Prevention Science

, Volume 18, Issue 2, pp 245–252 | Cite as

The Differential Effects of an Opt-Out HIV Testing Policy for Pregnant Women in Ethiopia When Accounting for Stigma: Secondary Analysis of DHS Data

  • Michelle R. KaufmanEmail author
  • Alyssa Mooney
  • Lakew Abebe Gebretsadik
  • Morankar N. Sudhakar
  • Rachel Rieder
  • Rupali J. Limaye
  • Eshetu Girma
  • Rajiv N. Rimal


Individual factors associated with HIV testing have been studied across multiple populations; however, testing is not just an individual-level phenomenon. This secondary analysis of 2005 and 2011 Ethiopia Demographic and Health Survey data was conducted to determine the extent to which the 2007 institution of an opt-out policy of HIV testing during antenatal care increased testing among women, and whether effects differed by women’s stigmatizing beliefs about HIV. A logit model with interaction between pre-/post-policy year and policy exposure (birth in the past year) was used to estimate the increased probability of past-year testing, which may be attributable to the policy. Results suggested the policy contributed to a nine-point increase in the probability of testing (95% CI 0.06–0.13, p < 0.0001). A three-way interaction was used to compare the effects of exposure to the policy among women holding higher and lower HIV stigmatizing beliefs. The increase in the probability of past-year testing was 16 percentage points greater among women with lower stigmatizing beliefs (95% CI 0.06–0.27, p = 0.002). Women with higher stigmatizing beliefs were less likely to report attending antenatal care (ANC), testing at their last ANC visit, or being offered a test at their last ANC visit. We encourage researchers and practitioners to explore interventions that operate at multiple levels of socio-ecological spheres of influence, addressing both stigma and structural barriers to testing, in order to achieve the greatest results in preventing HIV.


HIV testing Stigma Antenatal care Ethiopia HIV policy 


Compliance with Ethical Standards


None of the authors received funding to conduct this secondary analysis.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Research Involving Human Participants

This article does not contain any studies with human participants or animals performed by any of the authors. It is a secondary analysis of publicly available, de-identified data.

Informed Consent

For this type of study, formal consent is not required; presumably, it was obtained by the organization collecting the original data.


