HIV & AIDS is one of the three main infections that dominate the global burden of communicable diseases.(2)  The HIV & AIDS pandemic has infected over 25 million adults on the African continent with women comprising of more than half of those infected, excluding around 1 million children infected via mother-to-child-transmission.(3) Children born with HIV in South Africa annually number around 70,000; their infection reflects inadequate prevention of mother-to-child transmission of HIV & AIDS.(4) Medical interventions now offer the potential to reduce this vertical transmission that is particularly significant in developing countries. These interventions, which focus on the antenatal administration of anti-retroviral drugs, have as an implicit programme component the identification of HIV-positive women via methodical HIV-counselling and testing among pregnant women. This is known as prevention of mother to child transmission (PMTCT). PMTCT complements the National Strategic Plan of South Africa on HIV & AIDS and STIs.(5) This CAI brief explores the challenges and the necessity of HIV testing amongst antenatal pregnant women in South Africa.

The necessity of testing antenatal women for HIV

Visits to antenatal clinics by pregnant women serve the purpose, amongst others, of screening women for infections that could potentially impair the impending mothers’ immune system. Such screening is especially important during pregnancy as the female’s immune system undergoes a complex transformation through which its cell-mediated immunity is rendered weaker, so as to allow for the partially foreign entity, the foetus, to grow safely. Cell-mediated immunity is necessary for the body’s defence against microbes that cause various diseases including toxoplasmosis.(6) Toxoplasmosis is a disease of the brain and is associated with severe immuno-suppression, and surfaces, for example, among people at the fourth stage of HIV & AIDS, commonly known as the AIDS stage, with the CD4 immune cell count below 200.

The need for pregnant women to attend antenatal clinics also helps to diagnose for other HIV and AIDS-associated conditions. Some of the conditions used to diagnose WHO Clinical Stage 4 (7) include, for adults and children: HIV wasting syndrome (weight loss > 10% of body weight and either chronic fever or diarrhoea in the absence of concurrent illness); various kinds of pneumonia and pulmonary diseases; candidiasis; atypical mycobacteriosis; extrapulmonary tuberculosis (EPTB); lymphoma (cerebral or B-cell Non Hodgkin); Kaposi’s sarcoma; HIV encephalopathy; and herpes recurrent bacteraemia or sepsis with NTS. These can present singly or in combination, and their emergence indicates a severely compromised immune system, which in turn, is of particular concern in pregnant women with already weakened immune systems. In order to address the potential threats these diseases and others pose as part of the syndrome that is AIDS, HIV testing is necessary – vital to both the antenatal mother and the foetus. An HIV test determines serostatus. The information it delivers then facilitates informed decisions.

Challenges faced by antenatal women

Antenatal women encounter various difficulties. This is especially true for HIV-positive women, and includes HIV-related maternal depression (8) among others. Most people including antenatal women who become pregnant by engaging in sex without a condom,(9) do not know when – or sometimes how - they became infected with HIV. They only receive a diagnosis once they undergo an HIV test.

However, at the initial stage of infection, the infected can experience flu-like symptoms such as fever, headache, sore muscles and joints, stomach ache, swollen lymph glands or a skin rash for a few days or weeks. During this period, the HI-virus will replicate rapidly, and though the infected person might test negative to the virus, he or she is infectious.(10) Only once the immune system responds and starts producing antibodies does the outcome of the test register as positive; but an effective immune response will, at first, suppress any symptoms of illness. Indeed, after the first set of symptoms described earlier, most people including antenatal women can be healthy for up to ten years or more, though the virus will continue multiplying and destroying the immune system. This is known as the window period, also known as the acute stage. The impact on the immune system can be measured by undergoing another test to count the CD4 cells.(11)

