Implementation of repeat HIV testing during pregnancy in southwestern Kenya: progress and missed opportunities

Abstract

IntroductionRepeat HIV testing during the late antenatal period is crucial to identify and initiate treatment for pregnant women with incident HIV infection to prevent perinatal HIV transmission and keep mothers alive. In 2012, the Kenya Ministry of Health adopted international guidelines suggesting that pregnant women be offered retesting three months after an initial negative HIV test. Our objectives were to determine the current rate of antenatal repeat HIV testing; identify successes, missed opportunities and factors associated with retesting; and estimate the incidence of HIV during pregnancy.MethodsRetrospective analysis of longitudinal data was conducted for a cohort of 2145 women attending antenatal care clinic at a large district hospital in southwestern Kenya. Data were abstracted from registers for all women who attended the clinic from the years 2011 to 2014.ResultsAlthough 90.2% of women first came to clinic prior to their third trimester and 27.5% had at least four clinic visits, 58.0% of all women went to delivery without a retest. Missed opportunities for retesting included not returning to clinic at all, not returning when eligible, or late gestational age (>28 weeks) at first clinic visit making them ineligible for retesting (accounting for 14.2%, 26.8% and 9.6% of all clinic attendees respectively); and failure to be retested even when eligible at one or more visits (accounting for 73.2% of eligible returnees). Being unmarried and aged 20 or younger was associated with an increase in mean gestational age of first visit by 2.52 weeks (95% CI: 1.56, 3.48) and a 2.59 increased odds (95% CI: 1.90, 3.54) of failing to return to clinic, compared to those who were married and over 20 years of age. On retest, two women tested HIV positive, suggesting an incidence rate of 4.4 per 100 person‐years. After adjusting for potential confounders, only later year of last menstrual period (2013 vs. 2012 and 2011) was associated with retesting.ConclusionsAdoption of retesting guidelines in 2012 appears to have successfully increased retesting rates, but missed opportunities to identify incident HIV infection during pregnancy may contribute to continuing high rates of perinatal HIV transmission in southwestern Kenya.

High proportion of unknown HIV exposure status among children aged less than 2 years: An analytical study using the 2015 National AIDS Indicator Survey in Mozambique

“…Considering the high (over 4%) HIV incidence rate occurring during pregnancy and breastfeeding in previously HIV-uninfected women, reported in Mozambique, our findings are alarming [8,24]. Similar incidence rates, ranging from 4.4 to 16.8%, have been reported in other neighboring countries such as Kenya, South Africa, and Zimbabwe [9][10][11][12][25][26][27]. Pregnancy and postpartum are periods of persistent risk of HIV acquisition for a woman [26], and in this period, they have higher risks of vertical transmission than do women with chronic HIV infection [28].…”

“…A 2011 study on breastfeeding women in Mozambique showed an HIV incidence rate as high as 4.9% up to 18 months after a negative HIV test at delivery [8]. Other similar studies in neighboring countries also reported high incidence of seroconversion of women during pregnancy or postpartum period following an initial negative test [9][10][11][12].…”

Retest and treat: a review of national HIV retesting guidelines to inform elimination of mother‐to‐child HIV transmission (EMTCT) efforts

“…In addition, vague language in guidelines about who and when to retest can result in missed opportunities to offer peripartum women retesting. Prior studies in sub‐Saharan Africa suggest that only ~30% of pregnant women eligible for retesting who returned to the clinic received a test . In contrast, implementing retesting guidelines designed for the general population can also create confusion for healthcare workers to retest pregnant and postpartum women.…”

Accelerating progress towards the elimination of mother‐to‐child transmission of HIV: a narrative review

“…In settings where repeat HIV testing is prioritized, programmes should focus on missed opportunities for retesting (e.g. poor retention in antenatal care [46]); integration of testing into routine health platforms, including maternal and child health services; and use of newer HIV testing modalities (e.g. HIV self‐testing, home‐based testing).…”