HIV This Week

Moodley D, Esterhuizen TM, Pather T, Chetty V, Ngaleka L. High HIV incidence during pregnancy: compelling reason for repeat HIV testing. AIDS. 2009 May 18. [Epub ahead of print]

The objective of this study was to determine the incidence of HIV during pregnancy as defined by seroconversion using a repeat HIV rapid testing strategy during late pregnancy. In this cross-sectional study nested in a prevention of mother-to-child transmission program, pregnant women were retested between 36 and 40 weeks of gestation, provided that they had been tested HIV negative at least 3 months prior. Among the 2377 HIV-negative women retested, 1099 (46.2%) and 1278 (53.4%) were tested at urban and rural health facilities, respectively. Seventy-two women (3%) were HIV-positive (679 woman years of exposure) yielding a HIV incidence rate of 10.7/100 woman years [95% confidence interval (CI) 8.2-13.1]. HIV incidence in pregnancy was higher but not statistically significant at the urban facilities (12.4/100 woman years versus 9.1/100 woman years) and at least two-fold higher among the 25-29 and 30-34-year age groups (3.8 and 4.5%, respectively) as compared with the less than 20-year age group (1.9%). Single women were at 2.5 times higher risk of seroconverting during pregnancy (P = 0.017). HIV incidence during pregnancy was four times higher than in the non-pregnant population reported in a recent survey. Public health programs need to continue to reinforce prevention strategies and HIV retesting during pregnancy. The latter also offers an additional opportunity to prevent mother-to-child transmission and further horizontal transmission. Further research is required to understand the cause of primary HIV infection in pregnancy.

Editors’ note: Condom use, multiple sex partners, and the frequency of sexual activity were not significantly different between HIV-negative and seroconverting women in this study, giving support to the idea that hormonal changes affecting either genital mucosa or immune responses may be key. The striking HIV incidence of 10.7 per 100 women-years underscores the importance of counselling and community education about HIV prevention in pregnancy, as has been done for cigarette smoking and alcohol, to protect pregnant women. Repeat HIV testing offers an additional opportunity to prevent mother-to-child and sexual transmission, along with clinical assessment and care for women who seroconvert.

Helleringer S, Kohler HP, Frimpong JA, Mkandawire J. Increasing Uptake of HIV Testing and Counseling Among the Poorest in Sub-Saharan Countries Through Home-Based Service Provision. J Acquir Immune Defic Syndr. 2009 Apr 6. [Epub ahead of print].

Uptake of HIV testing and counselling is lower among members of the poorest households in sub-Saharan countries, thereby creating significant inequalities in access to HIV testing and counselling and possibly antiretroviral treatment. Helleringer and colleagues set out to measure uptake of home-based HIV testing and counselling and estimate HIV prevalence among members of the poorest households in a sub-Saharan population. Residents of 6 villages of Likoma Island ( Malawi) aged 18-35 and their spouses were offered home-based HIV testing and counselling services. Socioeconomic status, HIV testing history, and HIV risk factors were assessed. Differences in uptake of HIV testing and counselling and in HIV infection prevalence between members of households in the lowest income quartile and the rest of the population were estimated using logistic regression. Members of households in the lowest income quartile were significantly less likely to have ever used facility-based HIV testing and counselling services than the rest of the population (odds ratio = 0.60, 95% confidence interval (CI): 0.36 to 0.97). In contrast, they were significantly more likely to use home-based HIV testing and counselling services provided during the study (adjusted odds ratio = 1.70, 95% CI: 1.04 to 2.79). Socioeconomic differences in uptake of home-based HIV testing and counselling were not due to underlying differences in socioeconomic characteristics or HIV risk factors. The prevalence of HIV was significantly lower among members of the poorest households tested during home-based HIV testing and counselling than among the rest of the population (adjusted odds ratio = 0.37, 95% CI: 0.14 to 0.96). HIV testing and counselling uptake was high during a home-based HIV testing and counselling campaign on Likoma Island, particularly among the poorest. Home-based HIV testing and counselling has the potential to significantly reduce existing socioeconomic gradients in HIV testing and counselling uptake and help mitigate the impact of AIDS on the most vulnerable households.

Editors’ note: Less than a quarter of this study population had participated in facility-based HIV testing and counselling but more than 75% accepted to be tested and immediately retrieved their test results at home. HIV prevalence overall was 8%. This is the first study to document the impact that a home-based approach can have in increasing uptake of HIV testing and counselling among young adults in the poorest households. Young women from these households were the least likely to have used facility-based testing and were the second most likely to participate in home-based HIV testing and counselling after their male counterparts. Reaching out to poorer people in their homes can help ensure that access to HIV prevention and treatment services is more equitable.