title: Program synergies and social relations: implications of integrating HIV testing and counselling into maternal health care on care seeking.
abstract: BACKGROUND
  Women and children in sub-Saharan Africa bear a disproportionate burden of HIV/AIDS. Integration of HIV with maternal and child services aims to reduce the impact of HIV/AIDS. To assess the potential gains and risks of such integration, this paper considers pregnant women's and providers' perceptions about the effects of integrated HIV testing and counselling on care seeking by pregnant women during antenatal care in Tanzania.
  
  
  METHODS
  From a larger evaluation of an integrated maternal and newborn health care program in Morogoro, Tanzania, this analysis included a subset of information from 203 observations of antenatal care and interviews with 57 providers and 190 pregnant women from 18 public health centers in rural and peri-urban settings. Qualitative data were analyzed manually and with Atlas.ti using a framework approach, and quantitative data of respondents' demographic information were analyzed with Stata 12.0.
  
  
  RESULTS
  Perceptions of integrating HIV testing with routine antenatal care from women and health providers were generally positive. Respondents felt that integration increased coverage of HIV testing, particularly among difficult-to-reach populations, and improved convenience, efficiency, and confidentiality for women while reducing stigma. Pregnant women believed that early detection of HIV protected their own health and that of their children. Despite these positive views, challenges remained. Providers and women perceived opt out HIV testing and counselling during antenatal services to be compulsory. A sense of powerlessness and anxiety pervaded some women's responses, reflecting the unequal relations, lack of supportive communications and breaches in confidentiality between women and providers. Lastly, stigma surrounding HIV was reported to lead some women to discontinue services or seek care through other access points in the health system.
  
  
  CONCLUSIONS
  While providers and pregnant women view program synergies from integrating HIV services into antenatal care positively, lack of supportive provider-patient relationships, lack of trust resulting from harsh treatment or breaches in confidentiality, and stigma still inhibit women's care seeking. As countries continue rollout of Option B+, social relations between patients and providers must be understood and addressed to ensure that integrated delivery of HIV counselling and services encourages women's care seeking in order to improve maternal and child health.
authors.affiliation: International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. sjan@jhu.edu.
authors.forename: Selena J
authors.initials: SJ
authors.lastname: An
authors.affiliation: International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. ageorg22@jhu.edu.
authors.forename: Asha S
authors.initials: AS
authors.lastname: George
authors.affiliation: International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. alefevre@jhsph.edu.
authors.forename: Amnesty
authors.initials: A
authors.lastname: LeFevre
authors.affiliation: Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, PO Box 65015, Dar es Salaam, Tanzania. rcmpembeni@gmail.com.
authors.forename: Rose
authors.initials: R
authors.lastname: Mpembeni
authors.affiliation: Department of Behavioural Sciences, Muhimbili University of Health and Allied Sciences, PO Box 65015, Dar es Salaam, Tanzania. ihmosha@yahoo.co.uk.
authors.forename: Idda
authors.initials: I
authors.lastname: Mosha
authors.affiliation: International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. dmohan3@jhmi.edu.
authors.forename: Diwakar
authors.initials: D
authors.lastname: Mohan
authors.affiliation: International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. ayang@jhsph.edu.
authors.forename: Ann
authors.initials: A
authors.lastname: Yang
authors.affiliation: International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. jchebet@jhsph.edu.
authors.forename: Joy
authors.initials: J
authors.lastname: Chebet
authors.affiliation: Jhpiego, Dar es Salaam, Tanzania. chrisostom.lipingu@jhpiego.org.
authors.forename: Chrisostom
authors.initials: C
authors.lastname: Lipingu
authors.affiliation: Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, PO Box 65015, Dar es Salaam, Tanzania. jkillewo@yahoo.co.uk.
authors.forename: Japhet
authors.initials: J
authors.lastname: Killewo
authors.affiliation: International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. pwinch@jhu.edu.
authors.forename: Peter
authors.initials: P
authors.lastname: Winch
authors.affiliation: International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA. abaqui@jhu.edu.
authors.forename: Abdullah H
authors.initials: AH
authors.lastname: Baqui
authors.affiliation: Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, PO Box 65015, Dar es Salaam, Tanzania. kilewo1950@gmail.com.
authors.forename: Charles
authors.initials: C
authors.lastname: Kilewo
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara; D003219:Confidentiality; D003376:Counseling; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D036861:Delivery, Obstetric; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006801:Humans; D007407:Interviews as Topic; D008403:Mass Screening; D008427:Maternal Health Services; D008429:Maternal Welfare; D008875:Middle Aged; D011247:Pregnancy; D011369:Professional-Patient Relations; D036301:Qualitative Research; D012424:Rural Population; D013636:Tanzania; D055815:Young Adult