Routine offer of antenatal HIV testing (“opt-out” approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe

843Bulletin of the World Health Organization | November 2007, 85 (11) Objective To assess the impact of routine antenatal HIV testing for preventing mother-to-child transmission of HIV (PMTCT) in urban Zimbabwe. Methods Community counsellors were trained in routine HIV testing policy using a specific training module from June 2005 through November 2005. Key outcomes during the first 6 months of routine testing were compared with the prior 6-month “opt-in” period, and clients were interviewed. Findings Of the 4551 women presenting for antenatal care during the first 6 months of routine HIV testing, 4547 (99.9%) were tested for HIV compared with 3058 (65%) of 4700 women during the last 6 months of the opt-in testing (P < 0.001), with a corresponding increase in the numbers of HIV-infected women identified antenatally (926 compared with 513, P < 0.001). During routine testing, more HIV-infected women collected results compared to the opt-in testing (908 compared with 487, P < 0.001) resulting in a significant increase in deliveries by HIV-infected women (256 compared with 186, P = 0.001); more mother/infant pairs received antiretroviral prophylaxis (n = 256) compared to the opt-in testing (n = 185); and more mother/infant pairs followed up at clinics (105 compared with 49, P = 0.002). Women were satisfied with counselling services and most (89%) stated that offering routine testing is helpful. HIV-infected women reported low levels of spousal abuse and other adverse social consequences. Conclusion Routine antenatal HIV testing should be implemented at all sites in Zimbabwe to maximize the public health impact of PMTCT. Bulletin of the World Health Organization 2007;85:843–850. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. Routine offer of antenatal HIV testing (“opt-out” approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe Winfreda Chandisarewa,a Lynda Stranix-Chibanda,b Elizabeth Chirapa,a Anna Miller,c Micah Simoyi,d Agnes Mahomva,e Yvonne Maldonadof & Avinash K Shetty g .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا a Zimbabwe AIDS Prevention Project, University of Zimbabwe, Harare, Zimbabwe. b UZ-UCSF Collaborative Research Program in Women’s Health, Harare, Zimbabwe. c Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA. d Chitungwiza Health Department, Chitungwiza, Zimbabwe. e Ministry of Health and Child Welfare, Harare, Zimbabwe. f Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA. g Department of Pediatrics, Wake Forest University Health Sciences, Winston-Salem, NC, USA. Correspondence to Avinash K Shetty (e-mail: ashetty@wfubmc.edu). doi: 10.2471/BLT.06.035188 (Submitted: 4 August 2006 – Final revised version submitted: 1 March 2007 – Accepted: 2 March 2007 – Published online: 21 September 2007) Introduction The perinatal HIV epidemic remains a major public health problem in Zim- babwe.1 Recent estimates indicate that over 20% of women aged 15–49 years presenting for antenatal care (ANC) are HIV-infected.1 Several trials have re- ported the efficacy of simple, low-cost antiretroviral prophylactic regimens to reduce mother-to-child transmission of HIV in sub-Saharan Africa.2–4 Although prevention of mother-to-child transmis- sion of HIV (PMTCT) interventions using single-dose nevirapine (sdNVP) have been implemented in many urban and rural clinics in Zimbabwe,5 up- take of these interventions remains low, primarily due to poor antenatal HIV testing rates.6 Detection of maternal infection early in pregnancy through voluntary counselling and HIV testing (VCT) is critical for PMTCT.7 In Zimbabwe, HIV testing is conducted after individual pre-test counselling, with clients actively choosing whether to be tested (i.e. an “opt-in” approach or client-initiated testing). The acceptance rate of VCT among our ANC clients has been low, ranging from 20% to 63%.6,8 Several reasons may account for poor antenatal VCT uptake among women in sub- Saharan Africa, including absence of prenatal care, fear of stigma and inad- equate counselling experiences.9–11 Thus innovative approaches to antenatal HIV testing are urgently required. Provider-initiated routine antenatal HIV testing (i.e. an “opt-out” approach) is the standard of care in the United States of America (USA) and other