Approaches for scaling up human immunodeficiency virus testing and counseling in prevention of mother-to-child human immunodeficiency virus transmission settings in resource-limited countries
2007; Elsevier BV; Volume: 197; Issue: 3 Linguagem: Inglês
10.1016/j.ajog.2007.03.006
ISSN1097-6868
AutoresOmotayo Bolu, Virginia Allread, Tracy Creek, Jeffrey S. A. Stringer, Fatu Forna, Marc Bulterys, Nathan Shaffer,
Tópico(s)HIV, Drug Use, Sexual Risk
ResumoPrevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT) programs have nearly eliminated mother-to-child transmission of HIV in developed countries, but progress in resource-limited countries has been slow. A key factor limiting the scale-up of PMTCT programs is lack of knowledge of HIV serostatus. Increasing the availability and acceptability of HIV testing and counseling services will encourage more women to learn their status, providing a gateway to PMTCT interventions. Key factors contributing to the scale-up of testing and counseling include a policy of provider-initiated testing and counseling with right to refuse (opt-out); group pretest counseling; rapid HIV testing; innovative staffing strategies; and community and male involvement. Integration of testing and counseling within the community and all maternal and child health settings are critical for scaling-up and for linking women and their families to care and treatment services. This paper will review best practices needed for expansion of testing and counseling in PMTCT settings in resource-limited countries. Prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT) programs have nearly eliminated mother-to-child transmission of HIV in developed countries, but progress in resource-limited countries has been slow. A key factor limiting the scale-up of PMTCT programs is lack of knowledge of HIV serostatus. Increasing the availability and acceptability of HIV testing and counseling services will encourage more women to learn their status, providing a gateway to PMTCT interventions. Key factors contributing to the scale-up of testing and counseling include a policy of provider-initiated testing and counseling with right to refuse (opt-out); group pretest counseling; rapid HIV testing; innovative staffing strategies; and community and male involvement. Integration of testing and counseling within the community and all maternal and child health settings are critical for scaling-up and for linking women and their families to care and treatment services. This paper will review best practices needed for expansion of testing and counseling in PMTCT settings in resource-limited countries. The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates that 1800 children acquire human immunodeficiency virus (HIV) infection daily.1UNAIDS. 2006 Report on the global AIDS epidemic. Available at: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp. Accessed July 24, 2006.Google Scholar More than 85% of HIV-infected children live in sub-Saharan Africa, and the vast majority of infections occur from mother-to-child transmission (MTCT).1UNAIDS. 2006 Report on the global AIDS epidemic. Available at: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp. Accessed July 24, 2006.Google Scholar Without intervention, there is a 15-45% chance of HIV transmission from mother to infant during pregnancy, delivery, and breast-feeding.2De Cock K.M. Fowler M.G. Mercier E. et al.Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice.JAMA. 2000; 283: 1175-1182Crossref PubMed Scopus (781) Google Scholar, 3Simonon A. Lepage P. Karita E. et al.An assessment of the timing of mother-to-child transmission of human immunodeficiency virus type 1 by means of polymerase chain reaction.J Acquir Immune Defic Syndr. 