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Socio-demographic associations of HIV among women attending antenatal care in selected rural primary care facilities in South Africa’s Eastern Cape province

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Socio-demographic associations of HIV among women attending antenatal care in selected rural primary care facilities in South Africa’s Eastern Cape province

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Background To effectively reduce vertical HIV transmission requires a reduction of HIV prevalence and incidence among pregnant women and a full understanding of its epidemiology. The study aimed to determine the prevalence of HIV among women attending antenatal care and further determine spousal support during antenatal care attendance in rural areas in Eastern Cape province, South Africa. Methods A Cross-sectional study of women attending antenatal care in four Primary Care facilities was conducted using an interviewer-administered questionnaire which collected information on socio-demographic characteristics and medical history. Binomial logistic regression analyses were used to determine factors associated with HIV and to estimate the prevalence ratio (PR). The 95% confidence interval (95%CI) is used for precision of estimates; p≤0.05 for statistical significance. Results A total of 343 participants were included in the final analysis. The antenatal HIV prevalence was 38.2% (95%CI: 33.2–43.9). For 75% of the women, the HIV diagnosis was made 141 days before the date of the interview (median=77 days, interquartile range=42–141 days). Participants between the age of 30 to 39 years were 50% more likely to be HIV positive compared to those who were between the age of 20 to 29, these differences were statistically significant (PR=1.5; p-value=0.001). Furthermore, self-employed women were 30% less likely to be HIV positive when compared to unemployed participants, this was also statistically significant (PR=0.7; p-value< 0.0001). Conclusion Despite a 100% antenatal HIV testing rate, the antenatal HIV prevalence remains high in this population, coupled with no spousal attendance in antenatal care. It is important to move beyond awareness about the HIV status to actionable strategies of reducing the HIV incident cases. It is therefore important to remain vigilant and monitor mother-to-child transmission that could be associated with this increased prevalence.
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R E S E A R C H A R T I C L E Open Access
Socio-demographic associations of HIV
among women attending antenatal care in
selected rural primary care facilities in
South Africas Eastern Cape province
Sikhumbuzo A. Mabunda
1,2*
, Khuthala Sigovana
2
, Wezile Chitha
3
, Teke Apalata
4
and Sibusiso Nomatshila
2
Abstract
Background: To effectively reduce vertical HIV transmission requires a reduction of HIV prevalence and incidence
among pregnant women and a full understanding of its epidemiology. The study aimed to determine the
prevalence of HIV among women attending antenatal care and further determine spousal support during antenatal
care attendance in rural areas in Eastern Cape province, South Africa.
Methods: A Cross-sectional study of women attending antenatal care in four Primary Care facilities was conducted
using an interviewer-administered questionnaire which collected information on socio-demographic characteristics
and medical history. Binomial logistic regression analyses were used to determine factors associated with HIV and
to estimate the prevalence ratio (PR). The 95% confidence interval (95%CI) is used for precision of estimates; p0.05
for statistical significance.
Results: A total of 343 participants were included in the final analysis. The antenatal HIV prevalence was 38.2%
(95%CI: 33.243.9). For 75% of the women, the HIV diagnosis was made 141 days before the date of the interview
(median=77 days, interquartile range=42141 days). Participants between the age of 30 to 39 years were 50% more
likely to be HIV positive compared to those who were between the age of 20 to 29, these differences were
statistically significant (PR=1.5; p-value=0.001). Furthermore, self-employed women were 30% less likely to be HIV
positive when compared to unemployed participants, this was also statistically significant (PR=0.7; p-value< 0.0001).
Conclusion: Despite a 100% antenatal HIV testing rate, the antenatal HIV prevalence remains high in this
population, coupled with no spousal attendance in antenatal care. It is important to move beyond awareness about
the HIV status to actionable strategies of reducing the HIV incident cases. It is therefore important to remain vigilant
and monitor mother-to-child transmission that could be associated with this increased prevalence.
Keywords: HIV, Antenatal, Prevention of mother-to-child transmission or PMTCT, South Africa
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* Correspondence: smabunda@georgeinstitute.org.au
1
The George Institute for Global Health and Research, University of New
South Wales, Level 5 1 King Street, Sydney, Newtown NSW 2042, Australia
2
Department of Public Health, Walter Sisulu University, Mthatha, South Africa
Full list of author information is available at the end of the article
Mabunda et al. BMC Infectious Diseases (2021) 21:61
https://doi.org/10.1186/s12879-020-05744-7
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Background
Accounting for almost 25.5% of the total disease burden,
South Africas HIV disease burden is four times higher
than that of high-income countries [13]. In 2018, this
translated to an estimated HIV population prevalence of
13.3% (~ 7.7 million people) [4]. The corresponding
prevalence in women of reproductive age (1549) was
20.4% [4]. More than a decade since the implementation
of the Prevention of Mother-to-Child Transmission
(PMTCT) programme of HIV, more than 90% of
pregnant women are said to know their HIV status, the
percentage of women living with HIV accessing anti-
retroviral treatment is estimated to have increased from
65% in 2010 to 87% in 2018 and there has been an 84%
reduction in HIV infected newborns [49].
