ῌ,**/ The Japanese Society for AIDS Research

The Journal of AIDS Research

Original Research Report

Characteristics of Voluntary Counseling and Testing (VCT)
Acceptance among Pregnant Women
Attending an Antenatal Care Clinic
at Lerdsin Hospital, Bangkok, Thailand
Reiko SATO+, ,, -, Boonyong KEIWKARNKA,, Sirikul ISARANURUG,,
Junya PATTARA-ARCHACHAI., Hideki YANAI+ and Keiko TSUNEKAWA/+

TB/HIV Research project, the Research Institute of Tuberculosis, Japan : , ASEAN Institute of Health Development (AIHD), Mahidol University, Thailand : - Japan Oversee
Cooperation Volunteers (JOCV), JICA Zambia : . Faculty of Medicine, Thammasat University, Thailand : / Visiting Research Fellow, Centre for Health Economics, Chulalongkorn
University, Bangkok

Objective : Mother to child transmission (MTCT) accounts for the majority of HIV
infections among children. As it is necessary to know the HIV status of pregnant women to
implement the preventive measures against MTCT, Voluntary Counseling and Testing(VCT) is promoted as the entry point to the prevention of MTCT (PMTCT). Since VCTcoverage among pregnant women in Thailand is high compared with that in other countries,
it could be a model of an e#ective VCT service.
Materials and Methods : A cross-sectional study was conducted to illustrate characteristics
of VCT at an antenatal clinic in Lerdsin Hospital in Bangkok. The data was collected from-++ pregnant women in January ,**-, using a self-administered questionnaire.
Results : Factor analysis covered . aspects of VCT : +) Accessibility and quality ofservices, ,) Social circumstances, -) Personal concern and .) Decision making process.
Fourteen components were then extracted : +) Availability of services, ,) Low-cost accessibility, -) High-cost accessibility, .) Local support, /) Support from the government, 0)
People’s negative reaction, 1) Maturity of epidemic, 2) Concern about health, 3) Fear of
HIV testing result, +*) Recognition of HIV/AIDS as an unavoidable and problematic
disease, ++) Expectation for being saved from problems, +,) Inﬂuence from other people, +-)Role of counseling and +.) Time required to make a decision.
Conclusion : Signiﬁcant policy implications were : +) Integrating VCT into antenatal
service is recommended for PMTCT for its convenience and low cost, ,) Continuity of
prevention, care and treatment services for sero-positive mothers and their babies is important to increase VCT acceptance, -) As the reaction of people close is an important factor for
accepting VCT, pre- and post-test counseling should concentrate on increasing women’s
conﬁdence in making an informed choice about the test result and .) Allowing VCT clientsenough time to make a voluntary decision is important, together with the quality ofcounseling.
Key words : Voluntary Counseling and Testing (VCT), Mother-to-child transmission(MTCT), Factor analysis
The Journal of AIDS Research 1 : +-+῍+.*ῌ ,**/

Introduction
Correspondence : Hideki YANAI, MD, Dr. PH, ResearchInstitute of Tuberculosis, -῍+῍,. Matsuyama, Kiyose, Tokyo ,*.῍**,+, JapanFax : 2+῍.,.῍3,῍2,/2
Received November ,/, ,**. ; Accepted May ,-, ,**/

Mother-to-child transmission (MTCT) accounts forthe largest number of HIV infections in children below
the age of +/. According to the Joint United Nations
Programme on AIDS (UNAIDS) in ,**+, about ,.0+-+