1994; 7: 952-957PubMed Google Scholar, 4Bertolli J. St Louis M.E. Simonds R.J. et al.Estimating the timing of mother-to-child transmission of human immunodeficiency virus in a breast-feeding population in Kinshasa, Zaire.J Infect Dis. 1996; 174: 722-726Crossref PubMed Scopus (146) Google Scholar, 5Mock P.A. Shaffer N. Bhadrakom C. et al.Maternal viral load and timing of mother-to-child HIV transmission, Bangkok, Thailand.AIDS. 1999; 13: 407-414Crossref PubMed Scopus (119) Google Scholar International studies have demonstrated that the risk of MTCT in resource-limited settings can be reduced substantially, depending on the interventions provided.2De Cock K.M. Fowler M.G. Mercier E. et al.Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice.JAMA. 2000; 283: 1175-1182Crossref PubMed Scopus (781) Google Scholar, 6Dorenbaum A. Cunningham C.K. Gelber R.D. et al.International PACTG 316 TeamTwo-dose intrapartum/newborn nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission: a randomized trial.JAMA. 2002; 288: 189-198Crossref PubMed Scopus (304) Google Scholar, 7Cooper E.R. Charurat M. Mofenson L. et al.Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission.J Acquir Immune Defic Syndr. 2002; 29: 484-494PubMed Google Scholar PMTCT interventions include HIV testing and counseling, antiretroviral prophylaxis or treatment for mother and infant, modified obstetric practices, and modified infant-feeding practices.2De Cock K.M. Fowler M.G. Mercier E. et al.Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice.JAMA. 2000; 283: 1175-1182Crossref PubMed Scopus (781) Google Scholar Comprehensive prevention of mother-to-child HIV transmission (PMTCT) programs have nearly eliminated MTCT in developed countries.1UNAIDS. 2006 Report on the global AIDS epidemic. Available at: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp. 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Available at: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp. Accessed July 24, 2006.Google Scholar, 10Temmerman M. Quaghebeur A. Mwanyumba F. Mandaliya K. Mother-to-child HIV transmission in resource poor settings: how to improve coverage?.AIDS. 2003; 17: 1239-1242Crossref PubMed Scopus (90) Google Scholar, 12Dabis F. Ekpini E.R. HIV-1/AIDS and maternal and child health in Africa.Lancet. 2002; 359: 2097-2104Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar, 13Bassett M.T. Ensuring a public health impact of programs to reduce HIV transmission from mothers to infants: the place of voluntary counseling and testing.Am J Public Health. 2002; 92: 347-351Crossref PubMed Scopus (46) Google Scholar In many sub-Saharan African countries, a vast majority of women of childbearing age do not know their HIV status. Increasing the availability, acceptability, and quality of HIV testing and counseling services will encourage more women to learn their HIV status, providing a gateway to PMTCT interventions. Several key approaches that have contributed to scale-up of testing and counseling for the purpose of providing PMTCT services include:•Provider-initiated testing and counseling.14UNAIDS Global Reference Group on HIV/AIDS and Human Rights. UNAIDS/WHO policy statement on HIV testing. Available at: http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf. Accessed July 24, 2006.Google Scholar, 15World Health Organization. The Right to Know. New Approaches to HIV Testing and Counseling. Geneva (Switzerland): World Health Organization/HIV2003.08. August 2003. www.searo.who.it/LinkFiles/Prevention_and_control_right_know_94E.pdfGoogle Scholar, 16Centers for Disease Control and PreventionHIV testing among pregnant women—United States and Canada, 1998-2001.MMWR Morb Mortal Wkly Rep. 2002; 51: 1013-1016PubMed Google Scholar, 17Centers for Disease Control and PreventionIntroduction of routine HIV testing in prenatal care—Botswana, 2004.MMWR Morb Mortal Wkly Rep. 2004; 53: 1083-1086PubMed Google Scholar, 18Van't Hoog A. Mbori-Ngacha D.A. Marum L.H. et al.Preventing mother-to-child transmission of HIV in western Kenya: operational issues.J Acquir Immune Defic Syndr. 2005; 40: 344-349Crossref PubMed Scopus (43) Google Scholar, 19Welty T. Bulterys M. Welty E.R. et al.Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon.J Acquir Immune Defic Syndr. 2005; 40: 486-493Crossref PubMed Scopus (63) Google Scholar•Group pretest counseling.19Welty T. Bulterys M. Welty E.R. et al.Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon.J Acquir Immune Defic Syndr. 2005; 40: 486-493Crossref PubMed Scopus (63) Google Scholar, 20Cartoux M. Sombie I. Van de Perre P. Meda N. Tiendrebeogo S. Dabis F. Evaluation of two techniques of HIV pretest counseling for pregnant women in West Africa.Int J STD AIDS. 1999; 10: 199-201Crossref PubMed Scopus (16) Google Scholar, 21Rutenberg N, Kalibala S, Baek C, Rosen J. Programme recommendations for the prevention of mother-to-child transmission of HIV: a practical guide for managers. Available at: www.popcouncil.org/pdfs/horizons/pmtctunicefevalprogmgr.pdf. Accessed July 24, 2006.Google Scholar•Rapid HIV testing with same day results.22Downing R.G. Otten R.A. Marum E. et al.Optimizing the delivery of HIV counseling and testing services: the Uganda experience using rapid HIV antibody test algorithms.J Acquir Immune Defic Syndr. 1998; 18: 384-388Crossref Scopus (66) Google Scholar, 23Malonza I.M. Richardson B.A. Kreiss J.K. Bwayo J.J. Stewart G.C. The effect of rapid HIV-1 testing on uptake of perinatal HIV-1 interventions: a randomized clinical trial.AIDS. 2003; 17: 113-118Crossref PubMed Scopus (65) Google Scholar•Human resource capacity: use of adjunct auxiliary health care workers and lay counselors to provide HIV testing and counseling.19Welty T. Bulterys M. Welty E.R. et al.Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon.J Acquir Immune Defic Syndr. 2005; 40: 486-493Crossref PubMed Scopus (63) Google Scholar, 24Mhazo M. Moyo S. von Lieven A. Maponga C. Bassett M.T. HIV counseling and testing amongst antenatal women using lay community volunteers: experience from urban Zimbabwe.in: Presented at the 13th International AIDS Conference, 2000, Durban, South Africa.2000Google Scholar, 25Cartoux M. Meda N. Van de Perre P. Newell M.L. de Vincenzi I. Dabis F. Acceptability of voluntary HIV testing by pregnant women in developing countries: an international survey.AIDS. 1998; 12: 2489-2493Crossref PubMed Scopus (105) Google Scholar, 26Shetty A.K. Mhazo M. Moyo S. et al.The feasibility of voluntary counselling and HIV testing for pregnant women using community volunteers in Zimbabwe.Int J STD AIDS. 2005; 16: 755-759Crossref PubMed Scopus (35) Google Scholar, 27Chi B. Sinkala M. Stringer E. et al.Employment of off-duty staff: a strategy to meet the human resource needs for a large PMTCT program in Zambia.J Acquir Immune Defic Syndr. 2005; 40: 381-382Crossref PubMed Scopus (7) Google Scholar, 28Bulterys M. Fowler M.G. Shaffer N. et al.Role of traditional birth attendants in preventing perinatal transmission of HIV.BMJ. 2002; 324: 222-224Crossref PubMed Google Scholar•Testing and counseling at labor and delivery.10Temmerman M. Quaghebeur A. Mwanyumba F. Mandaliya K. Mother-to-child HIV transmission in resource poor settings: how to improve coverage?.AIDS. 2003; 17: 1239-1242Crossref PubMed Scopus (90) Google Scholar, 21Rutenberg N, Kalibala S, Baek C, Rosen J. Programme recommendations for the prevention of mother-to-child transmission of HIV: a practical guide for managers. Available at: www.popcouncil.org/pdfs/horizons/pmtctunicefevalprogmgr.pdf. Accessed July 24, 2006.Google Scholar, 29Homsy J. Kalamya J.N. Obonyo J. et al.Routine intrapartum HIV counseling and testing for prevention of mother-to-child transmission of HIV in a rural Ugandan hospital.J Acquir Immune Defic Syndr. 2006; 42: 149-154Crossref PubMed Scopus (87) Google Scholar•Rescreening women who test negative during the prenatal period.•Ongoing provision of training and support tools on testing and counseling for PMTCT.•Male partner involvement and couples counseling.29Homsy J. Kalamya J.N. Obonyo J. et al.Routine intrapartum HIV counseling and testing for prevention of mother-to-child transmission of HIV in a rural Ugandan hospital.J Acquir Immune Defic Syndr. 