However, despite these strides and advances in HIV
care including universal test and treat [10,11], there is
still persistence of incident maternal and newborn HIV
infections [49]. Vertical transmission of HIV from
mother to child can take place during pregnancy, deliv-
ery and lactation [12]. The World Health Organization
(WHO) European regions especially the Eastern and
Central sub-regions reported an increase of HIV infec-
tion in infants and children during the perinatal period
from 347 to 494 per 1000 live births between the years
2004 and 2011 [13,14]. It is not clear what the rates are
currently.
In 2015, the estimated national HIV antenatal preva-
lence for South Africa was 30.8%, which is the highest
estimate recorded in the preceding 5-years [15]. Even
though high in the same period, the Eastern Cape prov-
ince exhibited a decline in its antenatal HIV prevalence
where it showed signs of stabilisation since 2005, having
increased by only 0.7% from 1990 to 2015 [15]. Over the
5-year period (20112015), the point prevalence esti-
mate reached a peak in 2013 and 2014 at 31.4% (95%CI:
29.433.5%); and declined by 1.2% in 2015 to 30.2% [15].
In women, the HIV risk has always been known to be
decreasing with increasing age [13,1417]. According
to Stats SA [17], approximately 20% of South African
women in their reproductive years (1549 years) are
HIV positive; however, HIV prevalence among those
aged 1524 has declined over time from 7.3% in 2002 to
4.6% in 2017 [17]. A previous 10-year trends analysis
(2003 to 2013) in South Africas KwaZulu-Natal Prov-
ince among pregnant women previously showed declin-
ing HIV prevalences among teenagers and increased
significantly among women 30 years and older [18].
Such high prevalences are of concern as they hinder
efforts for an HIV free generation. These high HIV prev-
alences have been previously associated with economic
dependence on the partner, age disparities of partner(s),
sex under the influence of alcohol, inconsistent condom
use, and having multiple sexual partners [19,20].
Effective HIV prevention among women in antenatal
care therefore needs incorporation of the biopsychoso-
cial approach to HIV care [19].
To effectively reduce the HIV incidence in newborns,
requires an increased HIV testing uptake among preg-
nant women, a reduction of HIV prevalence amongst
pregnant women, a suppressed viral load and a full un-
derstanding of the HIV epidemiology among pregnant
women. Every good policy needs continued monitoring,
comparisons from different implementation sites and
sharing of lessons that will lead to refinement [21]. With
all the policy changes in HIV care, assumptions are that
the epidemiology of HIV would have also been affected,
e.g. reduction in incidence, improved testing, reduced
stigma, etc. This has however, been found to not have
been the case as demonstrated by the increasing HIV
prevalences among pregnant women and the inability to
achieve an HIV free generation as yet [58,18,19,22].
The research aimed to determine the HIV antenatal
prevalence, socio-demographic associations of HIV and
the extent of the male partner attendance of antenatal
care. Study findings will provide valuable information to
health providers and will assist in prioritising, planning
and strengthening of the PMTCT programme.
Methods
Study design
This quantitative cross-sectional study included all preg-
nant women who had at-least one antenatal visit, who
used antenatal care services at the OR Tambo and Chris
Hani Districts in the Eastern Cape Province, South Af-
rica between March and November 2016. The period of
enrolment was chosen to ensure that all women had
been offered at least one HIV test (including those who
refused) and had results available in their antenatal care
records. Furthermore, this ensured that their partners
had a chance for at-least one antenatal visit before inter-
views. The HIV status of initially negative participants
was re-assesed at 3437 weeks of pregnancy to ascertain
a change in status from the initial interview. HIV posi-
tive participants were further recruited into a cohort
study for the HIV status of their newborns to be estab-
lished at 6 & 10 weeks. However, this article is only lim-
ited to findings on the HIV status of women attending
antenatal care and its socio-demographic determinants.
Study setting
The Eastern Cape Province is one of nine of South Afri-
cas Provinces. This is the Province with the second big-
gest surface area, the third most populous and the most
rural with eight health districts [23]. Two of these (OR
Tambo and Chris Hani) were purposefully selected for
this study due to being the districts with the second and
third highest HIV prevalences in the Eastern Cape
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Province [24]. Two facilities from each of these two dis-
tricts were purposefully selected due to the high head-
counts [24]. The province was chosen for this study due
to its rurality, size and high HIV prevalence.
Study design, population and sampling
Study Participants were recruited from four community
health centres. Participants under the age of 18 were in-
cluded after providing written consent from both them-
selves and their parents or guardians. All other pregnant
participants issued a voluntary informed, written consent
to participate.
