Women in this study however had better knowledge of HIV than women in an earlier 2001 Indian census sample. They were much more likely to have heard of HIV, to be aware of condoms, to know that consistent condom use is an effective way of preventing HIV, and to know that HIV can be transmitted through contact with infected blood

Levels of HIV testing amongst pregnant women in rural India are very low, and even women who have symptoms of sexually transmitted infections or tuberculosis are not being referred for voluntary HIV counselling or testing, according to a new study. Few women are aware of the existence of voluntary counselling and testing facilities, the study found.

‘Low utilisation of HIV testing during pregnancy: What are the barriers to HIV testing for women in rural India?' was published in the February 1 edition of the Journal of Acquired Immune Deficiency Syndromes. The population-based study included 400 women who were pregnant during the previous 12 months in the Aurangabad district of Maharashtra state.

The women were interviewed to determine their socio-demographic characteristics, level of antenatal care, and awareness and use of HIV testing facilities. To assess the women's risk of HIV they were asked if they had had symptoms suggestive of sexually transmitted infections or tuberculosis during the previous 12 months.

The HIV knowledge and risk of women in the study was compared to that of a sample of women from the same region who participated in the 2001 Indian census.

Women in the current study had much better knowledge of HIV than women in the 2001 census sample, being much more likely to have heard of HIV (87% vs 70%, p<0.01), to be aware of condoms (84% vs 49%, p<0.01), to know that consistent condom use is an effective way of preventing HIV (72% vs 33%, p<0.01), to know that HIV can be sexually transmitted (84% vs 65%, p<0.01), to know that HIV can be transmitted through contact with infected blood (84% vs 66%, p<0.01), and to know that sexually transmitted infections can increase the risk of HIV infection (57% vs 8%, p<0.01).

However, despite this better knowledge of HIV, only 6% of women in the study could correctly name an HIV testing facility. Furthermore, only 8% reported receiving HIV counselling during pregnancy, and only 3% of women had an HIV test done.

Of the 13 women who had undergone an HIV test, 12 did so at a private facility. The main reason for doing the test was a recommendation from their doctor. None of the women who had an HIV test were aware of voluntary counselling and testing facilities.

The women who tested for HIV were older than those who did not (mean age: 22 years vs 20 years, p=0.05), were educated to a lower level (higher secondary education, 23% vs 42%, p=0.03), lived in homes with more rooms (mean, four rooms vs three rooms, p<0.001), had a better knowledge of HIV (correctly answered all questions on HIV, 46% vs 13%, p=0.002), were more likely to have had a blood test for any reason during pregnancy (92% vs 44%, p<0.001), were more likely to have received HIV counselling (54% vs 6%, p=0.008), and were more likely to be aware of antiretroviral therapy (92% vs 53%, p=0.02).

A total of 35 women reported symptoms of a sexually transmitted infection or tuberculosis during pregnancy, but only one of these individuals had done an HIV test. Of the 26 women with symptoms of sexually transmitted infections, nearly all received antenatal care, and almost all sought medical treatment for their symptoms.

There are approximately 2.5 million cases of HIV in India, with 60% of these occurring amongst the rural population. Married women of childbearing age are considered to be at high risk of HIV because of their husbands' pre-marital and extra-marital sexual activities.

Pregnancy-related health concerns are a major reason why women in rural India seek healthcare, and this could provide an opportunity for the diagnosis of HIV. Surveillance studies suggest that between 0.5%-2% of women in some regions of the country are HIV-positive.

India's National AIDS Control Organisation (NACO) has emphasised the importance of expanding HIV voluntary testing and counselling and services to prevent mother-to-child transmission of HIV to all Indian women, including those living in rural areas.

But little is known about the HIV risk profiles of women in rural India and their access to and use of HIV testing facilities.

“To our knowledge, this is the first community-based study reporting extremely low HIV testing amongst rural Indian women during pregnancy, a major target population for India's HIV prevention efforts,” write the investigators. They identify two barriers to HIV testing amongst women in rural India: a lack of discussion about HIV testing by antenatal care-providers, and a lack of knowledge about HIV testing facilities, including voluntary counselling and testing.

The investigators conclude: “India's current policy for universal access to prevention of mother-to-child transmission requires strategies to promote HIV testing amongst pregnant rural Indian women. Antenatal clinic-based programmes to increase rural women's awareness of voluntary HIV testing services, including provider-initiated assessment of HIV risk and discussion of HIV testing, should be developed and prospectively tested for their impact on utilisation of HIV testing and subsequent prevention, diagnosis, and prevention of mother-to-child transmission for women throughout rural India.”

Source: www.aidsmap.com, January 28, 2008