developed nations.12–16 Routine ante- natal HIV testing policy is rare in sub- Saharan Africa.17,18 Recent data from the PMTCT programme in Botswana demonstrated that routine HIV testing led to a significant increase in HIV- test acceptance at ANC clinics, where HIV prevalence has been  40% since 1995.18 A recent study from rural Zim- babwe found that routine antenatal HIV testing is acceptable to both clients and health-care providers.19 The objective 844 Bulletin of the World Health Organization | November 2007, 85 (11) Research Routine antenatal HIV testing in Zimbabwe Winfreda Chandisarewa et al. of this pilot study was to evaluate the impact of routine antenatal HIV testing in urban Zimbabwe. Methods Zimbabwe is a southern African country of approximately 12.5 million inhabit- ants whose capital city, Harare, has a population of 1.5 million. Antenatal HIV seroprevalence in urban clinics has been estimated to be around 21.3%.20 Our study was conducted at four antenatal clinics in Chitungwiza, a socioeconomi- cally disadvantaged community 25 km south of Harare. Provider-initiated routine HIV test- ing with right of refusal was offered to all new ANC clients between June 2005 and November 2005. Before implemen- tation of the routine HIV testing policy, a VCT site instrument was used to assess the adequacy of staffing levels, adherence to PMTCT protocols, availability of health education materials, availability of test kits and medical consumables, ad- herence to staff roles and responsibilities, and general aspects of site operations. A counsellor reflection form and a VCT client exit survey form were used to guide the implementation of the routine HIV testing policy. Community mobilization activities for improving public awareness of the routine HIV testing policy were carried out by community outreach counsellors. A drama skit was developed and pre- sented at health worker in-service train- ing workshops and at the community advisory board meetings for critiques and comments before presentation. The community counsellors performed the skit on a rotational basis at the four clin- ics on Tuesday, Wednesday and Thursday mornings for new ANC clients and during the afternoons in the community and at colleges, churches and industrial facilities. Before implementation of the rou- tine HIV testing policy, clinic staff members at the four sites attended a two-day training session conducted by the PMTCT programme staff in which the new strategy was discussed in detail, including data collection and interview techniques. Fig. 1 depicts the routine HIV testing algorithm that was modi- fied from the pilot project on routine HIV testing in Botswana18 and imple- mented for all new ANC clients. Under the new system, existing PMTCT clinic counsellors held 15- minute group education and discussion sessions with pregnant women, using a structured flip chart as a discussion guide. The discussion focused on HIV transmission, PMTCT, sdNVP prophy- laxis and routine HIV testing for all mothers, specifying the right to refuse. Women who did not want any one of the routine antenatal tests were referred for individual pre-test counselling to dis- cuss their concerns. Women who arrived for ANC when no group was conducted received the same education individu- ally via pre-test counselling. Women who did not refuse and gave verbal in- formed consent individually had blood drawn for rapid HIV testing on-site by clinic nurses in addition to routine syphilis, blood group and haemoglobin level testing. Maternal HIV status was deter- mined on-site using two rapid tests in Group education about HIV and PMTCT for all women presenting for ANC Consultation and examination including routine antenatal blood draw for HIV testing, RPR and Hb Woman tested for HIV Woman refuses testing Individual post-test counselling Individual pre-test counselling HIV-positive: emphasis on psychosocial support, availability and access to HIV care, ongoing supportive counselling and PMTCT interventions HIV-negative: emphasis on maintaining negative serostatus Woman refuses testing Infant feeding counselling appropriate to HIV serostatus Fig. 1. Provider-initiated routine HIV counselling and testing algorithm ANC, antenatal care; Hb, haemoglobin; PMTCT, prevention of mother-to-child transmission of HIV; RPR, rapid plasma reagin. parallel (Uni-Gold Test, Trinity