All pregnant women attending antenatal care who
were present in the facility on the day of the visit were
recruited into the study if they met the inclusion criteria
until the sample size was reached. Facilities were
weighted at 48, 34, 9 and 9% based on their headcounts.
Using this equation (n¼pð100 pÞz2
d2), a one-sided 95%
confidence interval and a 5% significance level (z= 1.96),
an estimated antenatal HIV prevalence of 29.5% (p) [16]
and a desired precision (d) of 5%, a minimum sample
size of 320 participants was calculated. An addition of
10% (n=32) to give allowance for non-responses, yielded
a desired sample size of 352 participants. Nine partici-
pants were excluded due to missing date of birth (9)
with either spousal information (7) and/or condom use
information (8).
Measurements
A validated interviewer administered questionnaire that
was adapted from three instruments that have previously
been used to measure HIV prevalence, PMTCT effect-
iveness and HIV stigma in developing countries [2527].
It obtained information on socio-demographic charac-
teristics, perception of health status and the medical his-
tory including HIV status (main outcome). The HIV
status, the gestational age and antenatal care history
were confirmed from the antenatal care card. Social de-
sirability bias and language bias were mitigated through
the use of a validated instrument, semi-private interview-
ing space, training of researchers on professional con-
duct during interviews (e.g. phrasing of questions,
avoidance of gestures, etc.) and the translation of the
questionnaire into the local language (isiXhosa) respect-
ively. The instrument was piloted among 12 pregnant
women in the four study sites. This pilot allowed for the
refinement of the instrument before data collection.
Statistical analysis
Stata version 14.1 (STATA Corp, College Station, Texas,
USA) was used to analyse data. Considering the low
levels of missing data, missing data are analysed using
complete case analysis. Numerical variables were
explored for normality using the Shapiro Wilk test [28].
Numerical data were not normally distributed and thus
reported on using the median and Interquartile Range
(IQR). The Wilcoxon Sum rank test (Mann-Whitney U
test) was used to test for the equality of two medians,
e.g. age in years by HIV status. Categorical variables are
presented using, frequency tables, percentages and
graphs. Two categorical variables were compared using
the Chi-squared test if the expected frequencies were
5. The Fishers exact test was used for this purpose if the
expected frequencies were < 5 as was the case in the
comparison between the HIV and marital status.
Binomial logistics regression was used to determine
the associations of an HIV positive status and to esti-
mate the Prevalence Ratio (PR). The univariable models
and the multivariable model selected through the pur-
poseful selection of variables are presented [29]. This
process ensured that the model selected is the best fit
and adjusted for confounding and relevant covariates.
The clustered sandwhich estimator and the intraclass
correlation tests were used to assess for clustering by
primary care facility. The 95% Confidence Interval
(95%CI) was used to estimate the precision of estimates.
The level of significance was set at 5% (p-value 0.05)
for statistical significance.
The Walter Sisulu University Human Ethics and Bio-
safety Committee granted ethical clearance with ethics
approval number (052/2016). The Eastern Cape Provin-
cial Health Research Committee granted research access
approval (EC_2016RP27_272).
Results
Socio-demographic characteristics, HIV status and dur-
ation of HIV diagnosis of participants are presented in
Table 1. A total of 343/352 participants (97.4%; 95%CI:
95.298.8) were included in the final analysis, of whom
38.2% (n=131) were HIV infected. Four of the nine (4/9
or 44.4%) of the excluded participants were HIV posi-
tive. There was no significant difference in the HIV sta-
tus of participants in the four health facilities. HIV
positive participants (median age=30) were significantly
older than HIV negative participants (median=25; p-
value< 0.0001). The youngest participants were 15 years
old, with 35 teenagers (10.2%) and the oldest were 43
years. High school learners and tertiary students com-
prised 33 (9.6%) and 32 (9.3%) of participants respect-
ively. All participants knew their HIV status and the
main reasons for having an HIV test included the fact
that it was mandatory in antenatal care (44.0%); for
health reasons or tests as a routine (47.2%); for sake of
unborn baby (5.3%) and 3.5% reported to have tested
due to being medically unwell.