῍ 1+ ῎

R Sato et al : Acceptance of VCT among Pregnant Women

million pregnant women were infected with HIV worldwide and more than /**,*** transmitted the virus totheir infants+῍. At the end of ,**+, the estimatednumber of children living with HIV/AIDS was ,.1
million and 2**,*** children were newly infected. In
other words, more than ,,*** children daily become
infected with HIV through MTCT+῍. The number ofdeaths of children due to HIV/AIDS was /2*,*** in,**+,῍.
There are e#ective interventions to prevent MTCT,
but to take advantage of the interventions, pregnant
women need to know their sero-status and they must
therefore have access to Voluntary Counseling andTesting (VCT),῍. However, since the majority of countries where HIV is highly prevalent are also the poorest,
VCT is often not widely available due to a lack ofresources. For VCT services to be prioritized and fornecessary resources to be provided for its development,
demonstrating the e#ectiveness of VCT is essential.
In Thailand, the estimated number of adults andchildren with HIV/AIDS at the end of ,**+ was
01*,*** including ,,*,*** women between +/ and .3
years old and ,+,*** children under +/ years old-῍.
HIV prevalence among pregnant women was +..ῌ in,**,.῍ and approximately +*,*** children are born at
risk for MTCT each year/῍. The estimated number of
AIDS orphans was ,3*,*** in ,**+-῍.
A programme launched in +331 including VCT for
women attending antenatal care, a short course ofantiretroviral drugs during pregnancy for HIV-positive
women and subsidies for breast milk for one year,
achieved a /*ῌ reduction in number of HIV-infectedchildren under four by +3330῍. In early ,***, theMinistry of Public Health established a national policy
on preventing MTCT1῍.
The latest study in ,**, showed that VCT acceptance
rate among pregnant women was 31ῌ in Thailand.῍,which was signiﬁcantly high compared with that inother countries2῍. Although there are many factors
a#ecting VCT acceptance, the high VCT acceptance
rate in Thailand is seen as an e#ect of the government’s
strong commitment in dealing with the HIV/AIDS
problem. It is said that Thailand is leading perinatal
HIV prevention programs not only in Southeast Asia
but also throughout the developing world3῍.
Although previous studies pointed out numerous
factors a#ecting VCT acceptance, no study has been
conducted to describe those factors with orders of
relevance, which gives useful information for policymaking for VCT implementation. Since the high VCTacceptance rate is regarded as a success of intervention,
it is meaningful to explore and summarize reasons forsuch success to share information with other countries
facing a similar problem. Hence, this study aimed to+-, ῌ 1, ῍

illustrate the characteristics of VCT acceptance among
pregnant women attending an antenatal care clinic at
Lerdsin Hospital in Bangkok, Thailand.

Materials and Methods
A cross-sectional study was conducted with -++ pregnant women who had accepted VCT and attended at
Lerdsin Hospital located in Bangkok City between +1th
and ,.th January ,**-. Although they were purposively
selected, only those who had agreed to participate in the
study were included.
Data collection tool
Data was collected using a self-administered questionnaire. The questionnaire was initially prepared in
English and then translated into Thai. A pretest of thequestionnaire had been conducted with -* pregnant
women at Lerdsin Hospital and some wordings of thequestionnaire had been corrected. The questionnaire
covered the following main three issues :+) Socio-demographic characteristics
Six items including age, residence, marital status,
employment status, educational level and family income
were collected.
,) Characteristics of VCT acceptance
Fifty-six variables related to VCT acceptance were
derived from the literature review. The variables weregrouped into . di#erent aspects of VCT : +) Accessibility and quality of services (+/ variables), ,) Social
circumstances (,* variables), -) Personal concern (++variables) and .) Decision-making process (+* variables). The answers had / levels and scores for thelevels were given as follows : ”Strongly agree”῎/points, “Agree”῎. points, “Not sure”῎- points, “Disagree”῎, points and “Strongly disagree”῎+ point.
The score was calculated for each variable and wastransformed into standardized scores for analysis.
Factor analysis was done for each group.
-) Knowledge
Eighteen questions about the study participants’knowledge of MTCT, VCT and the National Policy
were collected.
Factor analysis
Factor analysis is an analytical method which summarizes complex and diverse relationships among a setof observed variables by uncovering a new set of fewer
numbers of hypothetical components which express
what is common among the original variables. Less
important variables are excluded in the process andcorrelated variables are grouped to constitute one component. Factor analysis helps illustrate a given phe-The Journal of AIDS Research Vol. 1

