Prenatal care coverage and correlates of HIV testing in sub-Saharan Africa: Insight from demographic and health surveys of 16 countries

Guidance for triangulating data and estimates of HIV prevalence among pregnant women and coverage of PMTCT using the Spectrum AIDS Impact Module

Background

Most countries use the Spectrum AIDS Impact Module (Spectrum-AIM), antenatal care routine HIV testing, and antiretroviral treatment data to estimate HIV prevalence among pregnant women. Non-representative programme data may lead to inaccurate estimates HIV prevalence and treatment coverage for pregnant women.

Setting

154 locations in 126 countries.

Methods

Using 2023 UNAIDS HIV estimates, we calculated three ratios: (1) HIV prevalence among pregnant women to all women 15-49y (prevalence), (2) ART coverage before pregnancy to women 15-49y ART coverage (ART pre-pregnancy), and (3) ART coverage at delivery to women 15-49y ART coverage (PMTCT coverage). We developed an algorithm to identify and adjust inconsistent results within regional ranges in Spectrum-AIM, illustrated using Burkina Faso's estimates.

Results

In 2022, the mean regional ratio of prevalence among pregnant women to all women ranged from 0.68 to 0.95. ART coverage pre-pregnancy ranged by region from 0.40 to 1.22 times ART coverage among all women. Mean regional PMTCT coverage ratios ranged from 0.85 to 1.51. The prevalence ratio in Burkina Faso was 1.59, above the typical range 0.62-1.04 in western and central Africa. Antenatal clinics reported more PMTCT recipients than estimated HIV-positive pregnant women from 2015 to 2019. We adjusted inputted PMTCT programme data to enable consistency of HIV prevalence among pregnant women from programmatic routine HIV testing at antenatal clinics with values typical for Western and central Africa.

Conclusion

These ratios offer Spectrum-AIM users a tool to gauge the consistency of their HIV prevalence and treatment coverage estimates among pregnant women with other countries in the region.

Evaluation of the prevention of mother-to-child transmission of HIV programs at the second immunization visit in Burkina Faso and Zambia

OBJECTIVE

Our study aimed to assess the PMTCT indicators in Burkina Faso and Zambia using a patient-orientated innovative strategy based on the second visit in the Expanded Program on Immunization (EPI-2) visit at 6-8 weeks.

DESIGN

This was a cross sectional study.

METHODS

We assessed women attending EPI-2 at primary healthcare facilities in Burkina Faso and Zambia with their children about their exposure to PMTCT interventions. For women living with HIV (WLHIV), viral load was measured and their children were tested for HIV DNA using point of care devices.

RESULTS

Overall, 25 093 were enrolled from Burkina Faso and 8961 women from Zambia. Almost, all women attended at least one antenatal care visit. Among those aware of their HIV-positive status, 95.8 and 99.2% were on antiretroviral therapy (ART) in Burkina Faso and Zambia, respectively. Among WLHIV on ART, 75 and 79.2% achieved a viral load suppression (viral load <1000 copies/ml) in Burkina Faso and Zambia, respectively. Infant postnatal prophylaxis was administered from birth until EPI-2 to 60.9 and 89.7% of HIV-exposed children in Burkina Faso and Zambia, respectively. In Burkina Faso, only 60 of 192 (31.3%) of HIV-exposed children were sampled at day 42 for early infant diagnosis (EID) and 3 (1.6%) received a result by EPI-2. In Zambia, these figures were 879 of 1465 (64.0%) and 9.9% (145/1465), respectively for HIV-exposed children sampled at birth.

CONCLUSION

This evaluation strategy at EPI-2 visit could strengthen program monitoring and help identifying gaps to be addressed on the last mile towards elimination of MTCT of HIV.

Understanding the uptake and determinants of prevention of mother-to-child transmission of HIV services in East Africa: Mixed methods systematic review and meta-analysis

BACKGROUND

Prevention of mother-to-child transmission (PMTCT) of HIV service is conceptualized as a series of cascades that begins with all pregnant women and ends with the detection of a final HIV status in HIV-exposed infants (HEIs). A low rate of cascade completion by mothers' results in an increased risk of HIV transmission to their infants. Therefore, this review aimed to understand the uptake and determinants of key PMTCT services cascades in East Africa.