  1. Angrist, J. D., & Pischke, J. S. (2009). Mostly harmless econometrics: An empiricist’s companion. Princeton: Princeton University Press.Google Scholar
  2. Bond, L., Lauby, J., & Batson, H. (2005). HIV testing and the role of individual- and structural-level barriers and facilitators. AIDS Care, 17, 125–140. doi: 10.1080/09541020512331325653.CrossRefPubMedGoogle Scholar
  3. Centers for Disease Control & Prevention. (2001). Revised recommendations for HIV screening of pregnant women. MMWR - Recommendations and Reports, 50, 63–85. quiz CE61-19a62-CE66-19a62.Google Scholar
  4. Centers for Disease Control & Prevention. (2002). HIV testing among pregnant women—United States and Canada, 1998–2001. MMWR. Morbidity and Mortality Weekly Report, 51, 1013–1016.Google Scholar
  5. Central Statistical Agency of Ethiopia, & ICF International. (2012). Ethiopia demographic and health survey 2011. Calverton, Maryland: ICF International.Google Scholar
  6. Chandisarewa, W., Stranix-Chibanda, L., Chirapa, E., Miller, A., Simoyi, M., Mahomva, A., . . . Shetty, A. K. (2007). Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. Bulletin of the World Health Organization, 85, 843–850.Google Scholar
  7. Conaty, S. J., Cassell, J. A., Harrisson, U., Whyte, P., Sherr, L., & Fox, Z. (2005). Women who decline antenatal screening for HIV infection in the era of universal testing: Results of an audit of uptake in three London hospitals. Journal Public Health (Oxford), 27, 114–117. doi: 10.1093/pubmed/fdh203.CrossRefGoogle Scholar
  8. Creek, T. L., Ntumy, R., Seipone, K., Smith, M., Mogodi, M., Smit, M., . . . Kilmarx, P. H. (2007). Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. Journal of Acquired Immune Deficiency Syndromes, 45, 102–107. doi: 10.1097/QAI.0b013e318047df88.Google Scholar
  9. Cremin, I., Cauchemez, S., Garnett, G. P., & Gregson, S. (2012). Patterns of uptake of HIV testing in sub Saharan Africa in the pre-treatment era. Tropical Medicine & International Health, 17, e26–e37. doi: 10.1111/j.1365-3156.2011.02937.x.CrossRefGoogle Scholar
  10. Crepaz, N., Lyles, C. M., Wolitski, R. J., Passin, W. F., Rama, S. M., Herbst, J. H., . . . Stall, R. (2006). Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials. AIDS, 20, 143–157. doi: 10.1097/01.aids.0000196166.48518.a0Google Scholar
  11. Dahl, V., Mellhammar, L., Bajunirwe, F., & Bjorkman, P. (2008). Acceptance of HIV testing among women attending antenatal care in south-western Uganda: Risk factors and reasons for test refusal. AIDS Care, 20, 746–752. doi: 10.1080/09540120701693990.CrossRefPubMedGoogle Scholar
  12. De Cock, K. M., Marum, E., & Mbori-Ngacha, D. (2003). A serostatus-based approach to HIV/AIDS prevention and care in Africa. Lancet, 362, 1847–1849.CrossRefPubMedGoogle Scholar
  13. Denison, J., O’Reilly, K., Schmid, G., Kennedy, C., & Sweat, M. (2008). HIV counseling and testing and behavioral risk reduction in developing countries: A meta-analysis, 1990–2005. AIDS and Behavior, 12, 363–373. doi: 10.1007/s10461-007-9349-x.CrossRefPubMedGoogle Scholar
  14. Dieffenbach, C. W., & Fauci, A. S. (2009). Universal voluntary testing and treatment for prevention of HIV transmission. Journal of the American Medical Association, 301, 2380–2382. doi: 10.1001/jama.2009.828.CrossRefPubMedGoogle Scholar
  15. Genberg, B. L., Kawichai, S., Chingono, A., Sendah, M., Chariyalertsak, S., Konda, K. A., & Celentano, D. D. (2008). Assessing HIV/AIDS stigma and discrimination in developing countries. AIDS and Behavior, 12, 772–780. doi: 10.1007/s10461-007-9340-6.CrossRefPubMedGoogle Scholar
  16. Girma, E., Gebretsadik, L. A., Kaufman, M. R., Rimal, R. N., Morankar, S. N., & Limaye, R. J. (2013). Stigma against people with HIV/AIDS in Rural Ethiopia, 2005 to 2011: Signs and predictors of improvement. AIDS and Behavior, 18, 1046–1053. doi: 10.1007/s10461-013-0611-0.CrossRefGoogle Scholar
  17. Granich, R. M., Gilks, C. F., Dye, C., De Cock, K. M., & Williams, B. G. (2009). Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet, 373, 48–57. doi: 10.1016/S0140-6736(08)61697-9.CrossRefPubMedGoogle Scholar
  18. Federal HIV/AIDS Prevention and Control Office (HAPCO), Federal Ministry of Health. (2007a). Guidelines for prevention of mother-to-child transmission of HIV in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health.Google Scholar
  19. Federal HIV/AIDS Prevention and Control Office (HAPCO), Federal Ministry of Health. (2007b). Multisectoral plan of action for universal access to HIV prevention, treatment, care and support in Ethiopia 2007–2010. Addis Ababa, Ethiopia: HAPCO.Google Scholar
  20. Federal Ministry of Health. (2007). Guidelines for HIV counseling and testing in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health.Google Scholar
  21. Homsy, J., King, R., Malamba, S. S., Opio, C., Kalamya, J. N., Mermin, J., . . . Obonyo, J. H. (2007). The need for partner consent is a main reason for opting out of routine HIV testing for prevention of mother-to-child transmission in a rural Ugandan hospital. Journal of Acquired Immune Deficiency Syndromes, 44, 366–369. doi: 10.1097/QAI.0b013e31802f1303.Google Scholar