nomenon with the fewer number of extracted components instead of dealing with many variables.
The result of factor analysis is given with factor
loadings, common variances and total variances.
Factor loading indicates the relationship between avariable and a component. The variables that havehigh factor loadings, which represent they are highly
correlated with one another, will be grouped together
and constitute one component. The component will be
named based on the constituent variables.
Common variance indicates the degree to which avariable can be explained only by the shared components. For example, if a common variance is 1*ῌ
(*.1), it means 1*ῌ is explained by the shared components but another -*ῌ is speciﬁc to the variable.
Total common variance shows the percentage thatshared components account for all of the variance in all
variables. When the total common variance is 1*ῌ
(*.1), the shared components can explain the speciﬁed
phenomenon by 1*ῌ of what all the remaining variables can.
A variable will be excluded either when +) it has low
factor loadings because it has less contribution to eachcomponent or ,) it has low common variance since thevariable cannot be explained by the shared components.

No. ,

,**/

will encourage pregnant women to accept VCT and v3)
Satisfaction with health services will encourage pregnant women to accept VCT. Although a wellfunctioning health system is essential as a basis for ane#ective VCT, the result implied that the study partici-

Table +

Socio-demographic characteristics of -++ pregnant
women who accepted VCT at an antenatal careclinic in Lerdsin Hospital, Bangkok, Thailand

Socio-demographic
characteristics

Frequency(n῏-++)

Percentage

ῐ,*

,,

14+

,*ῌ-/

,1,

214/

ῑ-/

+1

/4/

Age groups (years)

Mean῎SD῏,04/῎/4-Min4῏+1

Max4῏.,

Residence
In Bangkok

,3+

3-40

Outside of Bangkok

,*

04.

Single3,43

Married

,3/

3.43

1

,4-

Employed

,/2

2-4*

Unemployed

/,

+14*

No education,*40

Primary school

+-1

..4+

Secondary school

2*

,/41

High school

/3

+34*

College/University or above

--

+*40

ῐ1,***

1.

,-42

1,***ῌ3,333

/3

+34*

+*,***ῌ+.,333

3/

-*40

ῒ+/,***

2-,041

Marital status

Results
Socio-demographic characteristics (Table +)Age of the respondents ranged between +1 and .,years old with the mean of ,0./ years. The majority ofthem were between ,* and -/ years old (21./ῌ).
Approximately 3.ῌ of the respondents lived in Bangkok. The majority of them were married (3..3ῌ).
Nearly half of the respondents (...+ῌ) had primaryschool education, and a quarter (,/.1ῌ) had secondary
school education. There were , pregnant women who
had no education. Monthly family income ranged between -,*** Baht and /*,*** Baht, with a median of+*,*** Baht. Since the income distribution was
skewed, the median and the quartile values were used
for grouping.
Factor analysis on characteristics on VCT acceptance
Factor analysis I : Accessibility and quality of services(Table ,)Four variables related to the health system which had
low factor loadings or low common variances were
excluded from the analysis. These were : variable + (v+) Well-established health service system in the country
will encourage pregnant women to accept VCT, v,)
Safe delivery will encourage pregnant women to accept
VCT, v1) Providing enough information about VCT

Separated/divorced
Employment status

Educational level

Family income (Baht/month)

Median῏+*,***

Min4῏-,***

Max4῏/*,***+--

ῌ 1- ῍

R Sato et al : Acceptance of VCT among Pregnant Women

Table ,

Factor analysis I (Accessibility and quality of services)
Factor loadings

Variables

Commonvariance

Comp +

Comp ,

Comp -

v /4 Continuity of care from hospital for HIV῎*42+0

῏*4+,,

῏*4++.

*403.

v .4 Availability of medical care for HIV῎women*42+-

῏*4+/*

῏*4+--*41*+v -4 Availability of ARV for HIV῎women*4132

῏*4*3*

῏*4+.2*4001

v 04 Availability of ARV for children of HIV῎*4/2*

῏*4.21

*4++.

*4/20

v 24 Availability of trained health personnel*4/0+

῏*4..+

*4+*-

*4/+3

v++4 VCT available at all health facilities*4+--

῏*41.3῏*4*,2*4/13

v+.4 VCT provided at low cost

*4*33

῏*402+

῏*4.,,*40/,

v+-4 VCT provided for free of charge*4+/-

῏*400.