Biotech, USA; and Determine HIV1/2 test, Abott Laboratories, USA) on each blood sam- ple, and a third test (OraQuick, Abott Laboratories, USA) as a tie-breaker. Women received their test results the same day during extensive individual post-test counselling, with a focus on PMTCT interventions for HIV-infected women, enrolment into support groups, counselling for exclusive breastfeeding for 6 months according to WHO and national guidelines, sdNVP prophylaxis and mother-infant follow-up. To assess the acceptability of the routine HIV testing policy, a 15-item self-administered exit questionnaire was administered during the initial three months of implementation to women (n = 2011) in Shona, the local language, after completion of their first ANC visit. The questionnaire was adapted from the 845Bulletin of the World Health Organization | November 2007, 85 (11) Research Routine antenatal HIV testing in ZimbabweWinfreda Chandisarewa et al. pilot project on routine HIV testing in Botswana.18 To determine if there were any negative effects related to the routine HIV testing policy, women (n = 221) at- tending the four antenatal and postnatal clinics who had participated in routine HIV testing were interviewed individu- ally, regardless of HIV status, during the fifth month of study implementation. The standardized questionnaire was administered in Shona by four trained community counsellors who did not know the client’s serostatus. Data collection and analysis Quantitative data regarding acceptance of HIV testing and PMTCT interven- tions were collected according to cur- rent programme guidelines. Data was entered and analysed using EpiInfo 2004 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Impact on HIV testing acceptance rates, post- test return rates, acceptance of PMTCT interventions and follow-up were deter- mined by comparing data collected dur- ing the first 6 months of routine HIV testing (opt-out) with the prior 6 months opt-in period. A P-value of < 0.05 was considered statistically significant. Ethical considerations The Call-to-Action Project was approved by Zimbabwe Ministry of Health and Child Welfare, the Chitungwiza Health Department and the Institutional Review Board at Wake Forest University Health Sciences. Verbal informed consent was obtained individually from all participants after explaining the study protocol in detail. Strict confidentiality was maintained for all clients. Results Of the 4551 pregnant women present- ing for ANC during the first 6 months (June 2005 to November 2005) of rou- tine HIV testing, 4547 (99.9%) were tested for HIV compared with 3058 (65%) of 4700 pregnant women during the last 6 months (October 2004 to March 2005) of the opt-in testing period (P < 0.001), with a corresponding increase in the numbers of HIV-infected women identified ante- natally (n = 926, 20.4% seroprevalence, as compared with 513, 16.8% seropreva- lence, P < 0.001) (Table 1). Table 1. Selected indicators of the prevention of mother-to-child HIV transmission in four urban antenatal clinics included in the Call-to-Action programme in urban Zimbabwe Indicator October 2004–March 2005 (“Opt-in” VCT approach or client-initiated testing) Number (%) June 2005–November 2005 (“Opt-out” VCT approach or routine testing) Number (%) P-value VCT ANC bookings 4872 4551 – Pre-test counselled/group education 4872 (100%) 4551 (100%) – Tested for HIV 3058 (65.1%) 4547 (99.9%)a < 0.001 Women HIV-infected 513 (16.8%) 926 (20.4%)a < 0.001 Post-test counselled 2964 (96.9%) 4538 (99.8%)a < 0.001 Partners tested for HIV 196 (6.4%) 308 (6.8%) 0.531 Partners post-test counselled 196 (100%) 307 (99.7%) – Partners HIV-infected 44 (22.4%) 49 (15.9%) 0.065 HIV-infected women Post-test counselled and collected test results 487 (95%) 908 (98%)a < 0.001 Given sdNVP to take home at  28 weeks of gestation 372 (76.3) 663 (71.6%) 0.711 Known to have delivered in the four antenatal clinics 186 (38.1%) 256 (27.6%)a  0.001 Total infants receiving sdNVP 185 (36%) 257 (28%)b – Mothers and infants receiving sdNVP 185 (36%) 256 (28%) – Care, support and follow-up Mothers enrolled in mentorship programme 257 (52.7%) 526 (57.9%) 0.064 Mothers joining PSS group 42 (16.3%) 80 (15.2%) 0.681 Mother-infant pairs seen at the 6-week visit 49 (26.3%) 105 (41%)a 0.002 ANC, antenatal care; PSS, psychosocial support; sdNVP, single-dose nevirapine; VCT, voluntary