The median gestational age at antenatal care booking
for the 339 (98.8%) respondents who had complete
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Table 1 Socio-demographic characteristics (N=343)
Demographics and Medical characteristics HIV infected HIV uninfected p-value
N=131 N=212
HIV status; n (%) 131 (38.2) 212 (61.8) < 0.0001
Age, years; median (IQR
a
) 30 (10) 25 (9) < 0.0001
Duration of HIV diagnosis (N=127), days; median (IQR) 77 (99) ––
c
Gestational age at booking, weeks (N=339); median (IQR) 15.1 (11)
d
16 (8)
e
0.419
Age, years; n (%)
1519 8 (22.9) 27 (77.1) < 0.0001
2029 53 (28.8) 131 (71.2)
3039 60 (53.6) 52 (46.4)
4043 10 (83.3) 2 (16.7)
Facility; n (%)
Ngangelizwe CHC 61 (36.3) 107 (63.7) 0.672
Mhlakulo CHC 44 (37.9) 72 (62.1)
Ngcobo CHC 14 (48.3) 15 (51.7)
All Saints Gateway clinic 12 (40.0) 18 (60.0)
First Pregnancy; n (%)
No 100 (45.7) 119 (54.3) < 0.0001
Yes 31 (25.0) 93 (75.0)
Marital Status; n (%)
Married 35 (44.9) 43 (55.1) 0.037
b
Never Married 84 (34.3) 161 (65.7)
Cohabiting 9 (60.0) 6 (40.0)
Divorced 1 (33.3) 2 (66.7)
Widowed 2 (100.0) 0 (0)
Current Education; n (%)
High School Learner 8 (24.2) 25 (75.8) < 0.0001
Tertiary Student 3 (9.4) 29 (90.6)
Not currently studying 120 (43.2) 158 (56.8)
Employment; n (%)
Employed 33 (47.8) 36 (52.2) 0.662
Unemployed 83 (41.7) 116 (58.3)
Self-employed 4 (40.0) 6 (60.0)
Spouse in high school; n (%)
Yes 2 (6.1) 31 (93.9) < 0.0001
No 129 (41.6) 181 (58.4)
Spousal occupation; n (%)
Locally Employed 64 (41.8) 89 (58.2) 0.210
Employed in another town 42 (38.2) 68 (61.8)
Unemployed 22 (53.7) 19 (46.3)
Self-employed 1 (16.7) 5 (83.3)
a
IQR = Interquartile Range = 75th percentile 25th percentile
b
Fishers Exact test was used
c
This is the estimated gestational age at first antenatal care reading based on clinical records
d
n= 209;
e
n=130
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information was 15.6 weeks (IQR: 11.320.3) and there
was no significant difference between HIV positive and
HIV negative individuals. Whilst one patient had been
on HAART for 13-years, at-least 80.3% (n=102) of the
participants had their HIV status diagnosed in the index
pregnancy, with a median duration of diagnosis and ini-
tiation on HAART of 77 days (IQR: 42141).
Primigravidas accounted for 124 (36.1%) of all partici-
pants and there were statistical differences between HIV
positive and negative participants (p-value< 0.0001). All
2 widowed participants, 9/6 (60.0%) of cohabiting partic-
ipants, 35/78 (44.9%) married participants and 84/245
(34.3%) of participants who were never married had an
HIV positive diagnosis and this was statistically signifi-
cant (p-value = 0.037). Whilst 120/278 (43.2%) of those
who were currently studying were HIV positive, 8/33
(24.2%) of those in high school and 3/32 of those in ter-
tiary were HIV positive, this was statistically significant
(p-value< 0.0001). Unemployed participants accounted
for 199 (58.0%) of all participants, of which 83/199
(41.7%) were HIV positive. Spouses were distributed be-
tween those employed locally (44.6%), employed in an-
other town (32.1%), unemployed (12.0%), high school
learners (9.6%) and self-employed (1.8%). Only 2/33
(6.1%) of those whose spouses were in high school were
HIV positive. Of the participants whose spouses were
unemployed, 53.7% (n= 22/41) were HIV positive.
Paricipants reported their health status to be very good
or good (80.8% or n=277), moderate (17.2% or n=59), or
bad (2.0% or n=7) respectively (Fig. 1). Whilst 209
(60.9%) participants reported to condomise sometimes,
73 (21.3%) reported to never and 61 (17.9%) reported to
always condomise (Fig. 2). Only 72/73 respondents
(98.6%) stated reasons for never using a condom. One
respondent (1.4%) never used a condom because the
index pregnancy was her sexual debut. Others cited rea-
sons such as being married (3/72 or 4.2%); trusting part-
ner (13/72 or 18.1%); partner refusal (33/72 or 45.8%);
sexual preference (21/72 or 29.2%) and one respondent
(1.4%) associated condom use with swelling or rash in
the genital area.
Of the married HIV positive participants, 15/35
(42.9%) reported to either use condoms all the time or
sometimes (Fig. 3). Only three (3/43 or 7.0%) HIV nega-
tive participants who were married reported to always
use condoms, the majority (55.8% or 24/43) reported to
condomise sometimes.
Only 73 (21.3%) participantspartners were reported
to accompany them to antenatal care. Most participants
partners (92.4%) were, however, reported to show an
interest on the pregnancy. Partners did not attend ante-
natal care due to no longer being together (n=1); they
stayed far apart (37.4%); other commitments (41.9%);
had never discussed it (8.9%); partner refused to come
(5.9%) and 5.6% believed that males were not welcome
in antenatal care.