῏*4.,**40.+

v+*4 O#ering VCT at ANC*4.-3

῏*4///

*4*3+

*4/*3

v+/4 VCT provided at high cost

*4*/1

῏*4*3,

῏*42+.

*401/

v+,4 Far distance to VCT*4*1,

῏*4*01

῏*42+**4000

ῌ Total variance

,04+

,*40

+04*

0,40

pants did not recognize it as important when making
the decision whether to accept VCT or not.
Three components were created by grouping thehighly correlated variables. The ﬁrst component consisted of ﬁve variables : v-) Availability of ARV for
sero-positive pregnant women will encourage them toaccept VCT, v.) Availability of medical care for seropositive pregnant women will encourage them to accept
VCT, v/) Continuity of care from the hospital for
sero-positive pregnant women will encourage them toaccept VCT, v0) Availability of ARV for children bornto sero-positive mothers will encourage pregnant
women to accept VCT and v2) Availability of trained
health personnel who take care of VCT will encourage
pregnant women to accept VCT. All the variables
concern the availability of services, hence the ﬁrst component was named “Availability of services”.
The second component consisted of four variables : v+*) Providing VCT at an antenatal care clinic willencourage pregnant women to accept VCT, v++) If
VCT is available at all health facilities, it will encourage
pregnant women to accept VCT, v+-) VCT provided
free of charge will encourage pregnant women to accept
VCT and v+.) Low cost will encourage pregnant
women to accept VCT. If VCT is provided at all
facilities, pregnant women will be able to select the mostconvenient place for them which will result in reducing
the transportation cost. VCT at an antenatal careclinic is also convenient for pregnant women as they do
not need extra transportation for getting the VCT service. As all the variables will lead to low cost, thesecond component was named “Low cost accessibility”.
+-. ῌ 1. ῍

The third component consisted of two variables : v+,) If VCT is provided at a distant place, it will discourage pregnant women and v+/) High cost will discourage pregnant women from accepting VCT. As
these two variables will lead to high cost, the component was named “High cost accessibility”.
Factor analysis II : Social Circumstances (Table -)In the process of analysis, four variables were excluded : v+) Advice from husband/partner to access
VCT will encourage pregnant women to accept VCT, v
0) Being able to receive emotional support when the
result is positive will encourage pregnant women to
accept VCT, v+.) the Government’s responsibility oftackling HIV/AIDS problem will encourage pregnant
women to accept VCT and v+0) Providing VCT to all
pregnant women by the government will encouragethem to accept VCT.
Four components were created. The ﬁrst component consisted of six variables : v,) Husband or
partner’s accompaniment will encourage pregnant
women to accept VCT, -) Support from family
members will encourage pregnant women to accept
VCT, v.) Support from community members will encourage pregnant women to accept VCT, v/) Having
someone to talk to about VCT will encourage pregnant
women to accept VCT, v1) Being able to receive ﬁnancial support when the result is positive will encourage
pregnant women to accept VCT and v2) Recognition of
HIV/AIDS problem will encourage pregnant women to
accept VCT. These variables are related to support
from people who are close to pregnant women. Rec-

The Journal of AIDS Research Vol. 1

Table -

No. ,

,**/

Factor analysis II (Social circumstances)
Factor loadings

Variables

Commonvariance

Comp +

Comp ,

Comp -

Comp .

v /4 Talk with someone about HIV test

*41.1

*4+03

῏*4*0*

*4*,,

*4/3+

v .4 Support from community people

*41+,

*4+2+

῏*4*+1

*4*33

*4//*

v ,4 Husband/partner’s accompanying

*4011

*4+.0

*4*+3

*4*-3

*4.2,

v 14 Financial support when HIV῎

*401*

*4+1-

*4*03

*4+0-

*4/++

v -4 Support from family members

*40.2

*4,+3

*4*.,

*4+13

*4/*,

v 24 Recognition of HIV/AIDS

*4/.+

*4,33

*4*01

*4--/

*4.32

v+34 ARV to babies of HIV῎by Gov4

*4+13

*42+/

*4*1+

*4*21

*41+*

v+14 ARV to HIV῎by Gov4

*4,*0

*4102

῏*4*.,

῏*4*2+*40.*

v,*4 Medical care to HIV῎babies by Gov4

*4,/2

*4101

*4*+2

*4+0.