counselling and HIV testing. a Statistically significant. b Twin gestation. No negative effects were noted on ANC attendance, collection of test re- sults, post-test counselling rates or up- take of PMTCT interventions among HIV-infected women during the im- plementation of routine HIV testing. Overall, 4538 (99.8%) women returned to collect their test results during the routine antenatal HIV testing period compared to 2964 (96.7%) during opt- in testing period (P < 0.001) (Table 1). During the routine testing period, more HIV-infected women were identified antenatally (926 compared with 513, P < 0.001). Of these, significantly more HIV-infected women were post-test counselled and collected test results compared to the opt-in period (908 compared with 487, P < 0.001). Like- wise, there was a corresponding increase in deliveries by known HIV-infected women in the four clinics (256 com- pared with 186, P  0.001), resulting in higher numbers of mother/infant pairs receiving sdNVP prophylaxis during routine testing (n = 256) compared to the opt-in testing period (n = 185). In addition, more HIV-infected women during the routine testing period en- rolled in the mentorship programme led 846 Bulletin of the World Health Organization | November 2007, 85 (11) Research Routine antenatal HIV testing in Zimbabwe Winfreda Chandisarewa et al. by community counsellors (526 com- pared with 257, P = 0.064), joined psy- chosocial support groups (80 compared with 42, P = 0.681), and followed up with their babies at the clinics (105 com- pared with 49, P = 0.002) compared with women during the opt-in study period. Of the 4547 women who under- went routine HIV testing and were en- couraged to bring their partners for free VCT, only 308 men (6.8%) opted for HIV testing, and 307 (99.7%) returned to collect their results and received post- test counselling; of these, 49 (16%) were HIV-infected. Client exit survey Of the 2624 women who opted for routine HIV testing during the first 3 months of study and answered the ques- tionnaire at the end of their first ANC visit, 2011 (76.6%) completed the exit survey. The overall response was positive, with clients generally satisfied with the quality of counselling. Overall, 98% of respondents said that the informa- tion they were given by community counsellors on routine HIV testing had adequately prepared them for the result, 99% of women said they understand why their blood was being drawn, 99% of women said they were better prepared to manage their health after learning their HIV status and 98% said they were ready to disclose their HIV status to their partners. Follow-up survey A total of 221 women attending ante- natal and postnatal clinics who opted for routine testing were sampled and interviewed individually, regardless of their HIV status, to determine if there were any negative effects of routine HIV testing. The sample’s sociodemographic characteristics are shown in Table 2. The mean age was 24 years, with most women married (90%), educated through sec- ondary school (82%) and employed (67%). Of the 221 women interviewed, 219 (99%) were tested for HIV at the first antenatal visit; 109 women (49%) were HIV-infected. The most frequent reasons given for accepting the HIV test were to protect their children and concern for their own health. All women found the information provided by com- munity counsellors adequate to make informed decisions about routine HIV testing. Of 221 women interviewed, 88% (194) had disclosed their serostatus to their husbands (Table 3). Among those women who disclosed their test results (n = 197), 181 (92%) did not experience violence and the relationship contin- ued. However, only 7% of the partners were tested for HIV. Disclosure-related violence from their partners was expe- rienced by 8% [16 (14 HIV-infected, 2 HIV-uninfected) women]. The patterns of physical abuse included pushing, slap- ping and kicking; no injuries related to firearms, knife or burns were reported. The relationship ended in 4 couples (2%) due to divorce (1), separation (1), and abandonment by the male partner (2). Of 221 women interviewed, 11% (24) had not disclosed their serostatus to anyone. The reasons given for non- disclosure included fear of violence, divorce and stigma. Overall, 89% (197 of 221) women stated that offering routine HIV testing like other blood tests during