There are some crucial points about the opt-out approach that you need to understand. First, the woman can refuse the test — she can opt-out. Second, if the HIV test result is positive, the woman will be given post-test counselling. Third, women who opted-out (refused) will be provided with a longer session of counselling, which starts by letting them express their concerns and reasons for objection to the test, so you can address their specific questions and worries.
In order to counsel opted-out women effectively you need to build trust. Emphasise that getting an early diagnosis and starting treatment or prophylaxis greatly improves the chances of survival for women who are HIV-positive and their babies. Knowing her HIV status does not necessarily mean a woman's husband or partner has the right to know as well — it is her full right either to disclose her HIV status or to hide it. However, for better outcomes of follow-up and treatment, disclosing the truth to her family has a big advantage because they can support her. Assure the woman that HIV is no longer a disease that needs to be hidden, or one that people should be ashamed of. Also, it is not a disease that always leads to death, provided that people are diagnosed early and treatment is started early.
If a woman continues to refuse the HIV test, further counselling should be provided in subsequent antenatal care visits. She should be reassured that opting-out of HIV testing will not affect her access to antenatal care, labour and delivery care, postnatal care, or related services. Encourage her to reconsider testing. Do not pressure her to be tested, but let her know that if she changes her mind, an HIV test and further counselling can always be provided during a later visit. Document the reasons for her refusal in your notes as a reminder to offer her HIV counselling and testing the next time you see her. Box 16.3 summarises some common reasons why women refuse HIV testing.
Box 16.3 Common reasons why women refuse HIV testing
- Fear of being found HIV-positive and losing hope.
- Fear of a positive HIV result causing marriage disharmony and divorce.
- Fear of being found HIV-positive and not trusting the health professionals to keep the result private.
- Fear of a positive HIV test leading to stigma and discrimination by the community.