*402-

v+24 Medical care to HIV῎by Gov4

*4+03

*41/3

*4*10

*4+-+

*40,2

v+/4 Cooperation bet4 Gov4 and NGOs

*4-2/

*4/,*

*4*-1

*4+.-

*4..*

v++4 Fear of discrimination by family*4*+1

῏*4**.

*43,0

῏*4*,3*42/3v+,4 Fear of discrimination by neighbors

*4*+1

*4*.0

*43,/

*4**-

*42/1

v+-4 Stigmatization and discrimination

*4*-+

*4*1.

*4202

῏*4++.

*411-

v 34 Seriousness of HIV/AIDS problem

*4+/1

*4*-0

῏*4*2*

*42/1

*4101

v+*4 High HIV/AIDS prevalence

*4,,.

*4+3,

῏*4*1,

*411.

*403,

ῌ Total variance

+34,

+241

+/41

+*4+

0-40

ognition of HIV/AIDS problem will let people give
support to those who are su#ering from the disease.
The ﬁrst component was hence named “Local support”.
The second component consisted of ﬁve variables : v+/) Cooperation between the government and NGOs
will encourage pregnant women to accept VCT, v+1)
Providing ARVs for sero-positive pregnant women by
the government will encourage them to accept VCT, v+2) Providing medical care for sero-positive pregnant
women by the government will encourage them toaccept VCT, v+3) Providing ARVs for babies born tosero-positive mothers by the government will encourage
pregnant women to accept VCT and v,*) Providing
medical care for babies born to sero-positive mothers by
the government will encourage pregnant women to
accept VCT. The results implied that the government’s
role in providing services such as ARVs and medicalcare for both sero-positive mothers and their babies had
an inﬂuence on VCT acceptance. The second component was named “Support from the government”.
The third component consisted of three variables : v++) Fear of discrimination by family members will
discourage pregnant women from accepting VCT, v+,)Fear of discrimination by neighborhoods will discourage pregnant women from accepting VCT and v+-)
Stigmatization and discrimination towards HIV/AIDS

among people in the country will discourage pregnant
women from accepting VCT. These variables concern
the negative reaction to HIV positive patients and thecomponent was named “People’s negative reaction”.
The forth component consisted of two variables : v3)
Recognition of the seriousness of the HIV/AIDS problem will encourage pregnant women to accept VCT andv+*) High HIV/AIDS prevalence in the country willencourage pregnant women to accept VCT. This component was named “Maturity of epidemic”.
Factor analysis III : Personal Concern (Table .)One variable concerning mandatory HIV testing (v++) was excluded and four components were groupedfrom the remaining +* variables.
The ﬁrst component consisted of three variables : v+)
Concern about a pregnant woman’s own health willencourage her to accept VCT, v,) Concern about apregnant woman’s baby’s health will encourage her toaccept VCT and v-) Concern about sero-status willencourage her to accept VCT. The component wasnamed “Concern about health”.
The second component consisted of two variables : v/) People with HIV/AIDS will be stigmatized and v3)
Fear of knowing the results of HIV testing will discourage pregnant women from accepting VCT. These two+-/ῌ 1/ ῍

R Sato et al : Acceptance of VCT among Pregnant Women

Table .

Factor analysis III (Personal concern)
Factor loadings

Variables

Commonvariance

Comp +

Comp ,

Comp -

Comp .

v ,4 Concern about baby’s health*4200

῎*4**/

῎*4*1-

῎*4*/-*41/2

v +4 Concern about own health*42/0

῎*4**2

῎*4*.*

῎*4*,2*41-0

v -4 Concern about own sero-status*41//

῎*4*+3῎*4*.-

῎*4,,3*40//v /4 PLWHA will receive stigma

῎*4*,+*42*3

῎*4+++

*4++,

*402*

v 34 Fear of the result of HIV test

῎*4*-2*41.1

῎*4*,+

῎*4-,2

*4002

*4+/3

῎*4+,,

῎*42+1῎*4,-/*410-

῎*4*1/*4./3

῎*40*+

*4++2

*4/3+

v 24 MTCT can cause trouble in family

*4*1-

*4.2*

῎*4/1+

῎*4*-2*4/0-

v 14 MTCT can be prevented*4*23

῎*4*02

῎*4*.1῎*42/-*41.,

v+*4 Secrecy of the results of HIV test

*4,..