pregnancy is helpful because it is an empowering tool for women to exercise their rights and responsibilities by accessing relevant information to make informed decisions about PMTCT and infant feeding. Discussion We found that routine antenatal HIV testing was feasible and acceptable for Table 2. Sociodemographic characteristics of women who participated in a follow-up interview during the routine HIV testing pilot project (n = 221) Characteristics Number % 15–25 151 68.4 26–35 54 24.4 36–45 16 7.2 Marital status Single 10 4.5 Married 199 90.0 Divorced 1 0.5 Living with partner 11 5.0 Parity 0 53 24.0 1 88 39.8 2 53 24.0 3 19 8.6 4 or more 8 3.6 Level of education Primary 38 17.1 Secondary 181 82.0 Tertiary 2 0.9 Employment Employed 147 66.5 Unemployed 74 33.5 pregnant women in urban Zimbabwe, resulting in almost 100% of women opting for HIV testing, and overall significant improvement in quantita- tive PMTCT service statistics. Our data are consistent with recent reports from Africa, where routine antenatal HIV testing has been found to be acceptable and to significantly increase the HIV testing rates.17,18 The significantly high uptake at our site with routine HIV testing could be related to multiple factors. Women were probably less fearful of participat- ing in routine HIV testing because this approach would be perceived by her partner and family as “standard of care” offered to all ANC clients, thereby reducing the risk of stigma and other adverse social consequences when com- pared to the opt-in VCT policy. In addi- tion, community sensitization, counsel- ling sessions involving highly motivated community counsellors and availability of on-site rapid HIV testing may also have contributed to significantly high HIV testing rates among women in our study. Another important finding in this study was that the introduction of routine HIV testing did not lead to reductions in the number of women 847Bulletin of the World Health Organization | November 2007, 85 (11) Research Routine antenatal HIV testing in ZimbabweWinfreda Chandisarewa et al. Table 3. Disclosure of HIV serostatus among women participating in “opt-out” HIV testing (n = 221)a Response Frequency % Person informed Husband 197 89.1 Relative 33 14.9 Friend 5 2.3 None 24 10.9 Reason for non-disclosure (n = 24) Afraid of violence 8 33.3 Afraid of divorce 6 25.0 Afraid of stigma 5 20.8 Thought not useful 2 8.3 No response 7 29.2 Partners’ response (n = 197) No violence/relationship continued 181 91.8 Violence 16 8.1 Relationship stopped 4 2.0 Partner tested 13 6.6 Opinion of women on routine antenatal HIV testing (n = 221) Helpful 197 89.1 Not helpful 24 10.9 a This was a multiple response question and hence the percentages add up to more than 100%. attending ANC or those receiving test results compared to the opt-in period. In our study, 98% of HIV-infected women returned for test results. Improved com- munity awareness and group educa- tion about the importance of routine antenatal HIV testing and availability of on-site rapid testing with same-day results may explain the above findings. In contrast, a recent study in Botswana showed that a significant proportion of pregnant women (29%) who opted for routine HIV testing did not return to the clinic to collect their test results because HIV testing was conducted off- site and results were not immediately available.18 Likewise, in the Kenya study where routine antenatal HIV testing was offered, 31% of women (including 44% of HIV-infected women) did not return to obtain their test results.17 Policies to encourage early detec- tion of HIV infection during preg- nancy through routine testing have raised several ethical concerns regarding the definition and implementation of routine universal testing, especially in settings marked by poverty, illiteracy, gender inequalities, weak health-care infrastructure and poor access to an- tiretroviral treatment.21,22 Recently, a population-based survey from Botswana found that routine HIV testing was widely supported and reduced barriers to HIV testing.23 In the present study, the overall response to routine HIV testing was positive, with relatively low levels of miscomprehension and partner violence, which is often a major concern for HIV-infected women when they dis- close their infection status.9,24 Further- more, more than two-thirds of newly HIV-infected women