Skip to main content

Advertisement

SpringerLink
Log in

The Differential Effects of an Opt-Out HIV Testing Policy for Pregnant Women in Ethiopia When Accounting for Stigma: Secondary Analysis of DHS Data

  • Published:
Prevention Science Aims and scope Submit manuscript

Abstract

Individual factors associated with HIV testing have been studied across multiple populations; however, testing is not just an individual-level phenomenon. This secondary analysis of 2005 and 2011 Ethiopia Demographic and Health Survey data was conducted to determine the extent to which the 2007 institution of an opt-out policy of HIV testing during antenatal care increased testing among women, and whether effects differed by women’s stigmatizing beliefs about HIV. A logit model with interaction between pre-/post-policy year and policy exposure (birth in the past year) was used to estimate the increased probability of past-year testing, which may be attributable to the policy. Results suggested the policy contributed to a nine-point increase in the probability of testing (95% CI 0.06–0.13, p < 0.0001). A three-way interaction was used to compare the effects of exposure to the policy among women holding higher and lower HIV stigmatizing beliefs. The increase in the probability of past-year testing was 16 percentage points greater among women with lower stigmatizing beliefs (95% CI 0.06–0.27, p = 0.002). Women with higher stigmatizing beliefs were less likely to report attending antenatal care (ANC), testing at their last ANC visit, or being offered a test at their last ANC visit. We encourage researchers and practitioners to explore interventions that operate at multiple levels of socio-ecological spheres of influence, addressing both stigma and structural barriers to testing, in order to achieve the greatest results in preventing HIV.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  • Angrist, J. D., & Pischke, J. S. (2009). Mostly harmless econometrics: An empiricist’s companion. Princeton: Princeton University Press.

    Google Scholar 

  • Bond, L., Lauby, J., & Batson, H. (2005). HIV testing and the role of individual- and structural-level barriers and facilitators. AIDS Care, 17, 125–140. doi:10.1080/09541020512331325653.

    Article  PubMed  Google Scholar 

  • Centers for Disease Control & Prevention. (2001). Revised recommendations for HIV screening of pregnant women. MMWR - Recommendations and Reports, 50, 63–85. quiz CE61-19a62-CE66-19a62.

    Google Scholar 

  • Centers for Disease Control & Prevention. (2002). HIV testing among pregnant women—United States and Canada, 1998–2001. MMWR. Morbidity and Mortality Weekly Report, 51, 1013–1016.

    Google Scholar 

  • Central Statistical Agency of Ethiopia, & ICF International. (2012). Ethiopia demographic and health survey 2011. Calverton, Maryland: ICF International.

    Google Scholar 

  • Chandisarewa, W., Stranix-Chibanda, L., Chirapa, E., Miller, A., Simoyi, M., Mahomva, A., . . . Shetty, A. K. (2007). Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. Bulletin of the World Health Organization, 85, 843–850.

  • Conaty, S. J., Cassell, J. A., Harrisson, U., Whyte, P., Sherr, L., & Fox, Z. (2005). Women who decline antenatal screening for HIV infection in the era of universal testing: Results of an audit of uptake in three London hospitals. Journal Public Health (Oxford), 27, 114–117. doi:10.1093/pubmed/fdh203.

    Article  CAS  Google Scholar 

  • Creek, T. L., Ntumy, R., Seipone, K., Smith, M., Mogodi, M., Smit, M., . . . Kilmarx, P. H. (2007). Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. Journal of Acquired Immune Deficiency Syndromes, 45, 102–107. doi: 10.1097/QAI.0b013e318047df88.

  • Cremin, I., Cauchemez, S., Garnett, G. P., & Gregson, S. (2012). Patterns of uptake of HIV testing in sub Saharan Africa in the pre-treatment era. Tropical Medicine & International Health, 17, e26–e37. doi:10.1111/j.1365-3156.2011.02937.x.

    Article  Google Scholar 

  • Crepaz, N., Lyles, C. M., Wolitski, R. J., Passin, W. F., Rama, S. M., Herbst, J. H., . . . Stall, R. (2006). Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials. AIDS, 20, 143–157. doi: 10.1097/01.aids.0000196166.48518.a0

  • Dahl, V., Mellhammar, L., Bajunirwe, F., & Bjorkman, P. (2008). Acceptance of HIV testing among women attending antenatal care in south-western Uganda: Risk factors and reasons for test refusal. AIDS Care, 20, 746–752. doi:10.1080/09540120701693990.

    Article  CAS  PubMed  Google Scholar 

  • De Cock, K. M., Marum, E., & Mbori-Ngacha, D. (2003). A serostatus-based approach to HIV/AIDS prevention and care in Africa. Lancet, 362, 1847–1849.