*4-//

῎*4+/*

῎*4/11*4/.+

ῌ Total variance

,+43

+24*

+.4*

+-4+

014*

v .4 Everyone is at risk of infectionv 04 AIDS is mortal diseasevariables concern pregnant women’s fear of the test
result and its negative consequences. Hence, the second
component was named “Fear of HIV testing result”.
The third component consisted of three variables : v.) Everyone runs the risk of being infected with HIV, v
0) AIDS is a mortal disease and v2) MTCT will cause
trouble in the family. These variables mention that
HIV/AIDS is a deadly disease with a potential foreverybody to contract it. The third component wasnamed “Recognition of HIV/AIDS as an unavoidable
and problematic disease”.
The forth component consisted of two variables : v1)
MTCT can be prevented and v+*) Secrecy of the resultsof HIV testing will encourage pregnant women to
accept VCT. The second variable is related to theperception that conﬁdentiality will prevent further problems such as stigmatization and discrimination. The
component was named “Expectation of being saved
from the problems”.
Factor analysis IV : Decision Making Process (Table /)One variable concerning opinions from health personnel (v1) was excluded and three components weregrouped.
The ﬁrst component consisted of four variables : v.)
Opinion of the husband/partner of a pregnant woman
will inﬂuence her decision on VCT, v/) Opinion of thefamily of a pregnant woman will inﬂuence her decision
on VCT, v0) Opinion of the friends of a pregnant
woman will inﬂuence her decision on VCT and v2)
Other pregnant women’s decision to accept VCT willinﬂuence a pregnant woman’s decision on VCT. The
results implied that a pregnant woman’s decision on+-0 ῌ 10 ῍

VCT acceptance was inﬂuenced by the opinions of her
friends and by other pregnant women’s decisions.
Opinion from husbands or partners and family
members came as the next important factor. On theother hand, ‘opinions from health personnel’ was excluded by the analysis. The ﬁrst component wasnamed “Inﬂuence from other people”.
The second component consisted of three variables : v-) Belief in self-decision-making will inﬂuence pregnant
women to accept VCT, v3) A pregnant woman should
decide whether she accepts VCT before counseling andv+*) A pregnant woman should decide whether she
accepts VCT after receiving proper counseling. Vand v3 are both about decisions made by pregnant
women themselves. V3 and v+* are about the timingof decision making in relation to counseling. The
result implied that counseling inﬂuences pregnant
women’s decision on accepting HIV testing. This
component was named “Role of counseling”.
The third component consisted of two variables : v+)
Adequate time to consider will inﬂuence pregnant
women to make a voluntary decision for VCT acceptance and v,) Enough time to consider VCT will inﬂuence pregnant women’s decision making. Both variables were about necessary time to consider VCT. The
third component was named “Time required to make adecision”.
The characteristics of VCT acceptance were illustrated with the +. components categorized by four
aspects of the service uptake as follows :I) Accessibility and quality of services+) Availability of services,) Low-cost accessibility

The Journal of AIDS Research Vol. 1

Table /

No. ,

,**/

Factor analysis IV (Decision making process)Factor loadings

Variables

Commonvariance

Comp +

Comp ,

Comp -

v 04 Opinion of friends*42/+

῎*4*,,

*4*++

*41,0

v 24 Other pregnant women’s decision*4021

῎*4*.-

*4,30

*4/0+

v .4 Opinion of husband/partner*40.+

῎*4-2*

*4,*,

*4/31

v /4 Opinion of family members*40*+

῎*4,.-

*4-/*

*4/.-

v+*4 Decide after receiving proper counseling*4*13

῎*42,,

*4*1/

*4021

v 34 Pregnant women should decide by herself*4*10

῎*41*2

*4+21

*4/.,

v -4 Belief in self-decision-making*4.-.

῎*4/-+

*4+..