The situation of disease progression, from HIV infection to AIDS, is compounded by poverty, which also hits antenatal pregnant women hard. For instance, another difficulty in addressing antenatal HIV infection might be linked to the maternal level of HIV & AIDS treatment literacy and literacy overall.(12) This is because the level of literacy of the woman might determine her predisposition to optimal maternal care, including observance of environmental issues like proper sanitation and ventilation.(13) In addition, the woman’s level of literacy might be proportional to her ability to adhere to treatment regimens, as well as to relate it to mixing scientific and traditional medicines. For the women who are still nursing babies and are pregnant, further challenges include the constraints of adhering to infant feeding recommendations.(14) By what can be deduced from studies, the attitudes of these women can be beneficially modified by addressing the above-mentioned challenges to antenatal voluntary counselling and testing, including those emanating from society, communities, clinics, broader health systems and individual relationships.

Factors that affect Voluntary Counselling and HIV Testing among antenatal pregnant women

Factors that affect voluntary counselling and HIV testing among antenatal pregnant women revolve primarily around stigma and discrimination.(15) Stigma and discrimination fuel the HIV & AIDS epidemic, with the adverse effects extending beyond the infected individuals into the broad society.(16) Stigma is predominantly fuelled by domestic and societal pressures, as well as some cultural and religious ethos.(17) Another factor is the emotionally-laden disclosure of status, especially as it affects children.(18) Relevant factors that determine whether or not an individual will disclose his or her status include:

• Adverse reaction from relatives and the fear of hurting the parents: relatives of the subject including the parents might not take the news easily, especially as the condition is regarded as a terminal situation. For adults, it will be taken that the affected is/was promiscuous.
• Apprehension of an employer’s reaction: the subject might be worried about the way the employer will take the news, including the possibility of severance. This is predominant in organisations that subject their employees to HIV & AIDS tests.
• Loss of acquaintances: friends and associates of the affected might reduce interaction with the infect individual.
• Feeling of guilt, especially for members of same cultural community: this situation arises when such cultural affiliations attach much value to subjects revolving around sexual ethics, etc.
• The likelihood of having the integrity of one’s sexual relationship questioned or of losing a relationship: when one sexual partner tests positive, this might lead to questioning the sexual fidelity of the infected.
• The probability of being subjected to prejudice and stigma: this is very common especially in developing countries / societies. This is fuelled by ignorance about HIV & AIDS issues.
• The prospect of being labelled an unfit parent: this is also predominantly propelled by ignorance. There is the tendency to label the affected as being ‘sick’ with HIV.
• Vulnerability to violence, and in this context a woman intending to disclose to her partner. The difficulty here is that the woman needs to be supported and shielded from physical and emotional abuses as well as to prevent being re-infected or infecting her partner if sero-discordant. These are ultimately the responsibility of the partner to provide for, including economic support.

All of these factors highlight the necessity of social support in advocating for and implementing voluntary testing and counselling of antenatal pregnant women and preventing mother-to-child transmission of HIV.

Social support as a means of encouraging Voluntary Counselling and HIV Testing among antenatal pregnant women

Social support is regarded as a qualitative aspect of social relations and a catalyst for attaining goals with others aimed at changing a situation.(19) Social support with its various typologies involves the exploitation of interpersonal relationships to achieve some desired objective,(20) and includes more importantly, emotional support – providing empathy, care, love and trust; instrumental support – actions that directly help the person in need; informational support – providing the affected with self-coping information; appraisal support – needed for the self-education of the affected.(21) Being social animals, social support helps people, especially those with challenging emotional situations like being diagnosed with HIV & AIDS, to cope, adhere to treatment and generally live more productive and wholesome lives. Specifically with respect to a pregnant woman who is HIV positive, social support will facilitate her capacity to cope with the dual burden of her serostatus and perinatal situations.

Conclusion

Factors that affect voluntary counselling and HIV-testing among antenatal pregnant women hinge on challenges like stigma and beneficial factors associated with social support. The necessity of testing an antenatal woman for HIV is not only to enhance her quality of life through managing clinical conditions associated HIV & AIDS depending on her stage, but to prevent as much as possible the infection of the baby.