    Article  PubMed  Google Scholar 

  • Denison, J., O’Reilly, K., Schmid, G., Kennedy, C., & Sweat, M. (2008). HIV counseling and testing and behavioral risk reduction in developing countries: A meta-analysis, 1990–2005. AIDS and Behavior, 12, 363–373. doi:10.1007/s10461-007-9349-x.

    Article  PubMed  Google Scholar 

  • Dieffenbach, C. W., & Fauci, A. S. (2009). Universal voluntary testing and treatment for prevention of HIV transmission. Journal of the American Medical Association, 301, 2380–2382. doi:10.1001/jama.2009.828.

    Article  CAS  PubMed  Google Scholar 

  • Genberg, B. L., Kawichai, S., Chingono, A., Sendah, M., Chariyalertsak, S., Konda, K. A., & Celentano, D. D. (2008). Assessing HIV/AIDS stigma and discrimination in developing countries. AIDS and Behavior, 12, 772–780. doi:10.1007/s10461-007-9340-6.

    Article  PubMed  Google Scholar 

  • Girma, E., Gebretsadik, L. A., Kaufman, M. R., Rimal, R. N., Morankar, S. N., & Limaye, R. J. (2013). Stigma against people with HIV/AIDS in Rural Ethiopia, 2005 to 2011: Signs and predictors of improvement. AIDS and Behavior, 18, 1046–1053. doi:10.1007/s10461-013-0611-0.

    Article  Google Scholar 

  • Granich, R. M., Gilks, C. F., Dye, C., De Cock, K. M., & Williams, B. G. (2009). Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet, 373, 48–57. doi:10.1016/S0140-6736(08)61697-9.

    Article  PubMed  Google Scholar 

  • Federal HIV/AIDS Prevention and Control Office (HAPCO), Federal Ministry of Health. (2007a). Guidelines for prevention of mother-to-child transmission of HIV in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health.

    Google Scholar 

  • Federal HIV/AIDS Prevention and Control Office (HAPCO), Federal Ministry of Health. (2007b). Multisectoral plan of action for universal access to HIV prevention, treatment, care and support in Ethiopia 2007–2010. Addis Ababa, Ethiopia: HAPCO.

    Google Scholar 

  • Federal Ministry of Health. (2007). Guidelines for HIV counseling and testing in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health.

    Google Scholar 

  • Homsy, J., King, R., Malamba, S. S., Opio, C., Kalamya, J. N., Mermin, J., . . . Obonyo, J. H. (2007). The need for partner consent is a main reason for opting out of routine HIV testing for prevention of mother-to-child transmission in a rural Ugandan hospital. Journal of Acquired Immune Deficiency Syndromes, 44, 366–369. doi: 10.1097/QAI.0b013e31802f1303.

  • Hull, M. W., Wu, Z., & Montaner, J. S. (2012). Optimizing the engagement of care cascade: A critical step to maximize the impact of HIV treatment as prevention. Current Opinion in HIV and AIDS, 7, 579–586. doi:10.1097/COH.0b013e3283590617.

    Article  PubMed  Google Scholar 

  • Kalichman, S. C., & Simbayi, L. C. (2003). HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sexually Transmitted Infections, 79, 442–447.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Kilmarx, P. H., & Mutasa-Apollo, T. (2013). Patching a leaky pipe: The cascade of HIV care. Current Opinion in HIV and AIDS, 8, 59–64. doi:10.1097/COH.0b013e32835b806e.

    PubMed  Google Scholar 

  • Leon, N., Naidoo, P., Mathews, C., Lewin, S., & Lombard, C. (2010). The impact of provider-initiated (opt-out) HIV testing and counseling of patients with sexually transmitted infection in Cape Town, South Africa: A controlled trial. Implementation Science, 5, 8. doi:10.1186/1748-5908-5-8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Leta, T. H., Sandoy, I. F., & Fylkesnes, K. (2012). Factors affecting voluntary HIV counselling and testing among men in Ethiopia: A cross-sectional survey. BMC Public Health, 12, 438. doi:10.1186/1471-2458-12-438.

    Article  PubMed  PubMed Central  Google Scholar 

  • Limaye, R. J., Bingenheimer, J. B., Rimal, R. N., Krenn, S., & Vondrasek, C. (2013). Treatment-as-prevention in AIDS control: Why communication matters. Journal of Therapy and Management in HIV Infection, 1, 3–6. doi:10.12970/2309-0529.2013.01.01.1.

    Google Scholar 

  • Mahajan, A. P., Sayles, J. N., Patel, V. A., Remien, R. H., Ortiz, D., Szekeres, G., & Coates, T. J. (2008). Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward. AIDS (London, England), 22, S67.