2006; 42: 149-154Crossref PubMed Scopus (87) Google Scholar, 30Semrau K. Kuhn L. Vwalika C. et al.Women in couples antenatal HIV counseling and testing are not more likely to report adverse social events.AIDS. 2005; 19: 603-609Crossref PubMed Scopus (115) Google Scholar, 31Painter T. Voluntary counseling and testing for couples: a high-leverage intervention for HIV/AIDS prevention in sub-Saharan Africa.Soc Sci Med. 2001; 53: 1397-1411Crossref PubMed Scopus (189) Google Scholar•Community involvement.32Perez F. Zvandaziva C. Engelsmann B. Dabis F. Acceptability of routine HIV testing ("opt-out") in antenatal services in two rural districts of Zimbabwe.J Acquir Immune Defic Syndr. 2006; 41: 514-520Crossref PubMed Scopus (107) Google Scholar•Extension of testing and counseling into all maternal and child health (MCH) services.10Temmerman M. Quaghebeur A. Mwanyumba F. Mandaliya K. Mother-to-child HIV transmission in resource poor settings: how to improve coverage?.AIDS. 2003; 17: 1239-1242Crossref PubMed Scopus (90) Google Scholar, 21Rutenberg N, Kalibala S, Baek C, Rosen J. Programme recommendations for the prevention of mother-to-child transmission of HIV: a practical guide for managers. Available at: www.popcouncil.org/pdfs/horizons/pmtctunicefevalprogmgr.pdf. Accessed July 24, 2006.Google Scholar This paper reviews data supporting the approaches used to expand testing and counseling for PMTCT programs and discusses the priorities and best practices needed for ongoing expansion of testing and counseling for PMTCT in resource-limited settings. Current global recommendations from the World Health Organization (WHO) and UNAIDS advocate for provider-initiated testing and counseling with the right to refuse (opt-out) within PMTCT settings (antenatal, labor and delivery, and postdelivery settings).14UNAIDS Global Reference Group on HIV/AIDS and Human Rights. UNAIDS/WHO policy statement on HIV testing. Available at: http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf. Accessed July 24, 2006.Google Scholar, 15World Health Organization. The Right to Know. New Approaches to HIV Testing and Counseling. Geneva (Switzerland): World Health Organization/HIV2003.08. August 2003. www.searo.who.it/LinkFiles/Prevention_and_control_right_know_94E.pdfGoogle Scholar With provider-initiated testing and counseling, health care workers or providers recommend HIV testing as part of the standard package of services provided routinely to all clients. The client must specifically opt-out or refuse the test if she does not want to know her HIV status.14UNAIDS Global Reference Group on HIV/AIDS and Human Rights. UNAIDS/WHO policy statement on HIV testing. Available at: http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf. Accessed July 24, 2006.Google Scholar, 15World Health Organization. The Right to Know. New Approaches to HIV Testing and Counseling. Geneva (Switzerland): World Health Organization/HIV2003.08. August 2003. www.searo.who.it/LinkFiles/Prevention_and_control_right_know_94E.pdfGoogle Scholar There is no need for a separate written consent for HIV testing; consent is almost always verbal. This is a shift from the historical practice of client-initiated (opt-in) testing, or voluntary counseling and testing, in which the client specifically requests an HIV test and usually provides written consent. The rationale for provider-initiated testing and counseling is that it normalizes HIV testing in medical settings, increases the number of people who know their HIV status, and improves PMTCT program impact.14UNAIDS Global Reference Group on HIV/AIDS and Human Rights. UNAIDS/WHO policy statement on HIV testing. Available at: http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf. Accessed July 24, 2006.Google Scholar, 33De Cock K.M. Johnson A. From exceptionalism to normalisation: a reappraisal of