Couples' voluntary counselling and testing offered on the weekends in high-volume antenatal clinics was feasible, and when partners participated together in counselling and testing, women were more likely to present a study voucher at the time of delivery in both Kigali and Lusaka. In this study, carried out in 2001, CVCT helped prevent a loss to follow up, which meant more appropriate care was given during the delivery.
We found in Lusaka, where the NVP tablet and syrup were provided to pregnant women at post-test counselling sessions, that HIV-positive women were less likely to have a record of delivery than HIV-negative women. In contrast, in Kigali, where NVP syrup was available only in the labour and delivery ward, HIV-positive women were more likely to have a record of labour and delivery. Partner participation was not associated with differences in NVP use.
At the time of study conception (2000), VCT was not yet established in antenatal clinics in Kigali and Lusaka and CVCT had been implemented only in a few specialized research centres. VCT is now, as a matter of policy, offered in antenatal clinics in both Rwanda and Zambia. Antenatal CVCT, which provides an important opportunity to identify and reduce transmission of HIV among discordant couples, has been more slowly adopted, if at all. Since this study took place, research indicates that promoting CVCT in the community and inviting couples together increases the uptake of couples' counselling [22
Once discordancy is established through CVCT, special attention needs to be paid to couples where the woman is the HIV-positive partner. It has been shown, both here and in other studies, that couples where the woman is the positive partner are more often lost to follow up than couples where the man is the positive partner [33
]. HIV-positive women need more counselling and psychosocial support as they approach delivery in order to disclose their status and protect themselves and their infants [35
]. HIV-negative women in a discordant couple also need to be monitored so that, in the event that they become HIV infected as they near delivery, they and their infants can be provided with NVP.
The initial study design was to randomize women to VCT or CVCT, but, for ethical reasons, this changed. Though logistically practical, this method of service delivery and modification to the study design may have biased the study analysis. Those women who were able to attend CVCT with their partners may have been unique, i.e., their partners were willing to participate, when compared with those women who underwent VCT.
Also, the outcomes of interest, having a record of delivery and taking nevirapine at the appropriate time were subject to a loss-to-follow-up bias. However, the order of treatment delivery was the same in each city for all study participants, thus avoiding any "order" effects that could have influenced the outcome. The HIV prevalence findings of 14% in Kigali and 27% in Lusaka among antenatal clinic attendees in this study are consistent with published prevalence data for that time in both capital cities [7
A substantial proportion (33% in Kigali and 24% in Lusaka) of study participants were without a record of delivery (LFU). The follow-up rates were different between the two cities, indicating that delivery practices between cities may have impacted study findings. While these percentages seem high, Manzi et al
, who conducted an antenatal VCT/PMTCT study in Malawi in 2002/03, experienced a loss to follow up of 68% by the time of delivery, suggesting that this was not abnormally high for this intervention at the time [37
There was no difference in LFU between HIV-positive and HIV-negative women in Kigali. In 2001, 21% of the women in Kigali who came to the antenatal clinics participating in this study already knew their HIV status, perhaps diminishing the impact of VCT among this population. The significant difference in loss to follow up between women tested alone (36%) and those tested with their partners (31%) highlights the importance of partner participation not only in CVCT, but also in helping his partner to identify herself at delivery, enhancing PMTCT. In Lusaka, there was a significant difference in loss to follow up between HIV-positive and HIV-negative women. Here, the availability of NVP for both mother and infant contributed to more loss to follow up since those mothers did not have to disclose their status in order to protect themselves and their infants.
Fewer participants were lost to follow up when they delivered in the clinic where they received antenatal care and VCT, a place where their HIV status was already known, as was the case in Lusaka. In Kigali, where women delivered in the hospital, a different facility with different providers than their antenatal service providers, there were more HIV-positive women without a record of delivery.
Taking nevirapine meant disclosing the woman's HIV status, creating a risk of being stigmatized. PMTCT programmes utilizing single-dose NVP regimens may consider providing NVP syrup to mothers to administer to infants themselves [11
] in order to protect infants when a mother is too fearful to disclose her status. Self-report of NVP use was a limitation of this study. However, in another study of self-reported adherence to NVP in Kenya, 90% of women reported taking their dose of NVP [38
], similar to the 79% to 88% reported here.
In routine service delivery, there was potentially less incentive to self-identify since the study provided the delivery fee in return for the follow-up information. However, women who delivered at home or in a different facility would not need the vouchers, and women who preferred to keep their serostatus private may have preferred to pay labour and delivery costs rather than produce the voucher. Women in Kigali also faced greater distances to reach the one health service facility available to them for delivery.