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Background: Routine HIV counselling and testing as part of antenatal care has been institutionalized in Uganda as an entry point for pregnant women into the prevention of mother-to-child transmission of HIV (PMTCT) programme. Understanding how women experience this mode of HIV testing is important to generate ideas on how to strengthen the PMTCT programme. We explored pregnant HIV positive and negative women’s experiences of routine counselling and testing in Mbale District, Eastern Uganda and formulated suggestions for improving service delivery. Methods. This was a qualitative study conducted at Mbale Regional Referral Hospital in Eastern Uganda between January and May 2010. Data were collected using in-depth interviews with 30 pregnant women (15 HIV positive and 15 HIV negative) attending an antenatal clinic, six key informant interviews with health workers providing antenatal care and observations. Data were analyzed using a content thematic approach. Results: Prior to attending their current ANC visit, most women knew that the hospital provided HIV counselling and testing services as part of antenatal care (ANC). HIV testing was perceived as compulsory for all women attending ANC at the hospital but beneficial, for mothers, especially those who test HIV positive and their unborn babies. Most HIV positive women were satisfied with the immediate counselling they received from health workers, but identified the need to provide follow up counselling and support after the test, as areas for improvement. However, most HIV negative women mentioned that they were given inadequate attention during post-test counselling. This left them with unanswered questions and, for some, doubts about the negative test results. Conclusions: In this setting, routine HIV counselling and testing services are known and acceptable to mothers. There is need to strengthen post-test and follow up counselling for both HIV positive and negative women in order to maximize opportunities for primary and post exposure HIV prevention. Partnerships and linkages with people living with HIV, especially those in existing support groups such as those at The AIDS Support Organization (TASO), may help to strengthen counselling and support for pregnant women. For effective HIV prevention, women who test HIV negative should be supported to remain negative. © 2013 Rujumba et al.; licensee BioMed Central Ltd.
The study was conducted at the antenatal clinic, Mbale Regional Referral Hospital, about 245 kilometres East of Kampala, the capital city of Uganda. The district has a population of 416,600 [25], with the vast majority residing in rural areas [26]. Mbale Regional Referral Hospital has an estimated tertiary catchment population of 1.9 million people [14] from Mbale and the neighbouring districts in eastern Uganda. Antenatal care services at the hospital are provided daily on weekdays by an average staff of five health workers, mostly midwives. On average, 60 pregnant women attend the antenatal clinic daily. Over half of these are new attendees requiring HIV counselling and testing. All antenatal attendees are given HIV education/group pre-test counselling at the start of each clinic session, covering maternal and newborn care as well as HIV-specific areas such as modes of HIV transmission, prevention, the need to undergo HIV testing, PMTCT and positive living in case one is HIV positive. Health education talks are conducted daily, on average lasting for one hour. Talks are highly interactive involving health workers and antenatal attendees. Health workers provide information, but also solicit for responses from ANC attendees to build on what women already know about HIV and maternal and new-born heath before attending the clinic. The health education talks are conducted from the waiting area within the antenatal clinic by health workers on rotational basis. Whereas it is possible that the presence of the researchers during health education talks could have affected the quality and length of the talks, no major variations were observed in talks done at the start of the study and those at the end. Thus the influence of the researchers could have been minimal. The aim of the pre-test session is to prepare the women for the HIV test [1]. At the end of a pre-test session, new antenatal attendees move individually to the testing room located within the antenatal clinic to take the HIV test. At Mbale hospital, in line with the Uganda national guidelines, a sequential HIV testing algorithm, with same-day results is used. The testing algorithm includes three rapid tests used on one blood sample. ‘Determine’ is used for first screening, STAT-PAK for a second test and Uni-Gold as a ‘tie-breaker’ test. An individual is classified as HIV –uninfected if ‘Determine’ results are negative, or HIV infected if test results of both ‘Determine’ and STAT-PAK are positive. In case of discordant test results of ‘Determine’ and STAT-PAK, samples are tested using UNIGOLD. HIV results are given on the same day in an individual post-test counselling session conducted within the antenatal clinic. A previous study conducted in the same setting established that 99.5% of the antenatal attendees were tested for HIV [27]. All health workers were trained in PMTCT and routine HIV counselling and testing. The hospital was selected because it serves a rural population and it is one of the oldest PMTCT sites in Uganda. The PMTCT programme at Mbale Hospital started in May 2002 with HIV testing being offered under the voluntary counselling and testing (VCT) approach. In 2006, Mbale Hospital started providing HIV testing for PMTCT as a routine service integrated within antenatal and child birth clinics. A qualitative research design was adopted to provide an in-depth understanding of the experiences of pregnant women with