attitudes and practice around HIV testing.BMJ. 1998; 316: 290-293Crossref PubMed Scopus (109) Google Scholar International and national policies increasingly endorse provider-initiated testing and counseling within the context of pregnancy. Various articles in the past have referred to the provider-initiated testing and counseling with right to refuse as an opt-out strategy and client-initiated testing and counseling as an opt-in strategy, but for the purpose of this paper, we will use provider- and client-initiated testing and counseling when referring to these strategies. New WHO guidelines, to be released in early 2007, will further advocate for provider-initiated testing and counseling within various medical settings including PMTCT, sexually transmitted infection and tuberculosis clinics. As shown in the Table, data from both developed countries16Centers for Disease Control and PreventionHIV testing among pregnant women—United States and Canada, 1998-2001.MMWR Morb Mortal Wkly Rep. 2002; 51: 1013-1016PubMed Google Scholar, 34Sherr L. Fox Z. Lipton M. et al.Sustaining HIV testing in pregnancy—evaluation of routine offer of HIV testing in three London hospitals over 2 years.AIDS Care. 2006; 18: 183-188Crossref PubMed Scopus (12) Google Scholar, 35Stringer E.M. Stringer J.S. Cliver S.P. Goldenberg R.L. Goepfert A.R. Evaluation of a new testing policy for human immunodeficiency virus to improve screening rates.Obstet Gynecol. 2001; 98: 1104-1108Crossref PubMed Scopus (70) Google Scholar, 36Simpson W.M. Johnstone F.D. Boyd F.M. et al.A randomised controlled trial of different approaches to universal antenatal HIV testing: uptake and acceptability and Annex: antenatal HIV testing—assessment of a routine voluntary approach.Health Technol Assess. 1999; 3: 1-112PubMed Google Scholar and resource-limited countries17Centers for Disease Control and PreventionIntroduction of routine HIV testing in prenatal care—Botswana, 2004.MMWR Morb Mortal Wkly Rep. 2004; 53: 1083-1086PubMed Google Scholar, 18Van't Hoog A. Mbori-Ngacha D.A. Marum L.H. et al.Preventing mother-to-child transmission of HIV in western Kenya: operational issues.J Acquir Immune Defic Syndr. 2005; 40: 344-349Crossref PubMed Scopus (43) Google Scholar have shown an increase in the uptake of testing and counseling when the provider-initiated testing and counseling approach is implemented.TABLEComparison of HIV-testing uptake before and after implementation of provider-initiated testing and counseling during prenatal careStudy/locationClient-initiated testing and counselingProvider-initiated testing and counselingP2005, Van't Hoog et al18Van't Hoog A. Mbori-Ngacha D.A. Marum L.H. et al.Preventing mother-to-child transmission of HIV in western Kenya: operational issues.J Acquir Immune Defic Syndr. 2005; 40: 344-349Crossref PubMed Scopus (43) Google Scholar Large provincial hospital, Kenya2278/4142 (55%) (12 months)2799/4089 (68%) (12 months)<.0012004, Centers for Disease Control and Prevention17Centers for Disease Control and PreventionIntroduction of routine HIV testing in prenatal care—Botswana, 2004.MMWR Morb Mortal Wkly Rep. 2004; 53: 1083-1086PubMed Google ScholarMultisite study, Francistown, Botswana381/506 (75%) 3 months in 2003314/347 (90%) 4 months in 2004<.001National Data Botswana [Botswana national PMTCT program, unpublished data] From all 24 health districts Personal communication, Tracy Creek67%, 200392%, 2005—2001, Stringer et al35Stringer E.M. Stringer J.S. Cliver S.P. Goldenberg R.L. Goepfert A.R. Evaluation of a new testing policy for human immunodeficiency virus to improve screening rates.Obstet Gynecol. 2001; 98: 1104-1108Crossref PubMed Scopus (70) Google Scholar University of Alabama Hospitals, Birmingham, Alabama2561/3415 (75%) 12 months, 1998-19993324/ 3778 (88%) 12 months 1999-2000<.0011999, Simpson et al36Simpson W.M. Johnstone F.D. Boyd F.M. et al.A randomised controlled trial of different approaches to universal antenatal HIV testing: uptake and acceptability and Annex: antenatal HIV testing—assessment of a routine voluntary approach.Health Technol Assess. 