In univariable analysis, the antenatal HIV prevalence
was significantly higher in participants between the ages
of 3039 (PR = 1.5; p-value< 0.0001) and 4043 (PR =
4.3; p-value = 0.025) compared to those in the 20 to 29
year age group (Table 2). In addition, multigravida par-
ticipants were associated with 40% higher antenatal HIV
prevalences respectively when compared to primigravi-
das and this was statistically significant (PR = 1.4; p-
value < 0.0001). Other factors associated with a signifi-
cantly higher antenatal prevalence included participants
Fig. 1 Perceived Health Status
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who were not full-time students (PR = 1.6; p-value<
0.0001) and the spouse being unemployed (PR = 1.8; p-
value = 0.018).
Multivariable analysis had three variables in the
best fitting binomial logistic regression model (Table
2). Gravidity was not a statistically significant associ-
ation of antenatal HIV prevalence (p-value=0.329).
Those in the 30 to 39 year age group were 50% more
likely to be HIV positive and this was statistically
significant (PR = 1.5; p-value = 0.001). Likewise,
those in the 40 to 43 year age group were 3.6 times
as likely to be HIV positive when compared to those
in their 20s and this difference was borderline statis-
tically significant (PR = 3.6; p-value = 0.048). How-
ever, self-employed participants were 30% less likely
to be HIV positive when compared to unemployed
participants and this was statistically significant (p-
value< 0.0001).
Fig. 2 Reported Condom Use
Fig. 3 Frequency of Condom use by HIV and Marital status
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Discussion
This study will hopefully add evidence to the already
existing body of knowledge on South Africas HIV epi-
demiology, especially among pregnant women in rural
communities. It is a study which highlights a high HIV
antenatal prevalence, high antenatal HIV testing rates,
lack of expectation of spousal attendance in antenatal
care and challenges experienced with condom compli-
ance. In univariable analysis, multigravidity, being older
than 30 years and having an unemployed spouse was as-
sociated with higher HIV prevalences, confirming find-
ings that have previously been established in literature
[5,9,1820,22,30]. The study does not only provide an
update of the antenatal HIV prevalence but also seeks to
use epidemiological data to inform health promotion
practices in a rural South African environment. Lessons
from this high HIV burden country will hopefully also
be applicable to other LMIC and their planners. The
major difference between this study and the South Afri-
can antenatal surveys is that this study includes all preg-
nant women and not exclusively primigravidas [15,16].
Of the 10.2% of teenagers interviewed in the study,
94.3% were high school students and 22.9% (n=8) were
HIV positive. This teenage pregnancy rate is lower than
that described by Mchunu et al. [31] in a similar South
African population wherein 19.2% of women reported to
have fallen pregnant during their teenage years [31]. The
HIV prevalence among teenagers is comparable to a
prevalence of 17.2 to 22.5% reported in a 10 year cohort
in a neighbouring South African province of KwaZulu-
Natal [18]. Regardless of the percentage of teenagers
who were pregnant, it cannot be ideal for school
Table 2 Antenatal HIV Associated Factors
Characteristics n Univariable analysis Multivariable analysis
PR (95% Confidence interval) p-value PR (95% Confidence interval) p-value
Age, years
2029 53/184 ref 1 ref 1
1519 8/35 0.9 (0.81.1) 0.437 1.0 (0.71.4) 0.988
3039 60/112 1.5 (1.21.9) < 0.0001 1.5 (1.21.9) 0.001
4043 10/12 4.3 (1.215.2) 0.025 3.6 (1.012.6) 0.048
First pregnancy
Yes 31/124 ref 1 ref 1
No 100/219 1.4 (1.21.6) < 0.0001 1.1 (0.91.4) 0.329
Employment Status
Unemployed 83/199 ref 1
Employed 33/69 0.9 (0.71.2) 0.393 1.0 (0.81.2) 0.848
Self-employed 4/10 1.0 (0.61.6) 0.913 0.7 (0.60.8) < 0.0001
Current Education
Tertiary student 3/32 ref 1 ––
High school learner 8/33 1.2 (1.01.5) 0.115 ––
Not currently studying 120/278 1.6 (1.41.9) < 0.0001 ––
Perceived Health status
Good/Very Good 77/218 ref 1 ––
Moderate 18/59 0.9 (0.71.1) 0.187 ––
Bad 5/7 2.4 (0.77.9) 0.141 ––
Spouse in high school
Yes 2/33 ref 1 ––
No 129/310 1.6 (1.41.8) < 0.0001 ––
Spousal Employment
Self-employed 1/6 ref 1 ––
Locally employed 64/153 1.1 (0.91.3) 0.549 ––
Employed in another town 42/110 1.3 (0.92.0) 0.130 ––
Unemployed 22/41 1.8 (1.12.9) 0.018 ––
PR Prevalence Ratio, ref reference
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children who are themselves dependent on adults to be
pregnant as this often has an impact on their long-term
progress [31,32].
