Site factors may be more important than participant factors in explaining HIV test acceptance in the prevention of mother- to-child HIV transmission programme in Kenya, 2005 Abhijeet Anand 1,2 , Ray W. Shiraishi 3 , Abdullahi Ahmed Sheikh 4 , Lawrence H. Marum 3 , Omotayo Bolu 3 , Winfred Mutsotso 5 , Keith Sabin 6 , Robert Ayisi 4 and Theresa Diaz 3 1 Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA 2 Global Immunization Division, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, GA, USA 3 Global AIDS Program, National Center for HIV, Viral Hepatitis, STD and TB Prevention (NCHHSTP), CDC, Atlanta, GA, USA 4 Ministry of Health, National AIDS and STI Control Program (NASCOP), Nairobi, Kenya 5 Global AIDS Program, NCHHSTP, CDC, Nairobi, Kenya 6 HIV Department, World Health Organization, Geneva, Switzerland Summary objective To determine the role of participant factors on the acceptance of a Prevention-of-Mother- to-Child (PMTCT) HIV test programme in a situation with an opt-out testing strategy. methods We analysed antenatal clinic (ANC) HIV sentinel surveillance data. All 43 sites in the 2005 round of Kenya’s ANC surveillance offered opt-out PMTCT services and recorded if women were offered PMTCT HIV testing and whether they accepted or refused. Logistic regression was used to determine the role of participant-level factors on PMTCT acceptance. results During the period of sentinel surveillance, 13 026 women attended ANC and testing was offered to 12 030 women. Of those offered testing, 9690 (80.5%) accepted, with a large variation in the percent of acceptors by site. Age, residence and educational status were significant determinants of PMTCT acceptance. However, after adjusting for site none of the participant-level factors were sig- nificant determinants of PMTCT acceptance. conclusions Participant level factors were not significant determinants of PMTCT HIV test accep- tance after adjusting for sites. PMTCT programmes should collect and evaluate the role of site-level (provider and testing service) factors on PMTCT acceptance. Improvement of site-level factors could improve PMTCT uptake. keywords HIV / AIDS, PMTCT testing, Kenya, ANC surveillance, opt-out HIV testing Introduction The Joint United Nations Programme on HIV / AIDS (UNAIDS) estimates that each day 1800 children become infected with HIV, the majority through mother-to-child HIV transmission and the majority in sub-Saharan Africa (UNAIDS 2006). In 2005 in sub-Saharan Africa, <6% of pregnant women were offered services to prevent mother- to-child HIV transmission (PMTCT) (UNAIDS 2006). Since then there has been large scale-up of HIV testing services due to support by the President’s Emergency Plan for AIDS Relief, the Global Fund to fight AIDS, Tubercu- losis and Malaria and other donors. However, poor HIV testing coverage continues to be the most important factor hindering increase in coverage of PMTCT services (UNI- CEF 2007). HIV testing of pregnant women is a necessary first step to receive PMTCT interventions. In an opt-in testing strategy, women have to specifically request an HIV test. In contrast, with an opt-out testing strategy, testing is recommended to all women and all women are tested, unless they refuse testing. Studies have shown that routinely recommending HIV testing with the right to refuse testing (‘opt-out’) during the prenatal and intra- partum period is acceptable, feasible and results in a high coverage of HIV testing (Homsy et al. 2006; Perez et al. 2006; Creek et al. 2007b; Bolu et al. 2007) compared to when women must request HIV testing (‘opt-in’). Evalu- ations of HIV testing uptake in PMTCT programmes have focused on assessing the role of participant socio- demographic and behavioural factors of HIV testing and Tropical Medicine and International Health doi:10.1111/j.1365-3156.2009.02367.x volume 14 no 10 pp 1215–1219 october 2009 ª 2009 Blackwell Publishing Ltd 1215