from July to December 2018. Women aged 20–45 years, who were pregnant and planned to deliver at the facility, were included. Women were counseled and offered about Human Immunodeficiency virus (HIV) screening. A total of 718 women were included in the study. The screening was accepted by 32.3% of women. Six women tested positive in the study giving a seroprevalence of 0.8% in the population studied. Acceptance of counseling and screening varied significantly with age range, educational status, socioeconomic status, and employment status. Women aged 30 years and above (p = 0.023) and women with higher education (p < 0.001) were more likely to refuse counselling. Similarly, employed women (p = 0.041) and women of higher socioeconomic class (p = 0.039) refused counselling. However, when logistic regression was conducted, only educational status (p < 0.001) and occupational status (p = 0.039) were significantly associated with acceptance of counseling and screening. The acceptance of counselling and testing for HIV in antenatal care attendees was low. Women of higher educational status and having some employment refused counselling and testing more commonly.

Keywords

Human immunodeficiency virus screening antenatal care acceptance

Introduction

The first case of human immunodeficiency virus (HIV) appeared in Pakistan more than 30 years ago, and since then, the prevalence of the disease is slowly growing. Pakistan has now moved from a “low prevalence high risk’” to a “concentrated epidemic” state.¹ With this sudden escalation, we have an epidemic at our hands that needs to be contained. Awareness campaigns on the subject are frowned upon and considered derogatory and often seen as a stigma.² The worst hand is dealt to pregnant women who are unaware of the diagnosis; the condition deteriorates and the disease is transmitted to offspring. Mother to child transmission (MTCT) of HIV can easily be prevented through early diagnosis and treatment with antiretroviral therapy (ART), including maternal and neonatal prophylaxis and cesarean delivery for high or unknown viral count.³The National Institutes of Health, the American College of Obstetrics and Gynecology, and the Center for Disease Control and Prevention recommend HIV screening as a part of the initial prenatal laboratory testing and repeat screening in the third trimester in high-risk individuals and in high-prevalence regions.⁴ The acceptance of screening for HIV among pregnant women is the first step to ensure preventive strategies can be implemented in time. There is scarcity of data on the subject, and no study directly assesses the uptake of screening in this stratum of population.

There is a need to motivate, educate, and make people understand the importance of screening. HIV screening ensures that MTCT can be minimized by modification of antenatal care. Thus, this study was done to assess acceptance regarding HIV screening using rapid detection test and factors associated with acceptance.

Material and methods

This was a cross-sectional study conducted from July to December 2018. Women aged 20–45 years, who were pregnant and planned to deliver at the facility, were included. Non-consenting women and who did not deliver at the facility were excluded.

Consenting patients fulfilling the inclusion criteria were enrolled in the study. Brief history was taken. Women were asked about multiple sexual partners, other known hepatitis screening results, history of smoking, other addiction, multiple partners of the spouse, history of intravenous drug use receipt of blood transfusion, and history of any operations. Women who met the inclusion criteria were offered screening. The merits of screening, their results and possible implications of positive and negative result, and the confirmatory testing were explained. This approach enabled the woman to make a voluntary and informed choice. If she accepted screening, then she was labeled acceptor; if she refused, then she was labeled as a refuser.

All authors received formal training to obtain consent by trained HIV counselors. The eligible women were approached before their scheduled antenatal visit in the waiting room. Those who accepted to take part in the study were taken to a private room for testing. A room was set aside where counselling and testing was available. Privacy was ensured and confidentiality was maintained during the entire process.

Women were offered a point-of-care HIV test. Consenting women gave a blood sample that was collected through a lancet finger prick. Women were first tested using advanced quality Anti-HIV-1 and -2 rapid tests (InTec Products, Inc., Fujian, China). Those who tested negative were labeled as HIV-negative result. We confirmed reactive samples by HIV-1/2/O Tri-line HIV rapid test (ABON Biopharm, Hangzhou, China). Those with confirmed reactive samples were reported as HIV positive. These women were referred to the local infectious disease specialist for further treatment and management. The notification to health authorities takes place at the centers where the infectious disease specialists are based. There are two centers in the city. One is at a public sector hospital and the other at private sector hospital. The public sector center provides free of cost ART. We referred the patients to the public sector center.

