Qualitative Assessment of Possible Reasons for Refusal of HIV Testing at Public Hospital-Based Antenatal Care Clinics in Afar, Amhara, and Tigray Regions in Ethiopia
Background
Data collected on activities for the prevention of mother-to-child transmission of HIV (PMTCT) from Amhara, Tigray, and Afar reveal that only a small proportion of pregnant women who were offered HIV counseling and testing in hospital-based PMTCT settings in 2005 and 2006 accepted the services. Those women who did not accept services represent a considerable number of missed opportunities to prevent HIV disease.
This research used qualitative methods to seek a greater understanding of how women experience and overcome barriers to HIV counseling and testing at PMTCT sites. The results will be used to inform program improvements, which aim to increase rates of acceptance of PMTCT services.
Methods
Using a purposeful sampling strategy, the study selected six public hospitals that offer PMTCT services, yet have a history of low PMTCT uptake despite high numbers of clients seeking antenatal care (ANC) and a high HIV and AIDS disease burden. Two additional sites with known high PMTCT uptake were selected as comparison sites.
The study used three different methods of qualitative data collection: (1) In-depth, semistructured interviews of pregnant women who accepted testing, pregnant women who refused testing, and PMTCT counselors; (2) Focus group discussions of women attending ANC; and (3) Direct observation of counseling sessions and patient flow. Quantitative data was also gathered from ANC and PMTCT registers at the sites.
Findings
The research was expected to elucidate women's individual experiences of PMTCT services, highlighting their decision-making processes with regard to HIV testing. Results to date suggest that specific qualities of PMTCT service delivery are more important in explaining uptake of HIV testing within the context of PMTCT services than intrinsic characteristics of ANC attendees. Pregnant women understand the risk that accepting an HIV test might pose to their relationships with their husbands and other family members, especially if their test results are positive. Despite these risks, they are willing to be tested, especially when an opt-out approach—meaning that HIV testing is a routine part of ANC—is used.
Recommendations
The study identified a variety of practices for increasing the uptake of PMTCT services. These included: developing buy-in among ANC and labor and delivery (L&D) staff for novel approaches to counseling and testing; rewarding and affirming demonstrated leadership among PMTCT service providers; making modifications to improve patient flow for women seeking PMTCT services; using documentation systems effectively to capture all new clients so they meet the PMTCT counselors; lessening the work burden on PMTCT counselors by focusing their jobs on specific tasks; using an opt-out approach in ANC; shortening the lab time for HIV test results to be returned; and establishing the trustworthiness and reputation of PMTCT counselors.
