Prevention of mother-to-child transmission screening among pregnant women in southern Ethiopia from the perspective of the current WHO recommendation

Screening is the process of detecting an undiagnosed disease based on the results of tests, examinations, or other treatments that can be performed quickly.¹ Pregnant women, new mothers, their children, and families can receive a wide range of HIV-related prevention, care, treatment, and support services through prevention of mother-to-child transmission (PMTCT).²

Mother-to-child transmission (MTCT) service programs include preventing HIV infections among women of reproductive age (15–49 years), preventing unwanted pregnancies among HIV-positive women, and providing lifelong antiretroviral therapy (ART) to HIV-positive women to maintain their health and prevent transmission during pregnancy, labour, and breastfeeding. HIV screening for the prevention of HIV transmission from mother to child is the most important intervention point in ensuring that no child is born with HIV (PMTCT).^1,3

In 2016, the United Nation Organization for AIDS (UNAIDS) and the President’s Emergency Plan for AIDS Relief (PEPFAR) developed a framework calling for a worldwide spirit to end HIV/AIDS among children, adolescents, and young women.⁴ The PMTCT program in Ethiopia was launched in 2001 and implemented the service to reduce HIV epidemics in the general population and specifically in children. According to the WHO Prevention MTCT guideline, it was revised in 2007 and 2012.^4,5

Globally, around 1.8 million children <15 years old live with HIV, and 120,000 children died from AIDS-related illnesses in just 1 year. About 95% of these infections are mainly the result of MTCT of HIV during pregnancy, labor, and delivery or during breast feeding.⁶

The burden of disease transmission and death varies by region; nearly 75% occurs in Africa alone, with 91% occurring in sub-Saharan Africa and low- and middle-income countries.⁷ Ethiopia is one of the countries with a high burden of HIV, with around 66,517 children infected with HIV in 2017, where the main sources of child HIV infections were mostly vertical infections and MTCT.⁸ In the absence of therapy, there is a 15%–45% possibility of transferring the virus from mother to child during pregnancy, delivery, and lactation and 50% of all HIV-positive newborns will die before the age of 2 years.⁸ However, effective interventions can decrease the risk to below 5%.⁹

Ethiopia continues to have a low percentage of pregnant women who undergo HIV tests and pregnant women who test positive for HIV who receive antiretroviral medications (ARVs) for PMTCT. According to the Ethiopian demography and health surveillance (EDHS) report, only 19% of pregnant women received HIV counseling, were tested for HIV, and accepted HIV test results during their antenatal care (ANC) visit.¹⁰ Due to a lack of counseling, only a fraction of them are tested for HIV. Pregnant women are rarely tested for HIV in order to get PMTCT services. Furthermore, HIV transmission from mother to child continues to be a significant problem. Many barriers remain unsolved, especially when it comes to HIV testing and antiretroviral medicine for HIV-positive pregnant women.¹¹

According to a recently revised strategy for accelerated implementation of the PMTCT program in the “opt-out” strategy, HIV testing should be offered to all women during pregnancy, delivery, and postnatal care (PNC). However, the achievement has been low and lagging behind.¹² Screening of HIV for PMTCT service is one of the important areas that needs to be confirmed for achievement of the sustainable development goals (SDGs) related to health, mainly SDG 3. It is one of the national prevention priority programs of the Federal Ministry of Health (FMOH). The performance of the annual screening of HIV for PMTCT service was 57% in 2017, which is far below the national target of 91% and has decreased by 8% (from 63% to 57%). However, the HIV positivity yield has increased by about 22% compared with 2016.¹³ In Southern Nations, Nationalities, and Peoples’ Region (SNNPR), only 17.2% of pregnant women were screened for HIV for PMTCT service during ANC visits, where the performance remains very low as compared with the national standard.⁹ In 2010, the EFY Hadiya zone health management information systems (HMIS) report showed that only 42% of pregnant women were screened for HIV for PMTCT during ANC visits.¹⁴ There are a few studies carried out on screening for HIV for PMTCT services in developing countries, particularly in Ethiopia. The studies showed that many barriers were identified relating to screening for HIV for PMCT service.^15,16 Some important factors, such as referral linkage for HIV counseling and testing, were not addressed.