This is a poverty-stricken community with more than
half of the women interviewed being unemployed
(57.7%), never married (71.4%) and multiparous (63.9%).
Almost 45% of the womens partners were employed lo-
cally, suggesting that there were economic opportunities
locally that favour males. These compare to other ante-
natal care survey results such as that in another South
African province (Limpopo), where 808 pregnant women
were recruited, 51% from rural areas and 28% from peri-
urban areas [33]. In that study both rural and peri-urban
pregnant women had a high rate of being unemployed
and being unmarried [33]. The fact that self-employed
women were less likely to be HIV positive in the multi-
variable analysis (p-value< 0.0001) is consistent with
findings suggesting that economic independence could
improve the capacity to negotiate safer sexual practices
[19]. The results have to however be treated with
caution given that self-employed participants only
accounted for 10 (2.9%) of participants in the study.
Encouraging is the fact that 50% of women had their
first antenatal care visit at 16 weeks. This is good as it al-
lows adequate time for identification of congenital ab-
normalities, maternal or foetal risks and the suppression
of the viral load if HIV positive, thus reducing the
probability of Mother-to-Child-Transmission [13,14,22,
3436]. This compares to antenatal care survey results
of a Cameroonian study [37], of 293 pregnant partici-
pants, where 34% had started antenatal care in the first
trimester [37]. The explanations most commonly offered
for a late antenatal presentation were financial difficul-
ties and living a long way from the health facility [37].
The data shows that antenatal HIV prevalence is in-
creasing and higher than that presented in previous
studies for same area [15]. The crude antenatal HIV
prevalence of 38.2% is higher than the 31.9% (95%CI:
27.436.8) and the 33.3% (95%CI: 30.436.4) antenatal
prevalences previously reported for Chris Hani and
OR Tambo Districts respectively [15]. The differences
could be attributed to the inclusion of multigravida
women in this study [15,16]. The high prevalence
could be a result of an increasing incidence most
probably related to poor condom compliance and the
concurrent reduction of HIV related mortality due to
an improved antiretroviral programme [17,18,30].
The HIV status of participants was not dependent on
the facility from which they were recruited, and this
was not statistically significant (p-value = 0.672).
Findings from this study contrast the 2015 South Af-
rican National Antenatal Sentinel HIV and Syphilis
survey results which reported a declining HIV preva-
lence for the Eastern Cape Province [15].
Pregnancy in early adolescence has been found to be
associated with an increased incidence of HIV infection
among South African women [38]. The higher risk is as-
sociated with sexual risk behaviour such as multiple
partners and a greater age difference with partners [38].
This study, however, found a different phenomenon: the
prevalence is higher amongst older women which sug-
gests changes in the epidemiological characteristics pos-
sibly since the HIV infected women were infected many
years previously but only knew their HIV positive status
in the index pregnancy or it could well be a mark of an
increasing incidence among older women. The aim of
PMTCT programs is to improve the wellbeing of expect-
ant mothers and to reduce the incidence of HIV among
newborns [39,40]. Future retrospective cohort studies
should seek to quantify the HIV MTCT trends among
newborns in the same study population, especially since
multigravidas were associated with a higher prevalence
than primigravidas.
It is of little surprise that unemployed women had a
significantly higher risk of being HIV positive than self-
employed women. HIV is a disease of poverty [41],
which further explains the increasing HIV prevalence in
this community where more than 50% of the partici-
pants were unemployed [41]. Poverty may drive some
women into risky sexual behaviours such as transac-
tional sex and an inability to negotiate safer sexual prac-
tices with their partner [41].
Most women did not have an expectation for their
partners to accompany them during their antenatal care
visits. Spousal support during antenatal care can help
improve acceptance and utilisation of preventive
strategies in general and to an increased uptake of inter-
ventions to prevent vertical and sexual transmission of
HIV [42]. Partner/couple counselling in the antenatal
setting may have further benefits to individual VCT [42].
In a Kenyan study, male antenatal care attendance was
found to be associated with improved infant HIV-free
survival [43]. Promotion of HIV testing in men and en-
gagement in antenatal care services may improve out-
comes in infants [43].
The non-involvement of partners in antenatal care ser-
vices could discourage women in their ability to disclose
their HIV-positive status due to fear of rejection, stigma
and discrimination. It could also serve as a barrier to
women beginning treatment and adhering to it and may
disrupt HIV prevention services which could in turn re-
sult in poor HIV outcomes.
Even though attempts were made to reduce limitations
the study encountered a few. Firstly, findings from this
study are not representative of the Eastern Cape Prov-
ince as participants were recruited from only four health
facilities. Findings from this study do, however, give a
reasonable idea of the epidemiology of HIV in a rural
Mabunda et al. BMC Infectious Diseases (2021) 21:61 Page 8 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
environment amongst women attending antenatal care.
Secondly, the strength of the association between
women older than 40 years and those between 20 to 29
years is weak due to the borderline p-value and the wide
confidence interval.