*4.3+

v ,4 Enough time to consider about HIV testing*4,,0῎*4*3/

*420,

*42*.

v +4 Adequate time to consider about HIV testing*4+2/

῎*4,/.

*42+.

*410,

ῌ Total variance

,/4+

+34-

+34+

0-4/

-) High-cost accessibilityII) Social circumstances.) Local support/) Support from the government0) People’s negative reaction
1) Maturity of epidemicIII) Personal concern
2) Concern about health3) Fear of HIV testing result+*) Recognition of HIV/AIDS as an unavoidable
and problematic disease++) Expectation of being saved from problems
IV) Decision making process+,) Inﬂuence from other people+-) Role of counseling+.) Time required to make a decision
Knowledge (Table 0)
Women were relatively knowledgeable about the
VCT service provided by the government. However,they were less informed about the availability of treatment and care for HIV-positive mothers and infants.
Only /.2ῌ of the respondents knew that the seropositive mothers could not continue to receive ARV
free of charge after the delivery. A few (3.1ῌ) knew
the universal health insurance policy did not include theprovision of ARVs at the time of the study. More than2*ῌ of respondents knew about neither the potential
HIV infection through breastfeeding, nor the service ofproviding infant formula by the government. Nearly
1*ῌ of the respondents were aware that the infection
could occur during pregnancy.

Discussion
Factor analysis summarized the /0 variables by extracting shared components holding important variables for VCT acceptance. Instead of dealing withmany variables, the smaller number of the extracted
components are used to understand necessary factors
for an e#ective implementation of VCT.
This study is limited in its method since the extracted
components relied on the researchers’ view. In addition, the /0 variables were purposely derived from theliterature review, so the study might not cover all
aspects of VCT. Furthermore, the variables weregrouped into four aspects of VCT based on the
researchers’ hypothesis. If the grouping was donewith another assumption, the result might have been
di#erent. The study participants were those who accepted VCT. Therefore, the result lacks representation of those who did not accept VCT.
The remaining variables which constitute the +. components imply important factors for VCT implementation. Four important implications were identiﬁed
from the remaining variables as follows.
First, integrating VCT into antenatal service isrecommended for PMTCT because of its convenienceand low cost.
Cost is thought to be one of the most importantfactors which inﬂuences acceptance of VCT. On one
hand, high cost of VCT discourages poor people fromaccessing it+*῍. On the other, client fees are considered
a way to attach a value to the services and bearing thecost by themselves may motivate people to go back to+-1

ῌ 11 ῍

R Sato et al : Acceptance of VCT among Pregnant Women

Table 0Knowledge
Correct answers

Statements

Frequency(n῏-++)

Percentage

Knowledge about MTCT
+4 Mother will infect her baby with HIV during pregnancy

,+/

034+

,4 Baby will be infected with HIV through breastfeeding-4 All babies of HIV῎ mothers will be infected with HIV

,+
+,,

042
-243

.4 There are drugs which reduce the chance of MTCT

+*3

-/4+

/4 Avoidance of breastfeeding can reduce MTCT

++/

-14*

04 HIV testing looks for the presence of HIV in the blood
14 It takes - months after being infected to detect HIV

+1+
2,

//4*
,04.

24 Early detecting of HIV infection in pregnancy allows appropriate treatment in order toreduce MTCT

,,,

1+4.

34 Early detecting of HIV infection in pregnancy enables the woman to take decisions on
continuation or termination of the pregnancy and on future fertility+*4 HIV testing requires a small amount of blood

,**

0.4-

+2+

/24,

Knowledge about the national program++4 In Thailand, VCT are available for all pregnant women+,4 ARV will be provided to all HIV῎ pregnant women

+3.
2-

0,4.
,041

+-4 ARV will be provided to all infants of HIV῎ mothers+.4 Infant formula will be provided to infants of HIV῎ mothers for +, months+/4 Infants of HIV῎ mothers will have HIV testing+04 Thai government will provide proper medical care and treatment for mothers and children+14 All HIV῎ mothers will be able to continue receiving ARV free of charge after delivery+24 Treatment of HIV/AIDS is included into -* Baht scheme (Universal coverage policy)