antenatal-based HIV testing [28] and the meaning mothers attach to this experience [29]. This is relevant for our understanding of both the process and the outcome of health care policies and initiatives in health promotion and prevention [30]. A total of 30 pregnant women (15 HIV positive and 15 HIV negative) attending follow up antenatal clinics at Mbale Regional Referral Hospital participated in the study from January to May 2010. Women were interviewed on their subsequent ANC visit after the initial visit when they received HIV counselling and testing during the current pregnancy. Variations in age, parity and education level were considered in the selection of study participants. Inclusion in the study was based on consent to participate, being pregnant, and having taken an HIV test on their previous antenatal visit. All study participants were aged 18 years or over. Eligible women were identified in cooperation with the health workers involved in antenatal care, thus facilitating access to study participants [29]. The identified women were referred to members of the study team stationed at the antenatal clinic. The researchers explained the purpose of the study and obtained consent. The study participants were enrolled consecutively after undergoing their routine consultation and assessment. Interviewing continued until we felt that the information from later interviews did not differ from earlier interviews. Six health workers selected purposively on the basis of being involved in routine HIV counselling and testing participated in the study as key informants. These included one doctor, two counsellors and three nurse midwives. Semi-structured interviews [31] were conducted to elicit information on women’s experiences with routine HIV counselling and testing as part of antenatal care. Individual interviews were used since HIV is still a sensitive and stigmatizing condition. A pre-tested interview guide [32,33] was used to explore the pregnant women’s experiences with RCT and consisted of structured questions on women’s characteristics and open-ended qualitative questions on: prior knowledge about RCT provision, experiences with RCT, meaning of HIV test results, the conduct of health workers and suggestions to improve HIV counselling and testing. The interview guide was flexible with probes to allow an in-depth understanding of women’s experiences of the RCT programme as an entry point into the PMTCT programme and allowed women to identify areas requiring improvement from their own perspective as service users. Interviews lasted for about 40–45 minutes and most interviews (27) were audio recorded; the exceptions were three women (one HIV positive and two HIV negative) who did not consent to audio recording. Interviewers were paired, one asking questions and the other taking notes. Interviews were conducted in Lumasaba, Luganda and a few in English. The first author conducted interviews in English and Luganda and was assisted by three female research assistants, all university graduates and with experience in conducting qualitative interviews. Audio-recorded interviews were transcribed and translated into English by a research assistant. A key informant interview guide was used to conduct the interviews. The interviews explored health workers experience with RCT, the process, what they felt were women’s concerns about the RCT and what needs to be done to improve the programme. To gain more understanding of the context within which routine HIV counselling and testing services were offered, the first author and research assistants attended and made observations during health education talks and the process of HIV counselling and testing. These observations were not structured. Individual researchers noted observations and shared them in research team meetings held at the end of each day of data collection. The health education talks were not audio recorded. Preliminary data analysis was concurrent with data collection. At the end of each day of data collection, a research team meeting was held to share emerging issues and identify areas for further data collection. The first author de-briefed all co-authors on preliminary insights and emerging issues from the study. Further data analysis was conducted by the first author in close collaboration with the last author. The transcripts were exported to NVivo [34] version 9.0 and analyzed using a content thematic approach [35]. The analysis involved multiple readings of interview scripts to understand the data and to identify new themes and refine those in the interview guide. Data was then grouped under themes and sub-themes for interpretation. During the coding process, quotations illustrative of both the common and minority perspectives of women’s experiences of HIV testing as part of antenatal care were identified and are used in the presentation of the study findings. Concurrent triangulation was conducted which involved the analysis of findings from pregnant women and those from key informants at the same time to identify areas of agreement and disagreement. In addition, we conducted sub-group analysis of HIV positive and negative women. Ethical approval for the study was obtained from the Uganda National Council for Science and Technology, Makerere University, College of Health Sciences, Research and Ethics Committee and The Mbale Regional Referral Hospital Institutional Review Committee. Permission was also obtained from the management of Mbale Hospital and the Mbale District administration. All study participants provided written consent, they were assured of confidentiality and each interview was conducted in a separate room provided by the antenatal clinic management. Research assistants were trained on the approach to data collection and the ethical issues involved in HIV research.
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