Thirdly, the limited privacy during the interviews that
occurred as a result of infrastructure challenges could
have resulted in a social desirability bias, especially in
questions pertaining to sexual behaviour and the use of
condoms. Where this bias was noted results are reported
truthfully. It is however unlikely that these limitations
could have distorted the findings on the epidemiology of
HIV in this population especially since medical informa-
tion was triangulated from clinical records.
Conclusion
A successful PMTCT program is bolstered by an early
antenatal care attendance and high HIV testing rates.
This was evident in this study with a median antenatal
booking attendance of 15.6 weeks of gestation and an
HIV testing rate of 100%. The study has shown an ante-
natal HIV prevalence of 38.2% and found to be higher
among older and multigravida women.
This population showed a very low uptake of spousal
attendance in antenatal care as it was not an expectation
for spouses to attend. Antenatal care nurses and policy-
makers should therefore make extra effort for spouses to
be ecourage to attend antenatal care.
Abbreviations
ARVs: Antiretrovirals; CHC: Community Health Centres; HAART: Highly Active
Antiretroviral Therapy; LMIC: Low- and middle-income countries;
MTCT: Mother-to-Child Transmission; NCDs: Non-communicable diseases;
PMTCT: Prevention of Mother-to-Child Transmission; PR: Prevalence Ratio;
TB: Tuberculosis; UNAIDS: The Joint United Nations Programme on HIV and
AIDS; VCT: Voluntary Counselling and Testing; WHO: World Health
Organization
Acknowledgements
We would like to thank all study participants, the Eastern Cape Department
of Health, the OR Tambo and Chris Hani health Districts, the four health
facilities and the participants.
Authorscontributions
SAM and KS conceptualised, designed, executed and did the main drafting
of the manuscript and its revisions. SAM analysed the data and signed off on
the final version. WC sought funding and reviewed manuscript. TA and SN
provided critical review and approved the manuscript. The authors read and
approved the final manuscript.
Funding
The work reported herein was made possible through funding by the South
African Medical Research Council (SAMRC) through its Division of Research
Capacity Development under the SAMRC Research Strenghtening & Capacity
Development Initiative (RCDI) Programme as a research grant to Walter
Sisulu University. The content hereof is the sole responsibility of the authors
and does not necessarily represent the official views of the SAMRC.
Availability of data and materials
The datasets used and/or analysed during the current study are available on
request from the corresponding author on request.
Ethics approval and consent to participate
The Walter Sisulu University Human Ethics and Biosafety Committee granted
ethical clearance and approval for the study to be conducted with ethics
approval number (052/2016). The Eastern Cape Provincial Health Research
Committee granted permission for the study to be conducted
(EC_2016RP27_272). District managers of Chris Hani and OR Tambo Districts
as well as the operational managers of the facilities concerned also granted
permission for the study to be conducted. In addition to the fact that each
participant gave informed written consent; confidentiality was maintained
abiding by the four ethical principles of autonomy, beneficence, non-
maleficence, and justice. Participants under the age of 18 were included after
providing written consent from both themselves and their parents or
guardians.
Consent for publication
No personal identifiers or participantsimages are contained in this study.
The consent did however mention that findings would be disseminated to
scientific audience, lay audience and policy makers.
Competing interests
The authors declare that they have no competing interests.
Author details
1
The George Institute for Global Health and Research, University of New
South Wales, Level 5 1 King Street, Sydney, Newtown NSW 2042, Australia.
2
Department of Public Health, Walter Sisulu University, Mthatha, South Africa.
3
Health Systems Enablement & Innovation Unit, University of the
Witwatersrand, Johannesburg, South Africa.
4
Department of Laboratory
Medicine, Walter Sisulu University, Mthatha, South Africa.