1999; 3: 1-112PubMed Google Scholar United Kingdom35%88%—2006, Sherr et al34Sherr L. Fox Z. Lipton M. et al.Sustaining HIV testing in pregnancy—evaluation of routine offer of HIV testing in three London hospitals over 2 years.AIDS Care. 2006; 18: 183-188Crossref PubMed Scopus (12) Google Scholar Three London hospitals, United Kingdom2309/2710 (85%), 2002774/850 (91%) 2004<.0001 Open table in a new tab Data from developed countries such as the United States and Canada show that HIV testing rates were generally higher in states or provinces that used provider-initiated testing and counseling than in those that used client-initiated testing—71-98%, compared with 25-83%.16Centers for Disease Control and PreventionHIV testing among pregnant women—United States and Canada, 1998-2001.MMWR Morb Mortal Wkly Rep. 2002; 51: 1013-1016PubMed Google Scholar These findings resulted in a change in U.S. policy to provider-initiated testing for women in prenatal care.37Gerberding JL, Jaffe HW. Dear colleague letter, April 22, 2003. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/hiv/projects/perinatal/2003/letter.htm. Accessed July 24, 2006.Google Scholar, 38American College of Obstetricians and GynecologistsPrenatal and perinatal human immunodeficiency virus testing: expanded recommendations. American College of Obstetricians and Gynecologists, ACOG Opinion Number 304, Washington (DC)2004Google Scholar In 2006, the U.S. government released new guidelines that recommend HIV screening for all patients in all health care settings after the patient is notified that testing will be performed, unless the patient declines (referred to as opt-out screening).39Centers for Disease Control and PreventionRevised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.MMWR Morb Mortal Wkly Rep. 2006; 55 (RR-14): 1-17PubMed Google Scholar Universal screening in health care settings was recommended despite the low national prevalence of HIV infection in the United States (less than 1%) because strategies that incorporated universal screening such as those among pregnant women and blood donors had resulted in increased testing and near elimination of perinatal transmission and transfusion-associated HIV infection. In addition, providers in busy health care settings often lack the time necessary to conduct risk assessments and might perceive counseling requirements as a barrier to testing. Furthermore, earlier diagnosis could lead to earlier treatment of HIV infection and potential reduction of risk behaviors by HIV-infected individuals.39Centers for Disease Control and PreventionRevised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.MMWR Morb Mortal Wkly Rep. 2006; 55 (RR-14): 1-17PubMed Google Scholar The lessons learned from developed countries in implementing provider-initiated testing and counseling have been adapted and used in resource-poor settings. Increases in HIV testing uptake have been reported in several African settings in which provider-initiated testing and counseling has been implemented. For example, Botswana implemented provider-initiated testing and counseling in 2004,17Centers for Disease Control and PreventionIntroduction of routine HIV testing in prenatal care—Botswana, 2004.MMWR Morb Mortal Wkly Rep. 2004; 53: 1083-1086PubMed Google Scholar following a declaration by the President for universal testing in medical settings. An evaluation of the early impact of routinely recommended testing on HIV-test acceptance and the rates of return for care in prenatal settings in Botswana's second largest city showed that acceptance of testing increased from 75.3% to 90.5% (Table); there was no difference in the percentage of tested women who did not receive results (29.4% client initiated vs 33.0% provider initiated, P = .29), and there was no change in the number of