  22. Hull, M. W., Wu, Z., & Montaner, J. S. (2012). Optimizing the engagement of care cascade: A critical step to maximize the impact of HIV treatment as prevention. Current Opinion in HIV and AIDS, 7, 579–586. doi: 10.1097/COH.0b013e3283590617.CrossRefPubMedGoogle Scholar
  23. Kalichman, S. C., & Simbayi, L. C. (2003). HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sexually Transmitted Infections, 79, 442–447.CrossRefPubMedPubMedCentralGoogle Scholar
  24. Kilmarx, P. H., & Mutasa-Apollo, T. (2013). Patching a leaky pipe: The cascade of HIV care. Current Opinion in HIV and AIDS, 8, 59–64. doi: 10.1097/COH.0b013e32835b806e.PubMedGoogle Scholar
  25. Leon, N., Naidoo, P., Mathews, C., Lewin, S., & Lombard, C. (2010). The impact of provider-initiated (opt-out) HIV testing and counseling of patients with sexually transmitted infection in Cape Town, South Africa: A controlled trial. Implementation Science, 5, 8. doi: 10.1186/1748-5908-5-8.CrossRefPubMedPubMedCentralGoogle Scholar
  26. Leta, T. H., Sandoy, I. F., & Fylkesnes, K. (2012). Factors affecting voluntary HIV counselling and testing among men in Ethiopia: A cross-sectional survey. BMC Public Health, 12, 438. doi: 10.1186/1471-2458-12-438.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Limaye, R. J., Bingenheimer, J. B., Rimal, R. N., Krenn, S., & Vondrasek, C. (2013). Treatment-as-prevention in AIDS control: Why communication matters. Journal of Therapy and Management in HIV Infection, 1, 3–6. doi: 10.12970/2309-0529.2013.01.01.1.Google Scholar
  28. Mahajan, A. P., Sayles, J. N., Patel, V. A., Remien, R. H., Ortiz, D., Szekeres, G., & Coates, T. J. (2008). Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward. AIDS (London, England), 22, S67.CrossRefGoogle Scholar
  29. Mirkuzie, A. H., Hinderaker, S. G., & Morkve, O. (2010). Promising outcomes of a national programme for the prevention of mother-to-child HIV transmission in Addis Ababa: A retrospective study. BMC Health Services Research, 10, 267. doi: 10.1186/1472-6963-10-267.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Mugore, L., Engelsmann, B., Ndoro, T., Dabis, F., & Perez, F. (2008). An assessment of the understanding of the offer of routine HIV testing among pregnant women in rural Zimbabwe. AIDS Care, 20, 660–666. doi: 10.1080/09540120701687034.CrossRefPubMedGoogle Scholar
  31. Odimegwu, C., Adedini, S. A., & Ononokpono, D. N. (2013). HIV/AIDS stigma and utilization of voluntary counselling and testing in Nigeria. BMC Public Health, 13, 465. doi: 10.1186/1471-2458-13-465.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Ole-Nguyaine, S., Crump, J. A., Kibiki, G. S., Kiang, K., Taylor, J., Schimana, W., . . . Thielman, N. M. (2004). HIV-associated morbidity, mortality and diagnostic testing opportunities among inpatients at a referral hospital in northern Tanzania. Annals of Tropical Medicine and Parasitology, 98, 171–179. doi: 10.1179/000349804225003163Google Scholar
  33. Perez, F., Zvandaziva, C., Engelsmann, B., & Dabis, F. (2006). Acceptability of routine HIV testing ("opt-out") in antenatal services in two rural districts of Zimbabwe. Journal of Acquired Immune Deficiency Syndromes, 41, 514–520. doi: 10.1097/01.qai.0000191285.70331.a0.CrossRefPubMedGoogle Scholar
  34. Rimal, R. N. (2008). Modeling the relationship between descriptive norms and behaviors: A test and extension of the theory of normative social behavior (TNSB). Health Communication, 23, 103–116.CrossRefPubMedGoogle Scholar
  35. Sarker, M., Sanou, A., Snow, R., Ganame, J., & Gondos, A. (2007). Determinants of HIV counselling and testing participation in a prevention of mother-to-child transmission programme in rural Burkina Faso. Tropical Medicine & International Health, 12, 1475–1483. doi: 10.1111/j.1365-3156.2007.01956.x.CrossRefGoogle Scholar
  36. Smith, R. A. (2007). Language of the lost: An explication of stigma communication. Communication Theory, 17, 462–485.CrossRefGoogle Scholar
  37. Topp, S. M., Chipukuma, J. M., Chiko, M. M., Wamulume, C. S., Bolton-Moore, C., & Reid, S. E. (2011). Opt-out provider-initiated HIV testing and counselling in primary care outpatient clinics in Zambia. Bulletin of the World Health Organization, 89, 328–335A. doi: 10.2471/BLT.10.084442.CrossRefPubMedPubMedCentralGoogle Scholar
  38. VanderWeele, T. J., & Knol, M. J. (2014). A tutorial on interaction. Epidemiologic Methods, 3, 33–72.Google Scholar
  39. Witte, K. (1992). Putting the fear back into fear appeals: The extended parallel process model. Communications Monographs, 59, 329–349.CrossRefGoogle Scholar

Copyright information

© Society for Prevention Research 2016

Authors and Affiliations

  • Michelle R. Kaufman
    • 1
    Email author
  • Alyssa Mooney
    • 2
  • Lakew Abebe Gebretsadik
    • 3
  • Morankar N. Sudhakar
    • 3
  • Rachel Rieder
    • 1
  • Rupali J. Limaye
    • 4
  • Eshetu Girma
    • 5
  • Rajiv N. Rimal
    • 6
  1. 1.Department of Health, Behavior & SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  2. 2.University of CaliforniaSan FranciscoUSA
  3. 3.Jimma UniversityJimmaEthiopia
  4. 4.Johns Hopkins University Center for Communication ProgramsBaltimoreUSA
  5. 5.Addis Ababa UniversityAddis AbabaEthiopia
  6. 6.George Washington UniversityWashingtonUSA

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