Received: 27 June 2020 Accepted: 27 December 2020
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Background Early initiation of antenatal care visits is an essential component of services to improving maternal and new born health. The Cameroonian Demographic and Health Survey conducted in 2011 indicated that only 34% of pregnant women start antenatal care in the first trimester. However, detailed study to identify factors associated with late initiation of care has not been conducted in Cameroon. The aim of this study was to assess the prevalence of late booking first ANC visit amongst attendance of first ANC and the determinants of late first ANC in Douala general hospital. Methods It was a cross sectional analytic study over the period of 5 months in Douala general hospital. The study subjects were pregnant women visiting the facilities for the first time during the index pregnancy. Data were collected using pre-tested questionnaire. Logistic regression analysis was done to identify factors associated with late first ANC with the level of significance set at 0.05. Results A total of 293 women participated in the study; 129 (44.0%) of them came for their first ANC visit late, after 12 weeks of gestation. Most common reasons for coming late for first ANC were financial constraints (34.5%, 45) and long distance to the hospital (34.5%, 45). Factors associated with late start of first ANC after logistic regression were: family size greater than 4 (OR = 2, 95% CI = 1.25–3.19, p value = 0.004), long distance to the hospital (OR = 1.84, 95% CI = 1.1–3.07, p value = 0.02) and low monthly income level less than 200US dollars (OR = 3.2, 95% CI = 1.33–3.54, p value = 0.002). Conclusion About half of pregnant women do not start ANC early in the first trimester largely due to large family size, low monthly income and long distance to the hospital. Keywords: Antenatal care, Late ANC, Booking, Determinants
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Background South Africa has utilized three independent data sources to measure the impact of its program for the prevention of mother–to–child transmission (PMTCT) of HIV. These include the South African National Health Laboratory Service (NHLS), the District Health Information System (DHIS), and South African PMTCT Evaluation (SAPMTCTE) surveys. We compare the results of each, outlining advantages and limitations, and make recommendations for monitoring transmission rates as South Africa works toward achieving elimination of mother–to–child transmission (eMTCT). Methods HIV polymerase chain reaction (PCR) test data, collected between 1 January 2010 to 31 December 2014, from the NHLS, DHIS and SAPMTCTE surveys were used to compare early mother–to–child transmission (MTCT) rates in South Africa. Data from the NHLS and DHIS were also used to compare early infant diagnosis (EID) coverage. Results The age–adjusted NHLS early MTCT rates of 4.1% in 2010, 2.6% in 2011 and 2.3% in 2012 consistently fall within the 95% confidence interval as measured by three SAPMTCTE surveys in corresponding time periods. Although DHIS data over–estimated MTCT rates in 2010, the MTCT rate declines thereafter to converge with age–adjusted NHLS MTCT rates by 2012. National EID coverage from NHLS data increases from around 52% in 2010 to 87% in 2014. DHIS data over–estimates EID coverage, but this can be corrected by employing an alternative estimate of the HIV–exposed infant population. Conclusion NHLS and DHIS, two routine data sources, provide very similar early MTCT rate estimates that fall within the SAPMTCTE survey confidence intervals for 2012. This analysis validates the usefulness of routine data sources to track eMTCT in South Africa.
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Purpose: A key global health challenge is the persistence of new pediatric HIV infections due to mother-to-child transmission (MCTC), particularly in sub-Saharan Africa. The purpose of this study was to identify the key strategies that some sub-Saharan African countries have used to successfully reduce new pediatric HIV infections. Methods: A qualitative study utilizing semistructured interviews with key stakeholders in 6 sub-Saharan African countries (Burundi, Malawi, Mozambique, South Africa, Swaziland, and Uganda) was conducted from September 2017 to September 2018. These stakeholders were situated in the National Department of Health or in international health-funding bodies relating to the provision of the HIV/AIDS implementation program in these countries. The countries were selected based on considerable success achieved with HIV treatment in pregnant women. Audio-recorded interviews were transcribed verbatim and thematic analysis was undertaken. Findings: In all, 6 interviews were conducted, and the mean time of the interviews was 62 min. There were similar numbers of men and women, and most were in the 35- to 45-year age group. Five in six were either a medical doctor or held a doctorate degree. Four in six had >10 years of experience working in the prevention of HIV (PMTCT). Four key strategies that contributed to significant reductions in pediatric HIV infection in the respective countries were identified: (1) committed political leadership; (2) support structures within the community; (3) innovation in service delivery; and (4) robust monitoring and evaluation systems. Stakeholders spoke about how their governments played a leading role in engagement with communities, and in the dissemination of services. Innovative service delivery comprising task-shifting initiatives and the integration of maternal, newborn, and child health and HIV PMCTC services played an important role in reducing the burdens experienced by women and health care workers, leading to improved health outcomes. Peer support also helped mothers to adhere to their treatment during and after pregnancy. The capacity of national programs to monitor and evaluate the PMTCT services and the importance of regular viral-load monitoring were highlighted by the stakeholders. Implications: These strategies can be reviewed for possible implementation by other sub-Saharan African countries as possible means of reducing new pediatric HIV infections.
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Most HIV-infected children in Sub-Saharan Africa are born where programs for the prevention of mother-to-child transmission of HIV (PMTCT) exist but are not universally operational. The expansion of PMTCT programs in Cameroon was among the largest in francophone Africa, but despite highly variable estimates of PMTCT uptake (ranging from 20% to 66%), it is clear that not enough HIV-infected pregnant Cameroonian women benefit from treatment to prevent HIV transmission to their children. The reasons why HIV-infected women in Cameroon do not use treatments to prevent this transmission remain partially unidentified. We conducted a qualitative study of the therapeutic itineraries (treatments taken and motivations) followed by HIV-infected pregnant women in Cameroon to understand the barriers to accessing high-quality PMTCT care. Here we construct the therapeutic itinerary for HIV-infected pregnant women, and identify the barriers at each step. Lack of financial independence, personal support, and empowering information were the primary obstacles at multiple steps.
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