As per the investigator’s search, no previous studies were found that specifically focused on HIV screening for PMTCT service utilization in our study area. Therefore, the aim of our study was to determine the prevalence and identify factors associated with HIV screening in pregnant women.

All pregnant women who were found in the Hadiya zone were the source population, and those selected women in the selected districts during the data collection period were considered as the study population. Pregnant mothers whose gestational age (GA) was 16 weeks or above in the selected kebeles and who gave consent to participate in the study were included. Pregnant mothers who were severely/critically ill, previously diagnosed mentally ill or unable to communicate verbally during the data collection and who did not volunteer to participate in the study were excluded from the study.

The sample size was calculated using a single population proportion formula

Where:

n = is the desired sample size;

Zα/₂ = was the standard score value for 95% confidence level for two-sided normal distribution which is 1.96;

p = the proportion of HIV testing of PMTCT service utilization among pregnant mothers in Mizan Amen; p = 53.7%;¹⁷

d = 0.05, which is the margin of sampling error.

Thus,

So, n = 382, with a design effect of 1.5, 1.5*382 = 573, then adding 10% non-respondent rate, the final sample size was 630.

To select study participants, we have used a multistage sampling technique. At the beginning, 3 districts and 1 town administration were randomly selected from 12 districts and 2 town administrations. In the second stage, we selected 30% of kebeles from selected districts, and after that, the total sample size was proportionally allocated to those selected kebeles. A list of pregnant women was obtained from updated family folders and registration books in the health posts of the selected kebeles and then a sampling frame was prepared. There were 1829 registered mothers in those randomly selected three districts and one town administration. Finally, a systematic random sampling method was used to get mothers by calculating the interval 1829/630 = 2.9 (since it is proportionally allocated, the interval was approximately three in every kebele). The first mother was selected randomly among the first three mothers, and then every third mother was selected systematically from the frame till we got the sample size (Figure 1).

In this study, it was found that only 45% of pregnant women screened for HIV for PMTCT service in their current pregnancy. This finding was lower when compared with the national recommendation set of national PMTCT guidelines, which recommends that every pregnant woman during an ANC visit should be tested for HIV for PMTCT service.⁸ Also, this finding was lower than studies conducted in Sebeta (86.9%),²² Adema (70.1%),²³ Bahir Dar (61.3%),²⁴ and Mizan Amen (53.7%).¹⁶ The possible reason for the difference between the findings might be due to differences in the methodology; this current study considered pregnant women from community-based and systematic sampling methods, whereas the mentioned studies considered ANC attendant mothers from health facilities and used convenient sampling techniques. Another possible reason might be the shortage of access to health services in study settings compared with the mentioned study settings. In addition, this finding is also lower than studies conducted in Uganda (85.5%).²⁵ The difference might be due to the socioeconomical differences, whereas this finding is higher when compared with the findings of the studies conducted in South Gonder (9.7%).²⁶ This discrepancy is due to the time gap between this study and the abovementioned study. As time increases, the awareness of people also increases due to the accessibility and availability of healthcare facilities. Another possible reason due to sociodemographic differences is that this study was conducted in both rural and urban settings, whereas the study conducted in South Gonder was only rural. Furthermore, this result was greater than the 19% found in the EDHS report from 2016.¹⁰ The discrepancy could be due to EDHS including more remote areas than this study area.