We labeled the confirmed non-reactive samples as indeterminate and asked women to repeat test in 4–6 weeks. All women were counseled before and after testing. The content of the counseling was HIV’s route of transmission, prevention, effect on pregnancy, and management. They were also counseled about the pathway that would be adopted in case of a positive result. The need for partner notification was also communicated to the women. They were counseled that results would be available within 10–15 min of taking the test; however, a positive rapid test would be confirmed by a further test.

Each counseling session lased 10–15 min, and the explanation of the result took another 10 min. Those with a positive result were asked to bring in their partners. A history was taken from the partners to identify risk factors, and the same consent and testing procedure was followed. The positive confirmed partners were also referred to the infectious disease specialist for management.

Data were analyzed on SPSS version 16. Frequencies and percentages will be calculated for the qualitative variables like age range, socioeconomic status, occupational status, educational status, parity, and acceptance (yes/no). Effect modifiers were controlled through stratification of maternal age, socioeconomic status, occupational status, educational status, and parity to see the effect of these on the outcome variable. Post-stratification chi-square test was applied taking p-value of ≤0.05 as statistically significant. A binomial logistic regression was conducted to assess the strength of association.

The hospital does not have a formal ethical review committee. In lieu of which, Helsinki’s Declaration was followed. All participants provided written and informed consent (copy attached as supplementary file). Data were coded prior to entry, and confidentiality was ascertained.

Results

During the study period, a total of 780 women presented for delivery and satisfied the inclusion criteria. Fifty three refused to provide consent for inclusion into study, and nine were lost to follow up and were excluded. A total of 718 women were included in the study. Most women (375, 52.2%) were of ages 25–29 years, had three or fewer children (615, 85.7%), and had low household monthly income (411, 57.2%). Of those included, 267 (37.2%) had no formal education and 369 (51.4%) were unemployed. The screening was accepted by 232 (32.3%) women. Three women tested positive by point-of-care testing; however, only two infections were confirmed in the study giving a seroprevalence of 0.86% in the population studied. The husbands of both women who tested positive were also positive for HIV. One spouse had multiple sexual partners, and the other was an intravenous drug user. Table 1 shows basic characteristics of women.

Table 1.

Characteristics of study population.

Characteristic	N%
Age
20–24 years	208 (29.0%)
25–29 years	375 (52.2%)
30–34 years	118 (16.4%)
35 years and above	17 (2.4%)
Parity
Three or less children	615 (85.7%)
Four or more	103 (14.3%)
Education
No formal education	267 (37.2%)
Primary (5 years of formal education)	357 (49.7%)
Secondary (10 years of formal education)	63 (8.8%)
Graduate	31 (4.3%)
Household monthly income
Low income ≤100,000 PKR	411 (57.2%)
Middle income 10,000–40,000 PKR	254 (35.4%)
High income >40,000 PKR	53 (7.4%)
Occupational status
Employed	349 (48.6%)
Unemployed	369 (51.4%)
Acceptance
Acceptor	232 (32.3%)
Refuser	486 (67.7%)

Acceptance of counseling and screening varied significantly with age range, educational status, socioeconomic status, and employment status. Women aged 30 years and above (p = 0.023) and women who were graduates (p < 0.001) were more likely to refuse counseling. Similarly, employed women (p = 0.041) and women of higher socioeconomic class (p = 0.039) refused counseling. Table 2.

Table 2.

Characteristics stratified according to acceptance.

