Response to opt-out approach to prevent mother-to-child transmission of HIV

I read with great interest the paper on routine HIV testing for pregnant women in Zimbabwe by Winfreda Chandisarewa et al.¹ The paper reported a significant increase in the acceptance of PMTCT (preventing mother-to-child transmission) services such as HIV testing, counselling and follow-up after the introduction of routine HIV testing (“opt-out” approach).

However, the conclusion that the opt-out approach for HIV testing was operationally feasible and acceptable to all women, and that HIV-infected women reported relatively low levels of spousal abuse and other adverse social consequences, seems to be overstated. Results from a survey of the tested mothers indicated that approximately 10% of those women who disclosed their test results still experienced negative effects. These findings hardly indicate “low levels of spousal abuse and other adverse social consequences” in consideration of these women’s personal safety.

It is necessary to evaluate the opt-out approach for HIV testing by comparing the incidence of adverse effects with mothers who opted-in to HIV testing to conclude whether the benefit of the opt-out approach outweighs the risk. More importantly, more attention must be paid to the issue of domestic violence by partners after disclosure, since many cases have been reported in African countries.^2–4 In addition, the authors should show the percentage of those mothers who had been tested and counselled before the study period. As the majority of mothers in the study were reportedly multiparae, they might have been tested for HIV in previous pregnancies. Mothers re-tested during the study are likely to have experienced fewer negative effects.

Moreover, I would like to suggest that the authors provide more information on the role of the community mobilization activities conducted before the introduction of the opt-out approach. Barriers and predictors to HIV testing have been investigated to improve the acceptance of HIV testing in PMTCT services.^5,6 This research shows that community activities play an important role in clearing some of the barriers to testing and counselling services, therefore providing an entry point to prevention and care services including PMTCT. These activities, together with high-quality counsellors, might have contributed to increasing the acceptance of HIV testing and counselling and to reducing its adverse effects.

The contents of the community mobilization activities, including male involvement, could be analysed more and shared with readers, so as to provide a good model to commencing provider-initiated HIV testing and counselling (PITC) in other areas.

There have been a lot of arguments about human rights and HIV testing. However, I would like to stress that we need more good practices with successful increased uptake of PMTCT services and minimal negative impact, so as to provide practical ideas for the adaptation of the WHO guidelines on PITC at country level.⁷ The activities outlined in this study, especially those conducted in the community, could help to provide such ideas. ■