at our site joined support groups, a vital component for any successful PMTCT programme. Several challenges were identified during the implementation of this rou- tine antenatal HIV testing project. First, the clinics are severely understaffed with regard to nurses. Nurses are often trained in counselling, but the increased clinic workload due to staff shortage has resulted in reluctance among staff members to take on the additional task of counselling. In addition, there are no funds to employ and train a new cadre of full-time professional counsellors to deliver VCT. Therefore, HIV counsel- ling has been conducted by community counsellors at our site since 1998, a so- lution that has been replicated at many antenatal clinics in Zimbabwe.6 This focus on group talk and discussion both reduces the pre-test counselling burden on health-care workers and facilitates individual post-test counselling for both HIV-negative and HIV-positive women. Second, the current economic hardships in Zimbabwe and high levels of midwife staff turnover requires more resources to be made available for training, especially to effectively communicate the new rou- tine HIV testing approach and dispel the misconception that it is mandatory testing. Intensive standardized health worker training at all levels of health ser- vice delivery is warranted. It is important to ensure proper logistic support and availability of laboratory supplies before the routine testing policy is implemented all over the country. Finally, countrywide public awareness campaigns through print and electronic media before the implementation of the routine antenatal HIV testing are critical. The low rate of HIV testing among male partners remains a major challenge for the PMTCT programme in Zimba- bwe. Innovative approaches to promote male involvement are urgently needed. PMTCT programmes should address gender-based issues, make ANC clin- ics more male-friendly, promote couple counselling and HIV testing, and enhance community mobilization and information- education-communication (IEC) activities to promote VCT among men.7 Significant advances have occurred in PMTCT.24 In resource-rich settings, perinatal HIV transmission rates are less than 2% due to widespread imple- mentation of prenatal HIV-1 testing, combination antiretroviral treatment during pregnancy, elective caesarean section and avoidance of breastfeeding.25 Therefore, routine HIV testing has be- come the standard of care for pregnant women in resource-rich countries.12–16 In contrast, routine HIV testing approach is unusual in sub-Saharan Africa,17,18 where HIV infection rates are very high and HIV testing faces considerable barriers, including the fear of stigma and discrimination.9,10 Although there has been scale-up of PMTCT in many resource-poor settings, ARV treatment programmes have only recently started to become available. In 2004, to in- crease access to PMTCT and ARV ther- apy in resource-limited countries, the UNAIDS/WHO recommended routine HIV testing of pregnant women with the right to refuse.26 Our study has certain limitations. The almost 100% antenatal HIV testing acceptance rate at our clinics could be attributed to the highly motivated clinic staff. The community counsellors are 848 Bulletin of the World Health Organization | November 2007, 85 (11) Research Routine antenatal HIV testing in Zimbabwe Winfreda Chandisarewa et al. Résumé Proposition systématique d’un test de dépistage du VIH anténatal (avec possibilité de refuser) en vue de prévenir la transmission de la mère à l’enfant de ce virus dans les zones urbaines du Zimbabwe Objectif Evaluer l’impact d’un dépistage anténatal systématique du VIH sur la prévention de la transmission de la mère à l’enfant de ce virus (PMTCT) dans les zones urbaines du Zimbabwe. Méthodes Des conseillers appartenant à la collectivité ont été formés à la politique de dépistage systématique du VIH à l’aide d’un module de formation spécial de juin à novembre 2005. Les principaux résultats obtenus au cours des 6 premiers mois d’application du dépistage systématique ont été comparés à ceux de la période où ce dépistage était pratiqué à la demande et les patientes ont été interrogées. Résultats Parmi les 4551 femmes s’étant présentées pour des soins anténataux pendant les 6 premiers mois de proposition systématique d’un dépistage du VIH, 4547 (99,9 %) se