Successful introduction of routine opt-out HIV testing in antenatal care in Botswana

Botswana has high HIV prevalence among pregnant women (37.4% in 2003) and provides free services for prevention of mother-to-child transmission (PMTCT) of HIV. Nearly all pregnant women (>95%) have antenatal care (ANC) and deliver in hospital. Uptake of antenatal HIV testing was low from 1999 through 2003. In 2004, Botswana's President declared that HIV testing should be "routine but not compulsory" in medical settings.

Health workers were trained to provide group education and recommend HIV testing as part of routine ANC services. Logbook data on ANC attendance, HIV testing, and uptake of PMTCT interventions were reviewed before and after routine testing training, and ANC clients were interviewed.

After routine testing started, the percentage of all HIV-infected women delivering in the regional hospital who knew their HIV status increased from 47% to 78% and the percentage receiving PMTCT interventions increased from 29% to 56%. ANC attendance and the percentage of HIV-positive women who disclosed their HIV status to others remained stable. Interviews indicated that ANC clients supported the policy.

Routine HIV testing was more accepted than voluntary testing in this setting and led to substantial increases in the uptake of testing and PMTCT interventions without detectable adverse consequences. Routine testing in other settings may strengthen HIV care and prevention efforts.