METHODS

We searched CINAHL, EMBASE, MEDLINE, Scopus, and AIM databases using a predetermined search strategy to identify studies published from January 2012 through to March 2022 on the uptake and determinants of PMTCT of HIV services. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. A random-effects model was used to obtain pooled estimates of (i) maternal HIV testing (ii) maternal ART initiation, (iii) infant ARV prophylaxis and (iv) early infant diagnosis (EID). Factors from quantitative studies were reviewed using a coding template based on the domains of the Andersen model (i.e., environmental, predisposing, enabling and need factors) and qualitative studies were reviewed using a thematic synthesis approach.

RESULTS

The searches yielded 2231 articles and we systematically reduced to 52 included studies. Forty quantitative, eight qualitative, and four mixed methods papers were located containing evidence on the uptake and determinants of PMTCT services. The pooled proportions of maternal HIV test and ART uptake in East Africa were 82.6% (95% CI: 75.6-88.0%) and 88.3% (95% CI: 78.5-93.9%). Similarly, the pooled estimates of infant ARV prophylaxis and EID uptake were 84.9% (95% CI: 80.7-88.3%) and 68.7% (95% CI: 57.6-78.0) respectively. Key factors identified were the place of residence, stigma, the age of women, the educational status of both parents, marital status, socioeconomic status, Knowledge about HIV/PMTCT, access to healthcare facilities, attitudes/perceived benefits towards PMTCT services, prior use of maternal and child health (MCH) services, and healthcare-related factors like resource scarcity and insufficient follow-up supervision.

CONCLUSION

Most of the identified factors were modifiable and should be considered when formulating policies and planning interventions. Hence, promoting women's education and economic empowerment, strengthening staff supervision, improving access to and integration with MCH services, and actively involving the community to reduce stigma are suggested. Engaging community health workers and expert mothers can also help to share the workload of healthcare providers because of the human resource shortage.

Factors associated with HIV testing among pregnant women in Rwanda: A nationwide cross-sectional survey

Human immunodeficiency virus (HIV) testing during pregnancy is crucial for the prevention of mother-to-child transmission of HIV, through aiding prompt treatment, care, and support. However, few studies have explored HIV testing among pregnant women in Rwanda. This study, therefore, aimed to determine the prevalence and associated factors of HIV testing among pregnant women in Rwanda. We used secondary data from the 2020 Rwanda Demographic and Health Survey (RDHS), comprising 870 pregnant women. Multistage stratified sampling was used by the RDHS team to select participants. We conducted bivariable and multivariable logistic regression to explore factors associated with HIV testing using SPSS (version 25). Of the 870 pregnant women, 94.0% had tested for HIV during their current pregnancy. Younger age (24-34 years), not working, large household size, multiple sex partners, as well as secondary, primary, and no education were associated with higher odds of HIV testing compared to their respective counterparts. However, being unmarried, belonging to the western region, having not visited a health facility, and not having comprehensive HIV knowledge were associated with lower odds of HIV testing. A high proportion of pregnant women had tested for HIV. The study revealed that individual-level factors had the greatest influence on HIV testing in pregnancy, with a few household-level factors showing significance. There is a need for maternal health stakeholders to design and develop HIV testing programs that are region-sensitive. These programs should target older, more educated, working, and unmarried women with limited HIV knowledge.

Socioeconomic inequalities in uptake of HIV testing during antenatal care: evidence from Sub-Saharan Africa

BACKGROUND

Measuring socioeconomic inequalities in healthcare usage represents a critical step towards promoting health equity, in alignment with the principles of universal health coverage and the United Nations' Sustainable Development Goals. In this study, we assessed the socioeconomic inequalities in HIV testing during antenatal care (ANC) in sub-Saharan Africa.

METHODS

Sub-Saharan Africa was the focus of this study. Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Mauritania, Mozambique, Rwanda, Sierra Leone, Uganda, Zambia, and Zimbabwe were the countries included in the study. This study used current Demographic and Health Surveys data spanning from 2015 to 2022. A total of 70,028 women who tested for HIV as part of antenatal contacts formed the sample for analysis. We utilized the standard concentration index and curve to understand the socioeconomic inequalities in HIV testing during antenatal care among women. Additionally, a decomposition analysis of the concentration index was ran to ascertain the contributions of each factor to the inequality.

RESULTS

Overall, 73.9% of women in sub-Saharan Africa tested for HIV during ANC. The countries with the highest proportions were Malawi, Rwanda, Zambia, and Zimbabwe. Mali Benin, Guinea, Mali, and Mauritania were the countries with the lowest proportions of HIV testing. Being among the richer [AOR 1.10, 95% CI: 1.02,1.18] and richest [AOR 1.41, 95% CI:1.30, 1.54] wealth quintiles increased the odds of HIV testing during ANC. The concentration value of 0.03 and the curve show that HIV testing is more concentrated among women in the highest wealth quintile. Hence, wealthy women are advantaged in terms of HIV testing. As the model's residual value is negative (-0.057), the model overestimates the level of inequality in the outcome variable (HIV during ANC), which means that the model's explanatory factors can account for higher concentration than is the case.