	Acceptance
	Acceptor	Refuser	p value
	N%	N%
Age range
20–24 years	81 (34.9%)	127 (26.1%)	0.023*
25–29 years	118 (50.9%)	257 (52.9%)
30–34 years	31 (13.4%)	87 (17.9%)
35 years and above	2 (0.9%)	15 (3.1%)
Parity
Three or less children	203 (87.5%)	412 (84.8%)	0.330
Four or more	29 (12.5%)	74 (15.2%)
Education
No formal education	74 (31.9%)	193 (39.7%)	<0.001*
Primary(5 years of formal education)	123 (53.0%)	234 (48.1%)
Secondary(10 years of formal education)	34 (14.7%)	29 (6.0%)
Graduate	1 (0.4%)	30 (6.2%)
Household monthly income
Low income ≤100,000 PKR	145 (62.5%)	266 (54.7%)	0.039*
Middle income 10,000–40,000 PKR	77 (33.2%)	177 (36.4%)
High income >40,000 PKR	10 (4.3%)	43 (8.8%)
Occupational status
Employed(full time/part time)	100 (43.1%)	249 (51.2%)	0.041*
Unemployed	132 (56.9%)	237 (48.8%)

*Chi-square or Fischer’s exact test was significant at the 0.05 level.

However, only educational status (p < 0.001) and occupational status (p = 0.039) were significantly associated with acceptance of screening Table 3.

Table 3.

Association of characteristics with acceptance.

	Acceptance
	Odds ratio	Confidence interval	p value
Age range			0.160
20–24 years	4.365	0.94–20.281	0.060
25–29 years	3.285	0.718–15.019	0.125
30–34 years	3.014	0.620–14.641	0.172
35 years and above ref
Parity
Three or less children	0.875	0.488–1.568	0.653
Four or more ref
Education			<0.001
No formal education	9.068	1.118–73.576	0.039
Primary(5 years of formal education)	13.160	1.642–105.476	0.015
Secondary(10 years of formal education)	28.412	3.381–238.781	0.002
Graduate ref
Household monthly income			0.068
Low income ≤100,000 PKR	1.288	0.569–2.914	0.544
Middle income 10,000–40,000 PKR	0.834	0.361–1.928	0.671
High income >40,000 PKR
Occupational status
Employed	0.692	0.490–0.977	0.039
Unemployed ref

Predictive variables: age range (20–24 years:1/25–29 years:2/30–34 years:3/35 and above years:0); parity range (<4:1/>4:0); educational status (no formal education:1/primary (5 years of education):2/secondary (10 years of education):3/graduates:0); household monthly income (low income (monthly income ≤10,000 PKR):1/middle income (monthly income 10,000 PKR–40,000 PKR):2/high income (monthly income >40,000 PKR): 0), occupational status (employed:1/unemployed:0).

The acceptance of HIV screening in women with different education levels is shown in Figure 1.

Figure 1.

Acceptance according to educational status.

Discussion

Main Findings

The acceptance of HIV screening was 32.3% in the study population. The seroprevalence of the infection was 0.86% in the population studied.

The acceptance was significantly different for women of higher age, educational status, monthly income, and employment status.

However, after logistic regression, the association was only found significant for educational status and employment.

Interpretation

HIV is a growing pandemic in Pakistan, although the rates are not as high as those reported from other regions of the world.⁵ Among the countries in Asia, Pakistan is a region where HIV cases are increasing steadily. Of the 94,000 cases in Pakistan, only 14,000 are registered with the government. The government does not have any data on the rest of 80,000 cases.⁶ The major source of this infection is people who inject drugs and sex workers. They are responsible for disseminating the infection to their spouses who may not be aware of the infection.⁷ Pregnant women are among the 11 major core groups which are considered high risk for transmission of HIV.^8,9 Our study reports data from a frequently overlooked group that can make a huge difference in controlling the infection.

Sibia et al.¹⁰ reported the seroprevalence in antenatal care attendees from North India to be 1.03%; seroprevalence in our study was 0.86%. The result still has significance because the cutoff for labeling an area high risk for HIV is 1%. Previous studies from the city reported HIV seroprevalence among general populations of 0.73%.¹¹ This finding further confirms the growing trend of this previously rare infection in the general population. The advantage of documenting the seroprevalence of HIV in pregnant women, a low-risk population, is twofold; it allows implementation of preventive strategies and helps in monitoring the spread of HIV in the country.

HIV testing is not routinely done for women seeking antenatal care in the country and is only offered to women with high-risk factors.¹² Our study shows that this approach may lead to ineffective implementation of the AIDS control program. This “opt in” approach leads to bias and women who are most at risk shy away from screening; in contrast, opt out strategy ensures these selected few are not missed. The cost of screening remains an issue, but we would argue that preventing infection in a baby is worthwhile.

