This is the first epidemiological study in Cambodia to assess the prevalence of and barriers to HIV testing after implementation of the PITC initiative. Most such studies have been done in African countries. Out of the mothers in this study, 76% were tested for HIV. This indicates that almost a quarter of the targeted mothers declined testing as part of the PITC strategy.
In some African countries, the acceptance of HIV testing among pregnant women after the adoption of a PITC strategy exceeded 90% [10–12]. For example, a study in urban clinics in Zimbabwe found that 99.9% of women present for ANC were tested for HIV as part of a PITC strategy, compared to 65% who were tested during voluntary counseling and testing (VCT). That said, the PITC strategy must be evaluated by comparing the incidence of adverse effects such as domestic violence experienced by mothers who opted-in to HIV testing . A study in Botswana found that the acceptance of HIV testing increased from 75.3% to 90.5% after adoption of a PITC strategy. In comparison, mothers in Cambodia face greater barriers to the acceptance of HIV testing that exceed the effects of the PITC strategy.
One barrier was the perceived need to obtain a partner's permission to be tested. Maman found that the fear of a partner's reaction to an HIV-positive result was an important barrier to HIV testing in Tanzania, and Dahl also found that the one of the most common reasons for test refusal among pregnant women was the need to discuss the issue with a partner beforehand in Uganda. However, a study conducted prior to the introduction of PITC at the same facility indicated that a partner's permission was not a significant barrier to HIV testing when HIV testing was offered in a VCT approach where male involvement was strongly encouraged in the form of group education and individual counseling sessions . Although simply comparing these results to the current results is not necessarily appropriate, the current results may be due to the simplification of test counseling. There is no doubt that PITC is a very effective strategy to foster greater acceptance of HIV testing, but involvement of male partners in PMTCT services such as group education and individual counseling still seems to be an important way to make partners aware of the benefits of HIV testing and help them better understand HIV testing by mothers even with a PITC approach. Although no effective interventions to improve partner attendance during ANC have been noted, women attending ANC in Kenya were asked to return with their male partner for individual or couple VCT . Sixteen-percent of women returned to ANC with their partners, and over 95% of the men attending ANC accepted HIV testing. Partner attendance during ANC was still a challenge, but the results implied that offering HIV testing and counseling services to men with options for couple and individual counseling during ANC are an acceptable strategy to increasing male involvement in PMTCT and promote male HIV testing.
Maternal knowledge about HIV prevention and treatment is a well-known factor related to the acceptance of HIV testing [18, 19]. The current results that ascertained basic knowledge about HIV prevention and treatment agreed with results from other studies. Communication strategies as well as counseling as part of PMTCT services could provide opportunities for mothers to learn about HIV prevention and treatment. However, a point worth mentioning is that only 46.5% of those mothers who were tested for HIV scored perfectly although the questions mothers were asked in this study were very basic. This suggests that many mothers receive HIV testing despite a lack of understanding about the advantages and disadvantages of HIV testing. This may lead to missing opportunities to receive adequate information and may even lead to refusal to undergo HIV testing. In Botswana, 68% of individuals who were tested for HIV under a national policy of PITC believed that they were not able to refuse the test when it was offered . In rural Zimbabwe, 55% of women who accepted HIV testing directly after group education as part of their routine ANC blood tests were not aware of the possibility of opting for individual pre-test counseling .
The guidelines on PITC state that greater knowledge of one's HIV status is critical to increasing access to HIV treatment, care, and support in a timely manner, and such knowledge offers people living with HIV the opportunity to receive information and tools to prevent HIV transmission to others . However, WHO/UNAIDS have reduced the emphasis on counseling in their revised testing guidelines, which include simplified pre-test counseling. For example, individual risk assessment and risk reduction plans are not covered during pre-test counseling, and pre-test information were only provided in the form of group health information talk rather than individual counseling session after adopting PITC strategy in Cambodia. Therefore, our result that more than half of mothers could not answer basic questions correctly about HIV prevention and treatment is considered to be caused by the simplified counseling as part of a PITC strategy. In addition, they may not know that they have the right to have additional information if they are susceptible to coercion to be tested. Introducing a PITC strategy may increase HIV testing, but mothers must understand basic information about HIV, including their right not to be tested.
Mothers who received ANC outside Phnom Penh had less chance of undergoing HIV testing than did mothers who received ANC in Phnom Penh. The number of testing sites around the country have increased and the number of people tested at licensed sites, which have rapid test kits and offer free counseling and HIV testing, increased from 1,766 in 1997 to 152,147 in 2005 . Nevertheless, HIV testing and counseling services are not as available outside Phnom Penh as they are within the city. The 2005 Cambodian Demographic and Health Survey found that less than 70% of pregnant women received ANC from trained personnel in rural areas, as compared to 80% who received it in urban areas. Numbers of ANC visits also differed. Less than a quarter of the mothers living in rural areas received ANC more than four times while nearly half of the mothers living in urban areas did . Mothers who received ANC outside Phnom Penh may have fewer opportunities to learn about HIV testing than do mothers who received ANC in Phnom Penh. As there are few data on the difference in ANC services in urban and rural areas of Cambodia, further studies on the quality of ANC in both urban and rural areas are needed.
However, a previous study showed that one of the differences was HIV services . Because the Cambodian regulations allow only laboratory technicians to perform HIV testing and these technicians are not assigned to all health facilities in rural areas, mothers who receive ANC in rural areas must lack the opportunity to be tested for HIV. Kanal showed that half-day training for non-laboratory staff such as midwives was a feasible way to provide sufficient proficiency to implement HIV testing. HIV testing should be made available in all health facilities in rural areas through strategic approaches such as efficient utilization of human resources.
Although this study provided important and useful information on the prevalence of HIV testing and it highlighted barriers that might hamper the acceptance of HIV testing services, it has some limitations. The study is hospital-based and does not include those mothers who delivered at other locations such as private facilities or at home. In rural areas, more than 80% of mothers deliver at home, and in Phnom Penh 40% of mothers deliver at private facilities (21.6%) or at home (21.6%) . Results of the current study may not be generalized and may only be applicable to the study site or to other major hospitals offering PITC services. That said, approximately 40% of babies in Phnom Penh are born at the current study site . In the future, a community-based investigation must be performed with a focus on barriers to use of services by mothers who give birth either at home or at other institutions., Perez suggests that in rural Zimbabwe knowledge about PMTCT must be enhanced among traditional birth attendants and that these individuals must be integrated into the health system in order to improve access to PMTCT services for mothers delivering at home . Interventions such as birth attendant training and home visits by trained health professionals must be considered in Cambodia.