11
.3
,//
+1.
+2
-*

,.42
+/42
2,4*
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/42
341

Knowledge about VCTthe VCT centre for their results. It can work to discourage inappropriate utilization++῍. The study indicates that the high levels of acceptance of VCT at anantenatal care clinic setting can be explained by the low
total cost. Location of VCT centres is also an important issue to consider when VCT is set up. If the VCTfacility is far from clients’ houses, people need moremoney to reach VCT services and as the transportsystem is often poor in developing countries, it may
reduce the up-take of VCT.
One of the biggest barriers to accepting VCT is a fearof disclosure to their partners, other family members
and neighbors. A study suggests that the fear forces
people select VCT facilities far from their home+,῍.
VCT services o#ered at antenatal care clinics is convenient for pregnant women since pregnant women canhave tests without making others suspicious. In addition, the total cost for the service will be low because
pregnant women do not have to pay extra money for
traveling to a special center for VCT.
+-2 ῌ 12 ῍Although making VCT services available at every
health facility might not be feasible in some developing
countries, integrating it into the routine antenatal careservice is viable and is recommended as part of
PMTCT.
Secondly, ensuring the continuity of prevention, careand treatment services for sero-positive mothers andtheir babies is important to increase VCT acceptance.
In developing countries, lack of ARVs and medical
and social support services for people with HIV isreported as an obstacle to increasing the uptake of
VCT++ῌ+-῍. Although VCT is recommended as an opportunity to encourage behaviour change to prevent
further infections and positive living even when there
are no prevention and care strategies+.῍, it was impliedin this study that provision of treatment and care services is important to motivate people to access the VCTservice. It is said that VCT services without any support will enhance the su#ering of sero-positive people+.῍.
Although general health care services are less

The Journal of AIDS Research Vol. 1prioritized in this study, a well-functioning health caresystem is necessary since it is the basis of an e#ective
VCT implementation. The health care system in Thailand has been established and has been prepared for
VCT implementation. Availability of general healthcare services should be considered when VCT is implemented in other developing countries.
It is recommended that response to MTCT should be
extended to include prevention, care and treatment
services to the sero-positive mothers and their children
for a longer term.
Thirdly, the reaction of people close to the pregnant
women would be an important factor for accepting
VCT. The study indicated that the perceived reactions
from people close to pregnant women inﬂuence VCT
uptakes. Access to VCT and other services o#ered tosero-positive people makes it virtually impossible forthem to keep their status secret from their families andpeople in the community. Fear of stigmatization by
their families, friends, and communities discourages
people from accepting VCT+-, +/, +0῍. Counseling, if
done in the right way, can help women to feel more
conﬁdent to disclose their status or can even help themlearn that there are options of not disclosing. Therefore, pre- and post-test counseling should concentrateon increasing women’s conﬁdence in making informed
choices about the test result including disclosing it totheir partners and families. In addition, the study
indicated that the decision on VCT acceptance should
be made voluntarily. There is no justiﬁcation whatsoever to force women to accept VCT against their will.
Finally, allowing enough time to make a voluntarydecision whether or not to accept VCT is also important, together with the quality of counseling. As thecounseling is an essential element for a pregnant woman
to make a voluntary decision on VCT, its quality must
be maintained high. Unless women receive adequate
and appropriate counseling to understand the beneﬁts
of testing, it may not be translated into beneﬁcial outcomes for the mother and child+,῍. Counseling is also
critical for supporting the e#ectiveness of medical interventions.
Acknowledgement : The authors would like to thank thedirectors and all nursing sta# at Lerdsin Hospital for
permitting us to conduct this study and for theircollaboration. Our special thanks go especially to Ms.
Sangsuree Tassanapoonchai for her support and valuable counsel during the data collection. We are deeply
indebted to Ms. Sidaa Ratnawan, Ms. Pornnipa Kumsuk
and Ms. Saengjun Nongna for their assistance in datacollection. This study was conducted as the ﬁrst
author’s dissertation at Mahidol University. Sincere
gratitude and deep appreciation go to the members of the

No. ,

,**/

dissertation advisory committee, for their continued support and understanding.

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