Date Published: May 6, 2008
Publisher: Public Library of Science
Author(s): David D Celentano
Abstract: David Celentano discusses a new study evaluating the uptake of 24-hour rapid HIV testing of women in a labor and delivery center in a rural teaching hospital in India.
Partial Text: Despite the downward revision of the estimated national prevalence of HIV infection in India from 5.7 million to 2.5 million in UNAIDS’ December 2007 report, the burden faced in providing national HIV prevention and care remains massive . The National AIDS Control Organization (NACO) of India estimated that some 60% of cases of HIV infection are found in rural areas, where about half of India’s citizens live . In rural and urban areas, women of reproductive age are principally at risk for HIV acquisition through marriage—this risk reflects their husband’s premarital behavior and sexual concurrency during marriage [3,4]. Therefore, NACO has focused on the expansion of voluntary counseling and testing (VCT) services to increase early case-finding, in large part through antenatal care in conjunction with the prevention of mother-to-child transmission (PMTCT) of HIV during labor and delivery .
The study found that acceptance of HIV testing in the labor ward was almost universal—98% of women offered HIV testing accepted it, 82% of whom had no prior history of HIV testing or had incomplete reports of testing at the time of admission to the labor ward. Importantly, only 30 women (2%) refused the confidential HIV test, most of whom perceived that they were not at risk or knew their prior HIV test result (which of course could be imperfect). A total of 15 women were found to be HIV infected using the HIV testing algorithm, giving a prevalence of 1.23%, a rate close to the 1% anticipated from the recent antenatal sentinel surveillance. Of the women who agreed to testing, 54% gave no history of a prior HIV test. Of women with a prior history of being tested for HIV, most (65%) reported a private health facility as the testing site (although an additional 24% could not recall their HIV test site). Nevertheless, 82% of the women who were tested during labor had either not been previously tested or had not received their HIV test results, suggesting that the labor ward is an important venue for testing otherwise low-risk women. Importantly, 11 of the HIV-infected women were newly identified and were immediately provided PMTCT treatment.
Data are often insufficient to alter health policy. As Sinha and colleagues point out in their sample in rural Maharashtra, many pregnant women have good HIV knowledge and risk awareness, yet providers remain a major roadblock to accessing HIV testing . Two recent reports of providing HIV testing in rural antenatal care clinics demonstrate the acceptability of VCT in this setting [7,8]. While NACO has recently affirmed its policy of expanding VCT in antenatal care, adoption of the testing approach advocated by Pai et al.  would appear to offer an optimal safeguard for HIV-infected women and allow the timely provision of PMTCT care during labor and delivery. Recently, Dandona and colleagues showed that combining PMTCT services with VCT offers optimal efficiency in the Indian setting .
It is clear that the labor and delivery setting offers the final opportunity to detect and prevent MTCT of HIV. The program outlined by Pai and colleagues is efficient, acceptable, and leads to reduced morbidity . Scaling up this program is clearly the next challenge, one that might require additional operational research efforts to convince policy makers of the utility of this approach. Without such effective programs, women are unlikely to be tested —an unacceptable situation that is relatively easy to address at this time.