Many setups have been established that offer free screening. This service can only be utilized if women are asked and assessed, and the taboo associated with these diseases is minimized.¹³ During our study, 53 women refused to give consent for participation. These numbers are an eye opener because the fear associated with testing positive can hamper all efforts of controlling the growing pandemic. The knowledge of MTCT of HIV and routes of transmission has been documented to be poor both in providers and recipients of care.¹⁴

The acceptance of screening is heavily influenced by beliefs held by women. The acceptance rate was only 32.3%; the acceptance rate for counseling and testing from India was 82.48%.¹⁵ This low acceptance rate could be due to lack of knowledge, firm fixed beliefs held by women, or fear of testing positive. Our study did not collect data on the reasons for opting out, and thus, it remains an area which needs to be addressed by further studies on the topic.

Data from all over the world show that women are more likely to accept counseling and testing of HIV if they are educated, have higher socioeconomic status, and are employed.¹⁶ These attributes are associated with women empowerment and help women to make better health-related decisions. The majority acceptors in our study were illiterate women of low socioeconomic group who did not have preconceived notions about testing positive. The interesting finding from our study was that acceptance of testing and counselling was lower in women who were highly educated and had a higher monthly income.¹⁷ Previous studies showed that women who are educated and have jobs are more likely to accept counseling. This observation did not hold true for our study population. The stigma associated with testing positive may be a possible factor in refusing testing. Women who were well educated, had jobs, and thus enjoyed greater autonomy still refused testing. These women may have been more aware of the derogatory remarks made by general population as HIV is frowned upon and considered a “filthy disease” in the region.¹⁸

Age is negatively associated with acceptance of counseling for HIV.¹⁷ Women who accepted counseling and testing were also of lower age. This finding is similar to that reported from Sudan where women of age 30 years or younger accepted counseling and testing for HIV.

Another point that warrants discussion is that women in Pakistan are unaware about the growing pandemic. They may consider themselves safe from this disease as the practices that are responsible for spread are mostly forbidden in Islam.¹⁹ But, as Pakistan is a country with high influx of immigrants, the statistics may be a poor reflection of the nationwide scenario. Our study highlights the need for better awareness programs that may help to disseminate knowledge and help increase uptake of counseling and screening by these high risk groups.

Strengths and limitations

Our study reports the results of HIV screening acceptance from a large tertiary care, frequented by people from different strata of society. The acceptance of counseling for HIV is a subject not discussed often. We thus report a unique study from the region, and this study fits in by providing seroprevalence and the acceptance rate of counseling and screening in pregnant women.

The major limitation of the study is its single-center design, and thus, generalizability of results cannot be ensured.

Conclusion

The acceptance of counseling and testing for HIV in antenatal care attendees was very low. Women of higher educational status and having some employment refused counseling and testing more commonly. We propose adoption of HIV counselling and screening in all women who present for antenatal care.

Supplemental Material

sj-pdf-1-std-10.1177_0956462420976262 – Supplemental Material for Frequency of pregnant women who accept HIV screening using rapid detection test and factors associated with acceptance

Supplemental Material, sj-pdf-1-std-10.1177_0956462420976262 for Frequency of pregnant women who accept HIV screening using rapid detection test and factors associated with acceptance by Aisha Khatoon, Samia Husain, Sonia Husain and Saba Hussain in International Journal of STD & AIDS

Footnotes

Ethics approval and consent to participate

The hospital does not have a formal ethical review committee. In lieu of which, Helsinki’s Declaration was followed. All participants provided written and informed consent. Data were coded prior to entry, and confidentiality was ascertained.

Authors’ contributions

Aisha Khatoon conceived and designed the experiment, performed the experiments, analyzed the data, contributed reagents/materials/analysis tools, and wrote the paper. Samia Husain analyzed the data, contributed reagents/materials/analysis tools, and wrote the paper. Saba Husain and Sonia Husain contributed reagents/materials/analysis tools and wrote the paper.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Samia Husain

Data accessibility statement

The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.

Supplemental material

Supplemental material for this article is available online.

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