CONCLUSION

We found that there is substantial wealth index-related inequalities in HIV testing, with women of the poorest wealth index disadvantaged in relation to the HIV testing. This emphasizes the necessity for sub-Saharan Africa public health programs to think about concentrating their limited resources on focused initiatives to grasp women from these socioeconomic circumstances. To increase women's access to HIV testing, maternal and child health programs in sub-Saharan Africa should attempt to minimize female illiteracy and poverty. Consequently, health education may be required to provide women with comprehensive HIV knowledge and decrease the number of lost opportunities for women to get tested for HIV. Given the link between knowledge of HIV and HIV testing, it is important to focus on community education and sensitization about HIV and the need to know one's status.

Temporal Trends and Determinants of HIV Testing at Antenatal Care in Sub-Saharan Africa: A Pooled Analysis of Population-Based Surveys (2005-2021)

BACKGROUND

In sub-Saharan Africa (SSA), integrating HIV testing into antenatal care (ANC) has been crucial toward reducing mother-to-child transmission of HIV. With the introduction of new testing modalities, we explored temporal trends in HIV testing within and outside of ANC and identified sociodemographic determinants of testing during ANC.

METHODS

We analyzed data from 139 nationally representative household surveys conducted between 2005 and 2021, including more than 2.2 million women aged 15-49 years in 41 SSA countries. We extracted data on women's recent HIV testing history (<24 months), by modality (ie, at ANC versus outside of ANC) and sociodemographic variables (ie, age, socioeconomic status, education level, number of births, urban/rural). We used Bayesian generalized linear mixed models to estimate HIV testing coverage and the proportion of those that tested as part of ANC.

RESULTS

HIV testing coverage (<24 months) increased substantially between 2005 and 2021 from 8% to 38%, with significant variations between countries and subregions. Two percent of women received an HIV test in the 24 months preceding the survey interview as part of ANC in 2005 and 11% in 2021. Among women who received an HIV test in the 24 months preceding the survey, the probability of testing at ANC was significantly greater for multiparous, adolescent girls, rural women, women in the poorest wealth quintile, and women in West and Central Africa.

CONCLUSION

ANC testing remains an important component to achieving high levels of HIV testing coverage and benefits otherwise underserved women, which could prove instrumental to progress toward universal knowledge of HIV status in SSA.

Partner testing with HIV self-test distribution by Ugandan pregnant women living with HIV: a randomized trial

INTRODUCTION

Secondary distribution of HIV self-tests (HIVST) by HIV-negative pregnant women to male partners increases men's testing rates. We examined whether this strategy promotes male partner testing for pregnant women living with HIV (PWLHIV).

METHODS

We conducted an open-label individually randomized trial in Kampala, Uganda, in which PWLHIV ≥18 years who reported a partner of unknown HIV status were randomized 2:1 to secondary distribution of HIVST for male partner(s) or standard-of-care (SOC; invitation letter to male partner for fast-track testing). Women were followed until 12 months post-partum. Male partners were offered confirmatory HIV testing and facilitated linkage to antiretroviral treatment (ART) or oral pre-exposure prophylaxis (PrEP). Using intention-to-treat analysis, primary outcomes were male partner testing at the clinic and initiation on PrEP or ART evaluated through 12 months post-partum (ClinicalTrials.gov, NCT03484533).

RESULTS

From November 2018 to March 2020, 500 PWLHIV were enrolled with a median age of 27 years (interquartile range [IQR] 23-30); 332 were randomized to HIVST and 168 to SOC with 437 PWLHIV (87.4%) completing 12 months follow-up post-partum. Of 236 male partners who tested at the clinic and enrolled (47.2%), their median age was 31 years (IQR 27-36), 45 (88.3%) men with HIV started ART and 113 (61.1%) HIV-negative men started PrEP. There was no intervention effect on male partner testing (hazard ratio [HR] 1.04; 95% confidence interval [CI]: 0.79-1.37) or time to ART or PrEP initiation (HR 0.96; 95% CI: 0.69-1.33). Two male partners and two infants acquired HIV for an incidence of 0.99 per 100 person-years (95% CI: 0.12-3.58) and 1.46 per 100 person-years (95% CI: 0.18%-5.28%), respectively. Social harms related to study participation were experienced by six women (HIVST = 5, SOC = 1).