There is urgent need for health and social systems to prioritise the fight against HIV & AIDS, especially in newborns and women of reproductive age. This will prioritise fighting the pandemic at its most strategic stance by cutting off infections in generations yet unborn.

NOTES:

(1) Michael Anikamadu is an External Consultant in Consultancy Africa Intelligence’s HIV & AIDS Unit ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
(2) R. Beaglehole, R.  Bonita, and T. Kjellstrom, 'Basic Epidemiology', WHO, 1997.
(3) UNAIDS, Report on the Global AIDS Epidemic, UNAIDS, 2008.
(4) 'World Health Statistics', WHO, 2009.
(5) 'HIV and AIDS and STI Strategic Plan for South Africa, 2007 – 2010', SA Department of Health, 2007.  
(6) A.G. Clarke, M.D. Kendall, “The thymus in pregnancy: the interplay of neural, endocrine and immune influences,” Immunology Today Vol. 15(11) (1994: 545-551.
(7) 'World Health Statistics', WHO, 2009.
(8) A. D. Murphy, E.L., Austin, and L. Greenwell, “Correlates of HIV-related stigma among HIV positive mothers and their uninfected adolescent children,” Women & Health Vol 44(3) (2006): 19–42.
(9)  M. J. Wawer, R. H. Gray, N. K. Sewankambo, D. Serwadda, X. Li, O. Laeyendecker, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis. 191 (2005): 1403–1409.
(10) Hence the advice to test again after 3 months.
(11) D. V. Havlir, D. D. Richman. The role of viral dynamics in the pathogenesis of HIV disease and implications for antiviral therapy. Springer Semin Immunopathol 18 (1997): 267–283.
(12) S. H. Eickmann,  A.C. Lima, M.O, Guerra, M.C. Lima,  P.I. Lira, S.R. Huttly, et al. “Improved cognitive and motor development in a community-based intervention of psychosocial stimulation in northeast Brazil,” Dev Med Child Neurol Vol. 45(8) (2003): 536–541.
(13) A. Rahman, R. Harrington, J. Bunn J. Can maternal depression increase infant risk of illness and growth impairment in developing countries? Child Care Health Dev (2002): 28: 51-6.
(14) E.M Stringer, B.H. Chi, N. Chintu, T.L. Creek, D.K.  Ekouevi, D. Coetzee, D., et al., «Monitoring effectiveness of programmes to prevent mother-to-child HIV transmission in lower-income countries.”. Bull World Health Organ, Vol. 86(1) (2008): 57–62.
(15) S. Kalichman and L. Simbayi, “HIV testing attitudes, AIDS stigma, and voluntary counselling and testing in a black township in Cape Town South Africa,” Sexual Transmitted Infections Vol. 79 (2003): 442-447.
(16) D. Skinner and S. Mfecane, "Stigma, discrimination and the implications for people living with HIV/AIDS in South Africa," Journal of social aspects of HIV/AIDS. Vol 1(3) (2004):157-164.
(17) M.S. Khan, “Operational Research Project on HIV/AIDS. Health and Population Extension Division,” Center for Health and population Research Working Paper (2000): 131.
(18) A.L. Lesch, A. Swartz, K. Kagee, Z. Moodley, L. Kafaar, L.. Myer, and M. Cotton, “Paediatric HIV/AIDS disclosure: towards a developmental and process-oriented approach,” AIDS Care Vol.19(6) (2007): 811-816.
(19) S. Cohen, L. G. Underwood, B. H. Gottlieb (2000); Social Support Measurement and Intervention. New York: Oxford University Press; 2000.
(20) W. Stroebe and M. Stroebe, Social Psychology and Health (Amsterdam: Open University Press, 1993).
(21) C. Dunkel-Schetter and T. L. Bennett, “Differentiating the cognitive and behavioral aspects of social support” in I. G. Sarason, B. R. Sarason, and G. R. Pierce (Eds.), Social support: An interactional view (New York: Wilely Press, 1990): 267-296.