Different factors were identified as significantly associated with the screening of HIV for PMTCT service. It was observed from the current study that pregnant women who had education status of secondary and above education (9–12)⁺ were 5 times more likely to be tested for HIV for PMTCT services as compared with those who had no formal education, and maternal educational level who had primary (1–8) levels were 1.79 times more likely to be tested for HIV for PMTCT services than mothers who had no formal education. This finding is supported by a finding from a study conducted in the Afar region, in which women who could read and write were 11 times more likely to be screened for HIV for PMTCT service than those who could not read and write.²⁷ Also, this finding is in line with findings from a study conducted in Wollega zone; pregnant women who had formal schooling were 6 times more likely to be screened for HIV for PMTCT service when compared with those who had no formal schooling. Likewise, a study done in Bahir Dara revealed that more than diploma-educated mothers were 1.43 times more screened for HIV for PMTCT service than those less than the diploma.²⁴ This finding also supports a study conducted in Kenya, where a mother who had an educational level of secondary or above was 1.4 times more likely to be screened for HIV for PMTCT service than those who had no formal education.²⁸ This could be because as mothers’ education levels rise, so does their health literacy, and mothers know what is right and beneficial for them. This may also result in the mothers’ increased decision-making power and enable them to better knowledge and better understanding of the benefits of HIV testing.

In the current study, pregnant women who visited health facilities for ANC 4 or more times during their current pregnancy were 4.25 times more likely to be HIV tested for PMTCT services when compared with those who visited once. This finding is consistent with a study in Gonder that showed a mother who had visited a health facility for ANC 2 or more times was 2.64 times more likely to be screened for HIV for PMTCT service than a mother who had visited once.²⁶ This could be because pregnant women who had more contact with health facilities were more aware of how to use services. Another study done in Adema indicated that a pregnant woman who had more than two visits was 2.59 times more likely to be screened for HIV for PMTCT service than a woman who had visited once.²³ Pregnant women who have more ANC visits are more likely to be checked for HIV and receive PMTCT services. Furthermore, a study conducted in Hawassa found that a mother who had four or more visits to a health facility was 1.04 times more likely to be tested for HIV for PMTCT service as compared with those who had only one visit.²⁹ This is because as the frequency of ANC visits grew, clients were more likely to get complete HIV education and to be concerned about their children’s and own health.

This study illustrates that pregnant women whose nearest health facility was less than 60 min away from their home were 1.93 times more likely to be screened for HIV for PMTCT service compared with mothers who had a distance of more than 60 min. This finding is supported by the finding of a study conducted in the Afar region that indicated that mothers who were nearest to health facilities were 6.5 times more likely to be screened for HIV for PMTCT service than their counterparts.²⁷ Another similar study done in Ethiopia applying a count regression showed that an increase in walking distance from a health facility would decrease the screening of HIV for PMTCT service³⁰ This might be due to having better access during ANC to PMTCT services, better education, information, and awareness about the PMTCT service.

Finally, this study showed that respondents who had high male partner involvement during ANC were 1.88 times more likely to be screened for HIV for PMTCT service when compared with those who had less male involvement. This finding is also consistent with the research conducted in Cameroon, where male partner involvement exceeds PMTCT service utilization by 16.8%.³¹ The findings of studies conducted in Wollega zone, Ethiopia, where people were 4.5 times more likely to be screened for HIV for PMTCT services than those who were not involved,³² and a study conducted in Bahir Dar indicated that involvement of a male partner has a significant association with women’s acceptance of voluntary HIV counseling and testing, which was 2.76 times more likely to be screened for HIV for PMTCT service when compared with pregnant women who had a male partner not involved.²⁴ This might be because if there is male partner engagement, it improves free HIV testing communication and boosts couples’ disclosure communication.

The magnitude of HIV testing among pregnant women in the study setting was 45%, which was lower coverage when compared with the national recommendation that every pregnant woman during an ANC visit should get HIV testing. In this study, male partner engagement, educational status (primary or above), number of ANC visits, and distance less than 60 min from the health facility were all found to be substantially linked with HIV testing for PMTCT. The government should ensure accessibility of services in the community by making them closer, female education, and enabling health extension workers by training and encouraging them to promote PMTCT services.

The authors give special thanks to the data collectors, supervisors, study participants, and the Gibe district health office. They also thank Jimma University.