CONCLUSIONS

Almost half of the partners of Ugandan PWLHIV tested for HIV with similar HIV testing rates and linkage to ART or PrEP among the secondary distribution of HIVST and SOC arms. Although half of men became aware of their HIV serostatus and linked to services, additional strategies to reach male partners of women in antenatal care are needed to increase HIV testing and linkage to services among men.

HIV testing and knowledge on mother-to-child transmission among pregnant women attending antenatal care at Vanga Hospital, Democratic Republic of Congo

Background

Human immunodeficiency virus (HIV) causes an infectious disease that can be transmitted from an infected mother to her child. Prevention of Mother-to-Child Transmission (PMTCT) programs provide a range of services to women and children that can reduce the risk of vertical transmission of HIV. Unfortunately, PMTCT programs face many challenges in the rural Democratic Republic of Congo (DRC).

Methods

A cross-sectional study was conducted among 460 pregnant women attending antenatal care at Vanga Hospital in the Vanga health zone, DRC from March 11th to June 25th, 2019. Serological tests were performed and a pre-tested questionnaire regarding HIV knowledge was given to all participants. Data were analyzed with STATA 13.0. Descriptive statistics of key variables were computed and logistic regression was used to assess the association between participant's characteristics and knowledge of MTCT.

Results

Among the participants, 95.4% (439/460) reported that they have heard about HIV, 82.4% (378/460) indicated sexual intercourse as one of the routes of HIV transmission but only 30.4% (139/460) mentioned MTCT as one of the routes. In addition, only 10.1% (46/460) had knowledge of the existence of PMTCT. Participants' age (>29 years), education level, previous antenatal care, and previous HIV tests were significantly associated with knowledge of MTCT. Also, age (>29 years) and education level were significantly associated with previous HIV test uptake. Most pregnant women 82.3% (376/460) reported that they have never been tested in the past for HIV infection and the prevalence was at 0.9% (4/460).

Conclusions

Knowledge of MTCT of HIV, previous uptake of HIV testing, and prevalence was low. The rural setting of Vanga and insufficient HIV sensitization activities are considered contributors to this. While the low prevalence is a positive finding, much needs to be done to improve the uptake of HIV testing and knowledge of HIV MTCT.

Combination HIV prevention during pregnancy and the post-partum period in Malawi and Zambia: a mathematical modelling analysis

INTRODUCTION

Despite widespread success in reducing vertical HIV transmission, most antenatal care (ANC) programmes in eastern and southern Africa have not emphasized primary prevention of maternal HIV acquisition during pregnancy and lactation/breastfeeding. We hypothesized that combination HIV prevention interventions initiated alongside ANC could substantially reduce maternal HIV incidence.

METHODS

We constructed a multi-state model describing male-to-female HIV transmission in steady heterosexual partnerships during pregnancy and lactation/breastfeeding, with initial conditions based on population distribution estimates for Malawi and Zambia in 2020. We modelled individual and joint increases in three HIV prevention strategies at or soon after ANC initiation: (1) HIV testing of male partners, resulting in HIV diagnosis and less condomless sex among those with previously undiagnosed HIV; (2) initiation (or re-initiation) of suppressive antiretroviral therapy (ART) for male partners with diagnosed but unsuppressed HIV; and (3) adherent pre-exposure prophylaxis (PrEP) for HIV-negative female ANC patients with HIV-diagnosed or unknown-status male partners. We estimated the percentage of within-couple, male-to-female HIV transmissions that could be averted during pregnancy and lactation/breastfeeding with these strategies, relative to base-case conditions in which 45% of undiagnosed male partners become newly HIV diagnosed via testing, 75% of male partners with diagnosed but unsuppressed HIV initiate/re-initiate ART and 0% of female ANC patients start PrEP.

RESULTS

Increasing uptake of any single strategy by 20 percentage points above base-case levels averted 10%-11% of maternal HIV acquisitions during pregnancy and lactation/breastfeeding in the model. Joint uptake increases of 20 percentage points in two interventions averted an estimated 19%-23% of transmissions, and with a 20-percentage-point increase in uptake of all three interventions, 29% were averted. Strategies achieving 95% male testing, 90% male ART initiation/re-initiation and 40% female PrEP use reduced incident infections by 45%.

CONCLUSIONS

Combination HIV prevention strategies provided alongside ANC and sustained through the post-partum period could substantially reduce maternal HIV incidence during pregnancy and lactation/breastfeeding in eastern and southern Africa.