    Article  Google Scholar 

  • Mirkuzie, A. H., Hinderaker, S. G., & Morkve, O. (2010). Promising outcomes of a national programme for the prevention of mother-to-child HIV transmission in Addis Ababa: A retrospective study. BMC Health Services Research, 10, 267. doi:10.1186/1472-6963-10-267.

    Article  PubMed  PubMed Central  Google Scholar 

  • Mugore, L., Engelsmann, B., Ndoro, T., Dabis, F., & Perez, F. (2008). An assessment of the understanding of the offer of routine HIV testing among pregnant women in rural Zimbabwe. AIDS Care, 20, 660–666. doi:10.1080/09540120701687034.

    Article  CAS  PubMed  Google Scholar 

  • Odimegwu, C., Adedini, S. A., & Ononokpono, D. N. (2013). HIV/AIDS stigma and utilization of voluntary counselling and testing in Nigeria. BMC Public Health, 13, 465. doi:10.1186/1471-2458-13-465.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ole-Nguyaine, S., Crump, J. A., Kibiki, G. S., Kiang, K., Taylor, J., Schimana, W., . . . Thielman, N. M. (2004). HIV-associated morbidity, mortality and diagnostic testing opportunities among inpatients at a referral hospital in northern Tanzania. Annals of Tropical Medicine and Parasitology, 98, 171–179. doi: 10.1179/000349804225003163

  • Perez, F., Zvandaziva, C., Engelsmann, B., & Dabis, F. (2006). Acceptability of routine HIV testing ("opt-out") in antenatal services in two rural districts of Zimbabwe. Journal of Acquired Immune Deficiency Syndromes, 41, 514–520. doi:10.1097/01.qai.0000191285.70331.a0.

    Article  PubMed  Google Scholar 

  • Rimal, R. N. (2008). Modeling the relationship between descriptive norms and behaviors: A test and extension of the theory of normative social behavior (TNSB). Health Communication, 23, 103–116.

    Article  PubMed  Google Scholar 

  • Sarker, M., Sanou, A., Snow, R., Ganame, J., & Gondos, A. (2007). Determinants of HIV counselling and testing participation in a prevention of mother-to-child transmission programme in rural Burkina Faso. Tropical Medicine & International Health, 12, 1475–1483. doi:10.1111/j.1365-3156.2007.01956.x.

    Article  CAS  Google Scholar 

  • Smith, R. A. (2007). Language of the lost: An explication of stigma communication. Communication Theory, 17, 462–485.

    Article  Google Scholar 

  • Topp, S. M., Chipukuma, J. M., Chiko, M. M., Wamulume, C. S., Bolton-Moore, C., & Reid, S. E. (2011). Opt-out provider-initiated HIV testing and counselling in primary care outpatient clinics in Zambia. Bulletin of the World Health Organization, 89, 328–335A. doi:10.2471/BLT.10.084442.

    Article  PubMed  PubMed Central  Google Scholar 

  • VanderWeele, T. J., & Knol, M. J. (2014). A tutorial on interaction. Epidemiologic Methods, 3, 33–72.

    Google Scholar 

  • Witte, K. (1992). Putting the fear back into fear appeals: The extended parallel process model. Communications Monographs, 59, 329–349.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 255, Baltimore, MD, 21205, USA

    Michelle R. Kaufman & Rachel Rieder

  2. University of California, San Francisco, CA, USA

    Alyssa Mooney

  3. Jimma University, Jimma, Ethiopia

    Lakew Abebe Gebretsadik & Morankar N. Sudhakar

  4. Johns Hopkins University Center for Communication Programs, Baltimore, MD, USA

    Rupali J. Limaye

  5. Addis Ababa University, Addis Ababa, Ethiopia

    Eshetu Girma

  6. George Washington University, Washington, DC, USA

    Rajiv N. Rimal

Authors
  1. Michelle R. Kaufman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alyssa Mooney
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lakew Abebe Gebretsadik
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Morankar N. Sudhakar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Rachel Rieder
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rupali J. Limaye
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Eshetu Girma
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Rajiv N. Rimal
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michelle R. Kaufman.

Ethics declarations

Funding

None of the authors received funding to conduct this secondary analysis.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Research Involving Human Participants

This article does not contain any studies with human participants or animals performed by any of the authors. It is a secondary analysis of publicly available, de-identified data.

Informed Consent

For this type of study, formal consent is not required; presumably, it was obtained by the organization collecting the original data.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kaufman, M.R., Mooney, A., Gebretsadik, L.A. et al. The Differential Effects of an Opt-Out HIV Testing Policy for Pregnant Women in Ethiopia When Accounting for Stigma: Secondary Analysis of DHS Data. Prev Sci 18, 245–252 (2017). https://doi.org/10.1007/s11121-016-0740-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11121-016-0740-6

Keywords

Search

Navigation