Very low levels of HIV testing amongst women in rural India

Levels of HIV testing amongst pregnant women in rural India are very low, and even women who have symptoms of sexually transmitted infections or tuberculosis are not being referred for HIV voluntary counselling or testing, according to a study published in the February 1^st edition of the Journal of Acquired Immune Deficiency Syndromes. The study also found that few women were aware of the existence of voluntary counselling and testing facilities.

There are approximately 2.5 million cases of HIV in India, with 60% of these occurring amongst the rural population. Married women of childbearing age are considered to be at high risk of HIV because of their husbands’ pre-marital and extra-marital sexual activity.

Pregnancy-related health concerns are a major reason why women in rural India seek healthcare and this could provide an opportunity for the diagnosis of HIV. Surveillance studies suggest that between 0.5 – 2% of women in some regions of the country are HIV-positive. India’s AIDS Control Organization has emphasised the importance of expanding HIV voluntary testing and counselling and services to prevent mother-to-child transmission of HIV to all Indian women, including those living in rural areas.

But little is known about the HIV risk profiles of women in rural India and their access to and use of HIV testing facilities.

Investigators therefore conducted a population-based study including 400 women who had been pregnant in the previous twelve months in the Aurangabad district of Maharashtra. The women were interviewed to determine their sociodemographic characteristics, use of antenatal care, and awareness and use of HIV testing facilities. To assess the women’s risk of HIV they were asked if they had had symptoms suggestive of sexually transmitted infections or tuberculosis in the previous twelve months.

The HIV knowledge and risk of the women in the study was compared to that of a sample of women from the same region who participated in the 2001 Indian census.

Women in the current study had much better knowledge of HIV than women in the 2001 census sample, being much more likely to have heard of HIV (87% vs. 70%, p

But despite this better knowledge of HIV, only 6% of women in the study could correctly name an HIV testing facility. Furthermore, only 8% reported receiving HIV counselling during their pregnancy and only 3% of women had an HIV test.

Of the 13 women who had an HIV test, twelve did so at a private facility. The main reason for having an HIV test was recommendation from their doctor. None of the women who had an HIV test were aware of voluntary counselling and testing facilities.

The women who tested for HIV were older than those who did not (mean age 22 years vs. 20 years, p = 0.05), were educated to a lower level (higher secondary education, 23% vs. 42%, p = 0.03), lived in homes with more rooms (mean, four rooms vs. three rooms, p

A total of 35 women reported symptoms of a sexually transmitted infection or tuberculosis during pregnancy, but only one of these individuals had an HIV test. Of the 26 women with symptoms of sexually transmitted infections, nearly all received antenatal care, and almost all sought medical treatment for their symptoms.

“To our knowledge, this is the first community-based study reporting extremely low HIV testing amongst rural Indian women during pregnancy, a major target population for India’s HIV prevention efforts,” write the investigators. They identify two barriers to HIV testing amongst women in rural India: a lack of discussion of HIV testing by antenatal care providers, and a lack of knowledge of HIV testing facilities, including voluntary counselling and testing.

The investigators conclude, “India’s current policy for universal access to prevention of mother-to-child transmission requires strategies to promote HIV testing amongst pregnant rural Indian women. Antenatal clinic-based programmes to increase rural women’s awareness of voluntary HIV testing services, including provider-initiated assessment of HIV risk and discussion of HIV testing, should be developed and prospectively tested for their impact on utilization of HIV testing and subsequent prevention, diagnosis, and prevention of mother-to-child transmission for women throughout rural India.”