Drought, HIV Testing, and HIV Transmission Risk Behaviors: A Population-Based Study in 10 High HIV Prevalence Countries in Sub-Saharan Africa

Droughts are associated with poor health outcomes and disruption of public health programming. Data on the association between drought and HIV testing and transmission risk behaviors are limited. We combined data from Demographic and Health Surveys from 10 high HIV prevalence sub-Saharan African countries with a high-resolution measure of drought. We estimated the association between drought and recent HIV testing, report of condomless sex, and number of sexual partners in the last year. Respondents exposed to drought were less likely to have an HIV test and more likely to have condomless sex, although effect sizes were small. We found evidence for effect modification by sex and age for the association between drought and HIV testing, such that the negative association between drought and HIV testing was strongest among men (marginal risk ratio [mRR] 0.92, 95% CI 0.89-0.95) and adolescents (mRR 0.90, 95% CI 0.86-0.93). Drought may hinder HIV testing programs in countries with high HIV prevalence.

Experiences of Mothers Living With HIV in a South African Prevention of Mother-to-Child Transmission of HIV Programme: A Qualitative Descriptive Study

ABSTRACT

More than 90% of all HIV infections in children result from mother to child transmission. Elimination of mother-child transmission is a global priority and vital for the improvement of child survival in high-burden, limited resource settings. Retention in HIV care is vital to reduce transmission risk. This qualitative study explored the experiences and adherence challenges of mothers living with HIV of the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme in Khayelitsha, Cape Town, South Africa. Interviews were conducted with purposively selected participants enrolled in a PMTCT programme at a primary care facility. Thematic analysis generated six themes. Findings demonstrate the complexity of living as a woman with HIV in a socioeconomically disadvantaged and marginalized periurban community. For each woman, there is a set of concerns relating to person, home, community, and clinic which may affect her understanding, acceptance of, and adherence to the PMTCT programme.

The HIV paradox: Perinatal mortality is lower in HIV-positive mothers-A field case-control study in Ethiopia

OBJECTIVE

Sub-Saharan African countries have the highest perinatal mortality rates. Although HIV is a risk factor for perinatal death, antioretroviral therapy (ART) programs have been associated with better outcomes. We aimed to investigate how maternal HIV affects perinatal mortality.

METHODS

The authors performed a nested case-control study at Saint Luke Hospital, Wolisso, Ethiopia. Data on sociodemographic characteristics, current maternal conditions, obstetric history, and antenatal care (ANC) services utilization were collected. The association between perinatal mortality and HIV was assessed with logistic regression adjusting for potential confounders.

RESULTS

A total of 3525 birthing women were enrolled, including 1175 cases and 2350 controls. Perinatal mortality was lower among HIV-positive women (18.3% vs. 33.6%, P = 0.007). Crude analysis showed a protective effect of HIV (odds ratio, 0.442 [95% confidence interval, 0.241-0.810]), which remained after adjustment (adjusted odds ratio, 0.483 [95% confidence interval, 0.246-0.947]). Among HIV-negative women, access to ANC for women from rural areas was almost half (18.8% vs. 36.2%; P < 0.001), whereas in HIV-positive women, no differences were noted (P = 0.795).

CONCLUSION

Among HIV-positive mothers, perinatal mortality was halved and differences in access to ANC services by area were eliminated. These data highlight the benefits of integrating ANC and HIV services in promoting access to the health care system, reducing inequalities and improving neonatal mortality.

Prevalence of undiagnosed HIV among children in South Africa, Côte d'Ivoire and Zimbabwe: a model-based analysis to inform paediatric HIV screening programmes

INTRODUCTION

To improve the diagnosis and survival of children living with HIV (CLWH), the World Health Organization recommends testing approaches beyond traditional infant HIV testing programmes. Information about undiagnosed HIV prevalence among children of varying ages in the general population is needed to guide innovative national/subnational case-finding and testing approaches.

METHODS

We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model to estimate the prevalence of undiagnosed HIV in 2-, 5- and 10-year-old children in South Africa, Côte d'Ivoire and Zimbabwe in 2018. We simulated cohorts of children born in 2008 (10-year-olds), 2013 (5-year-olds) and 2016 (2-year-olds). Country-/year-specific inputs for pregnant/breastfeeding women included: HIV prevalence (4.2-32.3%), HIV incidence (0.03-0.24%/month), knowledge of HIV status (27-89%) and antiretroviral drug coverage (36-95%). Paediatric inputs included early infant testing coverage (6-95%) and breastfeeding duration (0-20 months). We projected the proportion of surviving CLWH in whom HIV remained undiagnosed and the undiagnosed HIV prevalence among surviving children of each age in the general population. For children born in 2016, we projected survival and diagnosis of all CLWH through 2026. We conducted sensitivity analyses on model parameters.

