HIV This Week

Pai NP, Barick R, Tulsky JP, Shivkumar PV, Cohan D, Kalantri S, Pai M, Klein MB, Chhabra S. Impact of round-the-clock, rapid oral fluid HIV testing of women in labor in rural India. PLoS Med. 2008;5(5):e92.

Testing pregnant women for HIV at the time of labour and delivery is the last opportunity for prevention of mother-to-child HIV transmission measures, particularly in settings where women do not receive adequate antenatal care. However, HIV testing and counselling of pregnant women in labour is a challenge, especially in resource-constrained settings. In India, many rural women present for delivery without any prior antenatal care. Those who do get antenatal care are not always tested for HIV, because of deficiencies in the provision of HIV testing and counselling services. In this context, we investigated the impact of introducing round-the-clock, rapid, point-of-care HIV testing and counselling in a busy labour ward at a tertiary care hospital in rural India. After they provided written informed consent, women admitted to the labour ward of a rural teaching hospital in India were offered two rapid tests on oral fluid and finger-stick specimens (OraQuick Rapid HIV-1/HIV-2 tests, OraSure Technologies). Simultaneously, venous blood was drawn for conventional HIV ELISA testing. Western blot tests were performed for confirmatory testing if women were positive by both rapid tests and dual ELISA, or where test results were discordant. Round-the-clock (24 h, 7 d/wk) abbreviated prepartum and extended postpartum counselling sessions were offered as part of the testing strategy. HIV-positive women were administered prevention of mother-to-child HIV transmission interventions. Of 1,252 eligible women (age range 18 y to 38 y) approached for consent over a 9 month period in 2006, 1,222 (98%) accepted HIV testing in the labour ward. Of these, 1,003 (82%) women presented with either no reports or incomplete reports of prior HIV testing results at the time of admission to the labour ward. Of 1,222 women, 15 were diagnosed as HIV-positive (on the basis of two rapid tests, dual ELISA and Western blot), yielding a seroprevalence of 1.23% (95% confidence interval [CI] 0.61%-1.8%). Of the 15 HIV test-positive women, four (27%) had presented with reported HIV status, and 11 (73%) new cases of HIV infection were detected due to rapid testing in the labour room. Thus, 11 HIV-positive women received prevention of mother-to-child transmission interventions on account of round-the-clock rapid HIV testing and counselling in the labour room. While both OraQuick tests (oral and finger-stick) were 100% specific, one false-negative result was documented (with both oral fluid and finger-stick specimens). Of the 15 HIV-infected women who delivered, 13 infants were HIV seronegative at birth and at 1 and 4 mo after delivery; two HIV-positive infants died within a month of delivery. In a busy rural labour ward setting in India, Pai and colleagues demonstrated that it is feasible to introduce a program of round-the-clock rapid HIV testing, including prepartum and extended postpartum counselling sessions. Their data suggest that the availability of round-the-clock rapid HIV testing resulted in successful documentation of HIV serostatus in a large proportion (82%) of rural women who were unaware of their HIV status when admitted to the labour room. In addition, 11 (73%) of a total of 15 HIV-positive women received prevention of mother-to-child transmission interventions because of round-the-clock rapid testing in the labour ward. These findings are relevant for prevention of mother-to-child transmission programs in developing countries.

Editors´note: Despite the fact that labour is not an ideal time to make a decision about learning one’s serostatus, offering HIV testing during labour is the last chance for women who have had no antenatal care or were not given the opportunity to be tested during pregnancy. Acceptance was high in this study, with HIV prevalence of 1.23% mirroring the 1% anticipated in recent antenatal sentinel surveillance. Studies of cost-effectiveness may be needed to convince policy makers in some resource-constrained settings that this “catch up” approach for women of unknown HIV status has merit.