Rapid, opt-out HIV testing accepted by over 99% of women in an urban Malawi program

Acceptance of HIV testing among pregnant women at an urban clinic in Malawi has risen steadily since the testing programme was instituted in 2002, according to a retrospective analysis published in the January 2^nd edition of AIDS. Acceptance rose from 45% to 73% after rapid, same-day testing was made available in July 2003. With other improvements including the institution of opt-out testing in April 2005, the acceptance rate has risen to over 99%. HIV testing of newborns is still limited; of the children tested, 15.5% were HIV positive.

A prevention of mother-to-child transmission (PMTCT) programme was introduced at four maternity centres in urban Lilongwe, Malawi in April 2002. The programme includes education on prenatal care, nutrition, HIV and sexually transmitted infections, as well as routine prenatal care, voluntary counseling and testing (VCT), and the provision of PMTCT care. In this study, service usage and VCT uptake were retrospectively analysed based on monthly reports from the beginning of the program until December 2006.

The VCT program includes HIV antibody testing and pre- and post-test counselling. Originally, the VCT program used a standard ELISA test and required privately provided written consent; women had to return for the results in one to two weeks. In July 2003, rapid testing with same-day results replaced ELISA testing.

In the first year of the programme, approximately 20,000 pregnant women accessed the service. Between the second quarters of 2003 and 2004, VCT uptake (the percentage of women voluntarily agreeing to testing) increased from 45% (95% confidence interval [CI], 43.6 – 46.3) to 73% (95% CI, 71.5 – 74.0; p

In April 2005, in collaboration with the Malawi Ministry of Health, the test consent procedure was changed to an opt-out system requiring verbal consent only. Pre-test counseling and an explanation of the opt-out system were provided in small group settings; results and post-test counseling were provided individually. By the third quarter of 2005, uptake increased to over 99% (95% CI, 99.7 – 99.9, p

In the PMTCT programme, HIV-positive pregnant women are given a single 200 mg dose of nevirapine at week 32 of pregnancy, taken at the onset of labour. Babies born at the participating clinics are given 2 mg/kg of nevirapine within 72 hours of birth. If the mother delivers before receiving the drug, the baby is given nevirapine immediately after birth, with a second dose within 72 hours.

Earlier in the programme, full antenatal care was not provided, largely due to shortages of staff and medications. The increases in VCT uptake also coincided with improvements in staffing, staff training, medication and supply provision.

The percentage of deliveries at the programme's maternity clinics also increased, from 23.5% (95% CI, 21.7 – 25.5) in 2003 to 54.6% (95% CI, 52.9 – 56.4) in 2006 (p

Although the programme has offered HIV DNA PCR testing for infants at six weeks since 2004, most of the mothers do not return to access this testing. During the first year, only 19.4% of babies born to HIV-positive mothers were tested (95% CI, 17.82–21.05), of whom 26.6% were HIV-positive. In 2006, testing increased to 34.5% (95% CI, 32.85–36.19), of whom 15.5% were positive (p

The authors note that the rates of test acceptance and access to antenatal care at the Lilongwe sites are higher than those reported at many other sites in Africa. They note several weaknesses in the report: it is not a formal cohort study, there are no data on the mothers' rates of nevirapine compliance, and the reported mother-to-child transmission rates only reflect the mothers who voluntarily returned and hence are heavily biased by self-selection.

Nevertheless, the authors state that "integration of PMTCT services into routine antenatal care has proven crucial" for greatly increased uptake of voluntary counseling, testing, and PMTCT services, that their reported transmission rate of 15.5 – 16.5% "compares with that of a similar population enrolled in a multisite randomised study", and that "given the successes of [their] program, expansion to other centres… should be undertaken in a similar model."