RESULTS

In 2018, the projected proportion of surviving CLWH whose HIV remained undiagnosed in South Africa/Côte d'Ivoire/Zimbabwe was 44.2%/55.8%/52.9% among 2-year-old CLWH; 29.0%/37.8%/33.2% among 5-year-old CLWH; and 18.3%/25.4%/23.1% among 10-year-old CLWH. Projected general population undiagnosed HIV prevalence in South Africa/Côte d'Ivoire/Zimbabwe was 0.44%/0.32%/0.68% among 2-year-olds; 0.25%/0.17%/0.41% among 5-year-olds; and 0.24%/0.14%/0.38% among 10-year-olds. Among all CLWH born in 2016, 50-54% were projected to die without HIV diagnosis (and subsequently without treatment) within 10 years after birth; 80-85% of these deaths occurred in the first 2 years.

CONCLUSIONS

Projected population-level undiagnosed HIV prevalence is low and sharply decreases after age 2, with more CLWH dying than being diagnosed. Despite low undiagnosed prevalence in the general population of older children, we project that a large proportion of CLWH remain undiagnosed, suggesting that innovative strategies targeting untested children of all ages outside of health facility settings should be prioritized. Programmes could consider routine testing of the general population of children below 2 in all settings and children of all ages in high-prevalence settings.

HIV Prevention Tools Across the Pregnancy Continuum: What Works, What Does Not, and What Can We Do Differently?

PURPOSE OF REVIEW

Multiple tools exist to support the primary prevention of HIV in pregnant and postpartum women; however, there are opportunities to enhance their use and impact. This review summarizes the current status of HIV prevention tools and existing gaps and opportunities to improve their use along the pregnancy care continuum.

RECENT FINDINGS

HIV screening efforts have steadily improved with close to universal screening of pregnant women in several East and Southern African countries. Strategies to implement partner testing through the distribution of HIV self-test kits are promising though linkage to care remains challenging. Syphilis screening rates are increasing though detection of other sexually transmitted infections could benefit from improved diagnostic capacity. Male and female condoms are rarely used and are often not the optimal tool of choice during pregnancy. Oral pre-exposure prophylaxis (PrEP) is a promising tool, although barriers such as the need for daily adherence, side effects, and stigma may limit its use. There is a growing pipeline of PrEP agents with alternative delivery platforms that might suit women's preferences better and supports the notion that choice is vital to improving HIV prevention coverage during the pregnancy-postpartum continuum. Clear guidance on which tools to use and how to use them, safety data supporting their use, and surveillance data documenting the scale and effectiveness of the tools will be imperative in establishing a path to more impactful prevention efforts among pregnant and postpartum women.

HIV stigma limits the effectiveness of PMTCT in Guinea: the ANRS 12344-DIAVINA study

BACKGROUND

Nearly half of HIV-infected children worldwide are born in West and Central African countries where access to prevention of mother-to-child transmission of HIV (PMTCT) programmes is still limited. WHO recommends reinforced antiretroviral prophylaxis for infants at high risk of mother-to-child transmission of HIV (MTCT) but its implementation needs further investigation in the field.

METHODS

The prospective ANRS 12344-DIAVINA study evaluated the feasibility of a strategy combining early infant diagnosis (EID) and reinforced antiretroviral prophylaxis in high-risk infants as identified by interviews with mothers at Ignace Deen Hospital, Conakry, Guinea.

RESULTS

6493 women were admitted for delivery, 6141 (94.6%) accepted HIV testing and 114 (1.9%) were HIV positive. Among these, 51 high-risk women and their 56 infants were included. At birth, a blood sample was collected for infant EID and reinforced antiretroviral prophylaxis was initiated in 48/56 infants (86%, 95% CI 77%-95%). Iron supplementation was given to 35% of infants for non-severe anaemia. Retrospective measurement of maternal plasma viral load (pVL) at delivery revealed that 52% of women had pVL < 400 copies/mL attributable to undisclosed HIV status and/or antiretroviral intake. Undisclosed HIV status was associated with self-stigmatization (85% versus 44%, P = 0.02). Based on the results of maternal pVL at delivery, 'real' high-risk infants were more frequently lost to follow-up (44% versus 8%, P < 0.01) in comparison with low-risk infants, and this was associated with mothers' stigmatization (69% versus 31%, P < 0.01).