sont soumises à ce dépistage contre 3058 (65 %) parmi les 4700 femmes s’étant présentées pendant les 6 derniers mois de dépistage à la demande (p < 0,001), d’où une augmentation du nombre de femmes contaminées par le VIH détectées avant l’accouchement (926 contre 513, p < 0,001). Pendant la période de dépistage systématique, davantage de femmes contaminées sont venues rechercher leurs résultats que pendant la période de dépistage à la demande (908 contre 487, p < 0,001), ce qui s’est traduit par un accroissement significatif du nombre d’accouchements par des femmes séropositives pour le VIH (256 contre 186, p = 0,001) ; davantage de couples mère/enfant ont reçu un traitement prophylactique antirétroviral (n = 256 contre 185) ; et davantage de couples mère/enfant ont été suivis dans des dispensaires (105 contre 49, p = 0,002). Les femmes ont été satisfaites des conseils fournis et la plupart (89 %) ont déclaré que la proposition systématique d’un dépistage était utile. Les femmes contaminées par le VIH ont signalé de faibles niveaux de maltraitances conjugales et autres phénomènes sociaux préjudiciables. Conclusion Le dépistage systématique du VIH doit être mis en œuvre dans tous les sites du Zimbabwe pour maximiser le bénéfice pour la santé de la PMTCT. Resumen Oferta sistemática (con derecho a renuncia) de la prueba prenatal de detección del VIH para prevenir la transmisión del VIH de la madre al niño en una zona urbana de Zimbabwe Objetivo Evaluar el impacto de la prueba prenatal sistemática de detección del VIH en la prevención de la transmisión del VIH de la madre al niño (PTMN) en una zona urbana de Zimbabwe. Métodos Se formó a consejeros comunitarios en la política de realización sistemática de la prueba del VIH utilizando un módulo didáctico específico entre junio y noviembre de 2005. Los resultados principales obtenidos durante los 6 primeros meses de pruebas sistemáticas (sistema con derecho a renuncia, «opt-out») se compararon con el periodo con derecho de adhesión («opt-in») de los 6 meses previos, y se entrevistó a las usuarias. Resultados De las 4551 mujeres que realizaron una visita de atención prenatal durante los 6 primeros meses de pruebas people living with HIV/AIDS who have participated in previous PMTCT clinical trials at our site. This may not be the case at other antenatal clinics in Zimbabwe. The study findings are limited in terms of overall generalization and impact since only 25% of HIV-infected women identified in the city of Chitungwiza ac- tually deliver in the clinics; most women deliver in other urban or rural facilities or at home. Despite these limitations, we believe that our pilot data provide useful information for implementing routine antenatal HIV testing policy in Zimbabwe. To our knowledge, this study was the first to evaluate routine HIV testing in a large urban PMTCT programme in Zimbabwe. Although implementation was challenging given the scarcity of human and financial resources, we ob- served that routine HIV testing was op- erationally feasible and acceptable to all women, with significant improvement in quantitative PMTCT service statis- tics. In addition, HIV-infected women who participated in routine testing reported relatively low levels of spousal abuse and other adverse social conse- quences. High-quality post-test coun- selling and adequate staffing are critical before widespread implementation of routine HIV testing. We believe that routine antenatal HIV testing should become the standard of care and be ur- gently implemented at all antenatal sites in Zimbabwe. Given the high antenatal HIV prevalence, implementing routine HIV testing would have a significant public health impact on the perinatal HIV epidemic in Zimbabwe and other resource-limited countries. ■ Acknowledgements The authors wish to thank the Ministry of Health and Child Welfare and Chi- tungwiza Health Department, Family AIDS Initiatives Programme Partners, ISPED and Kapnek Trust, Elizabeth Glaser Pediatric AIDS Foundation administrative and technical staff in- cluding Patricia Mbetu, Jo Keatinge, Matthews Maruva, Chuck Hoblitzelle, Maurice Adams and Catherine Wilfert. We also thank Godfrey Woelk, Tsungai Chipato, Rose Kambarami, the UZ- UCSF Collaborative Program in Women’s Health, the departments of paediatrics, community medicine and obstetrics and gynaecology at the Uni- versity of Zimbabwe School of Medi- cine, PMTCT Partnership Forum, Tracy Creek (CDC Botswana), Shannon Hader (CDC Zimbabwe), Zimbabwe AIDS Prevention Project-Call-to-Action team, nurses, community counsellors, mobi- lizers and all the mothers and infants who participated in the study. Funding: This project was funded by the Elizabeth Glaser Pediatric AIDS Foundation and United States Agency for International Development. Parts of this paper were presented at the XIV International AIDS Conference, 13–18 August 2006 in Toronto, Canada. Competing interests: None declared. 