women seeking prenatal care. National data show that uptake of testing and counseling in prenatal settings in Botswana has similarly increased to more than 90%.17Centers for Disease Control and PreventionIntroduction of routine HIV testing in prenatal care—Botswana, 2004.MMWR Morb Mortal Wkly Rep. 2004; 53: 1083-1086PubMed Google Scholar Although the experience in other settings have shown that not all women will return for test results,40Kiarie J. Nduati R. Koigi K. Musia J. John G. HIV-1 testing in pregnancy: acceptability and correlates of return for test results.AIDS. 2000; 14: 1468-1470Crossref PubMed Scopus (38) Google Scholar the increased emphasis on rapid HIV testing with same-day results will increase the number of women who know their HIV status.14UNAIDS Global Reference Group on HIV/AIDS and Human Rights. UNAIDS/WHO policy statement on HIV testing. Available at: http://www.who.int/hiv/pub/vct/en/hivtestingpolicy04.pdf. Accessed July 24, 2006.Google Scholar, 15World Health Organization. The Right to Know. New Approaches to HIV Testing and Counseling. Geneva (Switzerland): World Health Organization/HIV2003.08. August 2003. www.searo.who.it/LinkFiles/Prevention_and_control_right_know_94E.pdfGoogle Scholar Despite the evidence, a number of resource-limited countries with generalized HIV epidemics (HIV prevalence greater than 1%) have either not adopted or fully implemented this approach. Even where it is the policy, field experience in Africa indicates that testing still needs to be greatly expanded to increase coverage and ensure wide provision of appropriate interventions.41De Cock K. Bunnell R. Mermin J. Unfinished business—expanding HIV testing in developing countries.N Engl J Med. 2006; 354: 440-442Crossref PubMed Scopus (104) Google Scholar There are also concerns that women may feel coerced into accepting testing and may not return for their test results and other PMTCT interventions if they accept testing in a provider-initiated program.40Kiarie J. Nduati R. Koigi K. Musia J. John G. HIV-1 testing in pregnancy: acceptability and correlates of return for test results.AIDS. 2000; 14: 1468-1470Crossref PubMed Scopus (38) Google Scholar, 42De Bruyn M. Paxton S. HIV testing of pregnant women—what is needed to protect positive women's needs and rights?.Sex Health. 2005; 2: 143-151Crossref PubMed Scopus (24) Google Scholar Despite these concerns, the provider-initiated testing and counseling approach has been found to be acceptable21Rutenberg N, Kalibala S, Baek C, Rosen J. Programme recommendations for the prevention of mother-to-child transmission of HIV: a practical guide for managers. Available at: www.popcouncil.org/pdfs/horizons/pmtctunicefevalprogmgr.pdf. Accessed July 24, 2006.Google Scholar, 32Perez F. Zvandaziva C. Engelsmann B. Dabis F. Acceptability of routine HIV testing ("opt-out") in antenatal services in two rural districts of Zimbabwe.J Acquir Immune Defic Syndr. 2006; 41: 514-520Crossref PubMed Scopus (107) Google Scholar and does not appear to deter women from returning for their results.17Centers for Disease Control and PreventionIntroduction of routine HIV testing in prenatal care—Botswana, 2004.MMWR Morb Mortal Wkly Rep. 2004; 53: 1083-1086PubMed Google Scholar Many PMTCT programs now provide HIV pretest information to groups of clients (rather than individually) and incorporate the information into general health talks.17Centers for Disease Control and PreventionIntroduction of routine HIV testing in prenatal care—Botswana, 2004.MMWR Morb Mortal Wkly Rep. 2004; 53: 1083-1086PubMed Google Scholar, 19Welty T. Bulterys M. Welty E.R. et al.Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon.J Acquir Immune Defic Syndr. 2005; 40: 486-493Crossref PubMed Scopus (63) Google Scholar, 20Cartoux M. Sombie I. Van de Perre P. Meda N. Tiendrebeogo S. Dabis F. Evaluation of two techniques of HIV pretest counseling for preg
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