CONCLUSIONS

Reinforced antiretroviral prophylaxis and EID at birth are widely feasible. However, mothers' self-disclosure of HIV status and antiretroviral intake do not allow adequate evaluation of MTCT risk, which argues for maternal pVL measurement near delivery. Furthermore, actions against stigmatization are crucial to improve PMTCT.

Prevalence and factors associated with self-reported HIV testing among adolescent girls and young women in Rwanda: evidence from 2019/20 Rwanda Demographic and Health Survey

BACKGROUND

HIV/AIDS remains a major public health problem globally. The majority of people living with HIV are from Sub-Saharan Africa, particularly adolescent girls and young women (AGYW) aged 15-24 years. HIV testing is crucial as it is the gateway to HIV prevention, treatment, and care; therefore this study determined the prevalence and factors associated with self-reported HIV testing among AGYW in Rwanda.

METHODS

We conducted secondary data analysis on the AGYW using data extracted from the nationally representative population-based 2019/2020 cross-sectional Rwanda Demographic and Health Survey (DHS). We described the characteristics of study participants and determined the prevalence of HIV testing and associated factors using the multivariable logistic regression model. We adjusted all our analyses for unequal sampling probabilities using survey weights.

RESULTS

There were a total of 5,732 AGYW, with the majority (57%) aged 15-19 years, 83% were not living with a man, 80% were from rural areas, 29% were from the East region, and 20% had a history of pregnancy. Self-reported HIV testing prevalence was 55.4% (95%CI: 53.7 to 57.0%). The odds of ever having an HIV test were significantly higher for those aged 20-24 years (aOR 2.87, 95%CI: 2.44 to 3.37); with higher education (aOR 2.41, 95%CI:1.48 to 3.93); who were rich (aOR 2.06, 95%CI:1.57 to 2.70); with access to at least one media (aOR 1.64, 95%CI: 1.14 to 2.37); who had ever been pregnant (aOR 16.12, 95%CI: 9.60 to 27.07); who ever had sex (aOR 2.40, 95%CI: 1.96 to 2.95); and those who had comprehensive HIV knowledge (aOR 1.34, 95%CI: 1.17 to 1.54).

CONCLUSIONS

We report an unmet need for HIV testing among AGYW in Rwanda. We recommend a combination of strategies to optimize access to HIV testing services, especially among the 15-19 years adolescent girls, including facility-based testing, school and community outreach, awareness campaigns on HIV testing, and home-based testing through HIV self-testing.

Factors Associated with HIV Testing among Reproductive Women Aged 15-49 Years in the Gambia: Analysis of the 2019-2020 Gambian Demographic and Health Survey

Voluntary counselling and testing for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) has always been one of the key policy interventions in the management and control of HIV/AIDS transmission. However, the prevalence of HIV testing among reproductive women in the Gambia remains low despite near universal information about HIV and Sexually Transmitted Infections (STIs) in the Gambia. Understanding factors influencing HIV testing uptake provides empirical data for the development of targeted evidenced-based strategies aimed at enhancing HIV testing uptake. Therefore, this study examined the factors associated with HIV testing among reproductive women aged 15−49 years in the Gambia. Data on weighted sample of 11,865 women from the 2019−2020 Gambia Demographic and Health Survey were analyzed in this study. Chi square, bivariate and multivariate logistic regression models were fitted and analysis conducted through Complex Samples Analysis in Statistical Package for Social Sciences (SPSS). Level of significance was set at p < 0.05 and 95% CI. Further analysis was conducted to determine the variability in HIV testing among women stratified by rural and urban centers. Prevalence of HIV testing among reproductive women was 42.1% (95% CI = 40.1−44.2%) in the Gambia. Women aged 20−24 years and 25−29 years (aOR = 3.10, 95% CI = 2.51−3.83) and (aOR = 4.52, 95% CI = 3.61−5.54) were more likely to test for HIV than those aged 15−19 years, respectively. Married women (aOR = 5.90, 95% CI = 4.84−7.02) were more likely to test for HIV compared to those who were not in any union. Respondents with higher education in urban centers (aOR = 2.65, 95% CI = 2.08−3.86) were likely to test for HIV compared to those in rural areas. HIV testing in the Gambia among reproductive women is low. Age, marital status, wealth index, place of residence, educational level, recent sexual activity, previous history of risky sexual behaviors, and history of an STI were associated with HIV testing. Health interventions targeted at increasing HIV testing uptake should factor in these.

