Is HIV Screening in the Labor and Delivery Unit Feasible and Acceptable in Low-Income Settings

Perspective D espite 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 [1]. 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 [2]. In rural and urban areas, women of reproductive age are principally at risk for HIV acquisition through marriage—this risk refl ects 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-fi nding, in large part through antenatal care in conjunction with the prevention of mother-to-child transmission (PMTCT) of HIV during labor and delivery [2]. What is the impact of these national policies on HIV testing during pregnancy in India? Sinha and colleagues found that out of a random sample of 400 recently pregnant women in rural Maharashtra State, where sentinel surveillance suggested an antenatal HIV rate of at least 1%, only 3.3% of women reported receiving VCT during pregnancy [5]. This exceptionally low rate of antenatal testing for HIV was attributed to two identifi ed barriers: (1) lack of discussion of HIV testing by antenatal care providers; and (2) women's lack of awareness of HIV testing, including VCT. Interestingly, of the 13 participants reporting VCT during antenatal care, 12 received it through the private sector—thus, only one woman (in 400) reported receiving the Indian standard of care for HIV testing during pregnancy through a government clinic. In this issue of PLoS Medicine, Nitika Pant Pai and colleagues evaluated the uptake of 24-hour rapid HIV testing of women in a labor and delivery center in a rural, tertiary teaching hospital in Sevagram, Maharashtra State, India [6]. The research team wanted to determine if offering round-the-clock rapid HIV testing would be feasible, lead to increased uptake of testing, and identify women in labor who could be provided optimal PMTCT. 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 confi …