849Bulletin of the World Health Organization | November 2007, 85 (11) Research Routine antenatal HIV testing in ZimbabweWinfreda Chandisarewa et al. sistemáticas de detección del VIH, 4547 (99,9%) fueron sometidas a la prueba del VIH, en comparación con 3058 (65%) de 4700 durante los 6 últimos meses de pruebas con derecho de adhesión (P < 0,001), aumentando así el número de mujeres seropositivas identificadas en la etapa prenatal (926 frente a 513, P < 0,001). Durante el periodo de pruebas sistemáticas, el número de mujeres infectadas que acudieron por los resultados fue mayor que entre las mujeres con derecho de adhesión (908 frente a 487, P < 0,001), lo que se tradujo en un aumento importante del número de partos por mujeres VIH-positivas (256 frente a 186, P = 0,001); el número de parejas madre/lactante que recibieron profilaxis antirretroviral fue consiguientemente mayor (n = 256) en comparación con el periodo con derecho de adhesión (n = 185); y lo mismo ocurrió con el número de parejas madre/lactante que se sometieron a seguimiento en consultorios (105 frente a 49, P = 0,002). Las mujeres estaban satisfechas con los servicios de asesoramiento (89%), y la mayoría consideraban conveniente el ofrecimiento de pruebas sistemáticas. Las mujeres VIH-positivas refirieron bajos niveles de violencia conyugal y otros efectos sociales adversos. Conclusión Si se quiere optimizar el impacto de la PTMN en la salud pública, es necesario implementar en todo Zimbabwe las pruebas prenatales sistemáticas de detección del VIH. صخلم ،لفطلا لىإ ملأا نم سويرفلا ةياسر يقوتل )لوبقلا مدع رايخ جهن(يشربلا يعانلما زوعلا سويرفل ةينيتورلا تارابتخلاا ءارجإ ضرع يوبابمز في ةيضرحلا قطانلما في لبق يشربلا يعانلما زوعلا سويرفل ةينيتورلا تارابتخلاا رثأ مييقت :فدهلا ةيضرحلا قطانلما في ،لفطلا لىإ ملأا نم سويرفلا ةياسر يقوت لىع ةدلاولا .يوبابمز في تارابتخلاا ةسايس لاجم في ةيعمتجلما ةروشلما ومدقم بِّرُد :ةقيرطلا ةيجذونم بيردت ةدحو مادختساب ،يشربلا يعانلما زوعلا سويرفل ةينيتورلا .2005 برمفون/نياثلا نيشرت لىإ ،2005 وينوي/ناريزح نم ةترفلا للاخ ،ةيعون ،ةينيتورلا تارابتخلال لىولأا ةتسلا رهشلأا ةترفل ةيساسلأا لئاصحلا تنروقو رايخ جهنل ًاقفو تارابتخلاا اهيف تيرجأ يتلا ةقباسلا ةتسلا رهشلأا ةترف عم .تاصوحفلا هذهل تاعضاخلا عم تلاباقم تيرجأو ،لوبقلا رهشلأا للاخ لمحلا ةياعر يقلتل َنْمِدَق ةديس 4551 ينب نم :تادوجولما ترجأ ،ةينيتورلا يشربلا يعانلما زوعلا سويرف تارابتخا ءارجلإ لىولأا ةتسلا )%65( ةديس 3058 ـب ةنراقم تارابتخلاا هذه )%99.9( ةديس 4547 اهيف تيرجأ يتلا ةيرخلأا ةتسلا رهشلأا ةترف للاخ ،ةديس 4700 ينب نم عم ،)0.001 نم لقأ لماتحلاا ةميق( لوبقلا رايخ جهنل اقفو تارابتخلاا يشربلا يعانلما زوعلا سويرفب تاباصلما ءاسنلا دادعأ في ةرظانم ةدايز دوجو ،513 ـب ةنراقم ةديس 926( لمحلا ةترف للاخ نهتباصإ تفشُتكا تيلالا ًاددع نأ ،تارابتخلاا ءارجإ ةترف للاخ ينبتو .)0.001 نم لقأ لماتحا ةميقب يتلا ةترفلاب ةنراقم ،جئاتنلا ةفرعلم ئنج سويرفلاب تاباصلما ءاسنلا نم بركأ ةميقب ،487 ـب ةنراقم 908( لوبقلا رايخ جهنل ًاقفو تارابتخلاا اهيف تيرجأ ددع في ًايئاصحإ اهب دتعي ةدايز ثودح لىإ ىدأ مام )0.001 نم لقأ لماتحا 256( يشربلا يعانلما زوعلا سويرفب تاباصم ةوسنل تتم يتلا تادلاولا لك نم بركأ ددع يقلتو ،)0.001 اهرادقم لماتحا ةميقب ،186 ـب ةنراقم )256 :ددع( ةيرقهقلا تاسويرفلا تاداضبم ئياقولا جلاعلل عيضرلاو ملأا نم ،)185 :ددع( لوبقلا رايخ جهنل ًاقفو تيرجأ يتلا تارابتخلاا ةترفب ةنراقم ـب ةنراقم 105( تادايعلا في عضرلاو تاهملأا نم لك نم بركأ ددع ةعباتمو تامدخ نع نهءاضر ةوسنلا تدبأو .)0.002 اهرادقم لماتحا ةميقب ،49 ةينيتورلا تارابتخلاا ءارجإ ضرع نأ )%89( نهمظعم ركذو ،ةمدقلما ةروشلما ءادتعا نع سويرفلا اذهب تاباصلما ةوسنلا غلابإ تلادعم تناكو .ديفم رمأ .ةضفخنم ةرئاضلا ةيعماتجلاا بقاوعلا نم كلذ يرغو ،نهيلع نهجاوزأ يشربلا يعانلما زوعلا سويرفل ةينيتورلا تارابتخلاا قيبطت يغبني :جاتنتسلاا ةياسر يقوتل ةيمومعلا ةيحصلا راثلآا ةدايزل يوبابمز في قطانلما عيمج في .دح صىقأ لىإ ،لفطلا لىإ ملأا نم سويرفلا References 1. 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