HIV self-testing and repeat testing in pregnancy and postpartum in Northern Nigeria

OBJECTIVE

Incident HIV infections in pregnant and breastfeeding mothers pose significant challenges to prevention of mother-to-child HIV transmission efforts in sub-Saharan Africa. We identified the predictors of willingness to self-test for HIV when retesting in pregnancy and postpartum among antenatal clients in a tertiary hospital in Northern Nigeria.

METHODS

Structured and validated questionnaires were administered to a cross section of antenatal attendees (n = 370) in March 2021. Willingness to self-test and adjusted odds ratios of potential predictors were generated from logistic regression models.

RESULTS

Of the 317 respondents who agreed to repeat HIV test during pregnancy, 29.3% (n = 93) were willing to self-test. Similarly, of those (n = 350) willing to retest after delivery, 27.4% (n = 96) were willing to self-test. Willingness to self-test during pregnancy was higher among respondents who were multiparous (2-4 births) (adjusted odds ratio, aOR = 2.40, 95% confidence interval CI, 1.14-6.43), employed (aOR = 1.49, 95% CI, 1.13-4.53) and those with at least secondary education (aOR = 2.96, 95% CI, 1.43-11.47). In contrast, willingness to self-test was lower among those who were unaware of the husband's HIV status (aOR = 0.05, 95% CI, 0.02-0.13). Willingness to self-test after delivery was higher among respondents who were married (aOR = 15.41, 95% CI, 3.04-78.2), multiparous (aOR = 2.01, 95% CI, 1.27-5.63), employed (aOR = 1.59, 95% CI, 1.08-2.35) and had at least to secondary education (aOR = 6.12, 95% CI, 1.36-27.47). In contrast, willingness to self-test postpartum was lower among those who booked late (≥29 weeks) (aOR = 0.11, 95% CI, 0.022-0.52), those who were unaware of the risk of HIV transmission during breastfeeding (aOR = 0.29, 95% CI, 0.12-0.68) and participants who were unaware of the husband's HIV status (aOR = 0.076, 95% CI, 0.03-0.19).

CONCLUSION

Willingness to self-test for HIV in pregnancy and postpartum was low in this population and was influenced by risk perception, socio-demographic and obstetric attributes. Communication interventions and training of potential mentor mothers among early adopters could improve self-testing in this group and similar settings.

Antenatal screenings and maternal diagnosis among pregnant women in Sao Tome & Principe-Missed opportunities to improve neonatal health: A hospital-based study

Newborn mortality and adverse birth outcomes (ABOs) in Sao Tome & Príncipe (STP) are overwhelmingly high, and access to quality-antenatal care (ANC) is one of the strategies to tackle it. This study aimed to fill the gaps in ANC screenings with a focus on how to improve neonatal outcomes. We conducted a retrospective hospital-based study in which ANC pregnancy cards were reviewed. Screenings were described and compared according to the total number of ANC contacts: 1-3 (inadequate), 4-7 (adequate), and ≥8 (complete). The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Statistical significance was considered at a p-value ≤0.05. A total of 511 ANC pregnancy cards were reviewed. Mothers' mean age was 26.6 (SD = 7.1), 51.7% had a first trimester early booking, 14.9% (76) had 1-3 ANC contacts, 46.4% (237) had 4-7 and 38.7% (198) ≥8. Screening absence was found in 24%-41%, lack of money was registered in 36%. Pregnant women had no screening performed for HIV in 4.5%, syphilis in 8.8%, HBV 39.3%, malaria 25.8%, hemoglobin 24.5%, blood glucose 45.4%, urine 29.7%, stool exams 27.8% and 41.1% had no ultrasound. Screening completion for blood group, HIV, malaria, urine, hemoglobin, and coproparasitological exam were found to have a statistically significant difference (p<0.001) for the complete ANC group when compared to other groups. Antenatal problems identified were: 1) bacteriuria (43.2%); 2) maternal anemia (37%); 3) intestinal parasitic infections (59.2%); 4) sickle cell solubility test positive (13%); and 5) a RhD-negative phenotype (5.8%). Missed-ANC treatments were up to 50%. This study reveals a coverage-quality gap in STP since no pregnant woman is left without ANC contact, although most still miss evidence-based screenings with an impact on neonatal outcomes. Strategies such as implementing a total free ANC screening package in STP would enhance maternal diagnosis and prompt treatments.