6 Strategies to Improve Antenatal HIV, HBV, Syphilis Screening

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Rates of maternal and neonatal morbidity and mortality among women and children in low- and middle-income countries continue to be burdened by the transmission of sexually transmitted infections (STIs) including HIV, hepatitis B, and syphilis. In fact, it is currently estimated that approximately 1.2 million pregnant women were positive for HIV in 2022—with an estimated 18% (range, 2 – 36) not receiving antiretroviral therapy to help prevent transmission to their children.¹

Efficient yet robust strategies to curb transmission among adversely impacted regions need to be better established and disseminated among clinicians to address the public health concern.

A recent rapid systematic review of 27 intervention-based studies identified 6 potentially viable strategies to improve the poor rates of antenatal screening for STIs including syphilis, hepatitis B, and HIV among persons in low- to middle-income countries.² Led by Jackson Harrison, MPH, of the Reproductive and Perinatal Centre at the University Sydney in South Wales, Australia, the team of investigators believe their findings could provide a diverse blueprint to policymakers, clinicians, and public health leadership to implement adequate and tailored strategies to mitigate the spread and effect of antenatal STIs globally.

Community Health Interventions

Approximately one-fourth of the relevant intervention studies analyzed included the implementation of practices outside of health care facilities designed to improve patient engagement. Among the strategies that may be beneficial include HIV screening offerings leveraged by community health workers at community or congregation settings—a practice that which may also serve to reduce stigmatization of diseases including HIV.

Health Technology Interventions

A trio of studies observing the utility of a tablet-based data system on HIV screening rates, a bi-directional text messaging system to prompt overall STI screening, and an antenatal ultrasonography program for HIV screening provided varied results. Though the text message-based system did not improve hepatitis B screening, Harrison and colleagues noted it provided benefit for HIV and syphilis screening rates.

Incentivization

The team highlighted a lone randomized, controlled trial in which pregnant persons were financially incentivized to undergo antenatal HIV screening—observing that it resulted in significantly increased screening rates.

Infrastructure Improvement

Another 3 trials analyzed how improving the specific infrastructure of health care systems could provide general benefit in antenatal STI testing. One showed that an implemented point-of-care testing intervention, combined with improved training and resources for staff, resulted in significantly improved HIV screening rates. Another study, however, found no such improvement in antenatal screening when applying a point-of-care testing intervention. A Guatemala-based study observed the implementation of a rapid testing intervention for HIV, syphilis and hepatitis B into antenatal care practice; the team only reported positive effects in HIV screening rates.

Policy Changes

Among the more common types of strategy observed in the analysis, a quartet of clinical trials with lower-quality evidence showed varying results with governance policy changes related to antenatal screening. One observed significantly increased screening rates in Nigeria when the national policy switched to opt-in testing—and additionally increased rates in Ethiopia when the national policy switched to opt-out testing instead. A Ghana policy change to point-of-care testing interventions provided no significant benefits, and the adaptation of World Health Organization (WHO) guidelines for antenatal HIV screening was associated with 100% screening rates in Malawi, South Africa and Tanzania.

Service Integration

Only a pair of clinical trials focused on service integration. Both resulted in significantly improved HIV screening rates with the integration of either the WHO’s Elimination of Mother-to-Child Transmission (eMTCT) and primary health care services, or tuberculosis services.

References

1. ^{HIV – Estimated percentage of pregnant women living with HIV who received antiretrovirals for preventing mother-to-child transmission. World Health Organization. The Global Health Observatory. Last updated July 11, 2023. Accessed February 28, 2024. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/estimated-percentage-of-pregnant-women-living-with-hiv-who-received-antiretrovirals-for-preventing-mother-to-child-transmission}
2. ^{Harrison J, Lind P, Sawleshwarkar S, Pasupathy D, Yapa HM. Rapid systematic review of interventions to improve antenatal screening rates for syphilis, hepatitis B, and HIV in low- and middle-income countries. Int J Gynaecol Obstet. Published online February 23, 2024. doi:10.1002/ijgo.15425}