There are two contrasting approaches to counselling pregnant women about the need for HIV testing: they are known as 'opt-in' and 'opt-out'. The opt-in approach involves counselling a woman for about 40 minutes in a private room, to inform her about everything she wants to know, so she can agree to be tested with informed consent (i.e. opt-in, or accepted by the woman). Of course, at the end of the counselling session, she may refuse to have the test. Opt-in was practised until 2006 in Ethiopia and is still the approach in many other countries.

The opt-out approach, on the other hand, involves informing the woman that she is about to have an HIV test. The main aim of the opt-out approach is to get as many women (and men) as possible tested for HIV infection. The differences between the opt-in and opt-out approaches are summarised in Table 16.2. As you can see, the opt-out approach is much more successful in achieving high test coverage than was the case with opt-in.

Table 16.2 Comparison of opt-in and opt-out counselling approaches to HIV testing.

National PMTCT of HIV guideline20012007
CounsellingPre-test and post-test (before and after test; pre-test can take a long time till the client accepts the test) Post-test (after the test result unless the client refused or opted-out)
Test take-up rate (number of persons tested)Very lowVery high
Helps people to see the HIV test as normal NoYes

Another big advantage of the opt-out approach is that HIV testing becomes a normal procedure for everyone. The normalisation of HIV testing helps to overcome fear of taking the test, so in the future it becomes just like any other routine test for any disease. Information about HIV testing can be presented in group sessions, which also helps to normalise it; for example, you may arrange a group meeting for pregnant women in your community to discuss aspects of focused antenatal care, and refer to the HIV test as a normal part of the routine visits. Finally, it is less time consuming for health workers, as it does not involve a long pre-test counselling session with each woman.