Introduction
Globally, HIV/AIDS is a significant public health concern affecting communities. With an estimated 38.4 million (33.9–43.8 million) people living with HIV in 2022, 53% of them being women and girls, 1.5 million children, 1.5 million new infections (ranging from 1.1 to 2.0 million) that year, and 650,000 AIDS-related deaths (ranging from 510,000 to 860,000) in 2021, the global HIV numbers are alarming. Furthermore, Sub-Saharan Africa (SSA) bears the highest burden of the HIV epidemic, accounting for more than two-thirds of the cases [
1‐
4]. In SSA, women experience a disproportionately high prevalence of HIV, despite the already elevated overall risk of HIV infection in the population. This means that women in SSA face a greater burden of HIV compared to other demographic groups, highlighting the urgent need for targeted interventions and strategies to address this disparity [
5,
6]. Although they constitute a smaller proportion of the overall population, adolescent girls and young women account for approximately one in three new infections [
6,
7]. Compared to their male counterparts, women in SSA are five times more likely to be living with HIV and have contracted the virus five to seven years earlier [
6‐
8]. Various biological, social, cultural, behavioral, economic, and structural variables contribute to this heavy burden [
9,
10]. In terms of social factors, the deterioration or inequality in education, poverty, unemployment, and access to other social services can lead to a loss of opportunities for HIV prevention, particularly among women. Behavioral factors, including abstinence or delaying sexual debut, improper condom use, engaging in unsafe or forced sex, practicing polygamy, increasing the number of sexual partners, and not participating in voluntary counseling and testing, also play a significant role [
10‐
12]. Additionally, being asymptomatic for sexually transmitted infections (STIs) poses a challenge for HIV infection prevention among women in SSA. Biological factors like this contribute to the complexity of addressing HIV transmission in the region [
10,
13]. Furthermore, according to the UNAIDS analysis of HIV prevalence in Kenya (2018), women account for 65% of the HIV-positive population, and the incidence among young women (11,000) is more than twice that among young men (5000) [
14].
Regarding the incidence of HIV infection Pre-exposure prophylaxis (PrEP) has been shown to have significant promise for significantly reducing HIV transmission among important populations worldwide [
15]. Hence, the World Health Organization (WHO) advises including PrEP in HIV prevention packages for women living in high-burden environments [
16]. The uptake of PrEP among women in SSA remains low, despite a significant percentage of women being vulnerable. However, there is a lack of evidence to support further investigation in this area. Additionally, a WHO report indicates that while there is increasing recognition of the potential of PrEP as an additional HIV prevention strategy, many countries are still in the early stages of exploring effective implementation methods. Moreover, the availability of PrEP outside of research and demonstration projects in lowand middle-income countries has been limited, resulting in a lack of practical experience in its provision [
17].
When PrEP is used as directed, it significantly reduces the risk of contracting HIV through sexual activity by 99% and through injectable drug use by 74%) [
18,
19]. Other studies have shown that when taken daily, PrEP prevents HIV acquisition in women by > 90% [
20,
21]. However, in SSA, the implementation of PrEP involves several multidimensional challenges. These obstacles can be divided into three categories: patient-related, clinical, and community. Patient-level obstacles include misperceptions of risk, concerns about side effects, and lack of knowledge regarding PrEP [
22,
23]. Clinic-level obstacles include inadequate patient communication, overworked personnel, excessive caseloads, and limited clinician competence [
23‐
25]. Stigma around premarital sex; stigma associated with HIV; restricted access to PrEP outside medical institutions; and a lack of support from partners, parents, and community members who could have an impact on a patient’s decision-making are examples of community-level hurdles [
23,
26,
27]. Challenges are continuing in developing countries, particularly in SSA.
There has been modest progress in overcoming obstacles to PrEP implementation, such as start and adherence, in countries where the PrEP initiative has been implemented [
28,
29]. These successes are attributed to recognizing the needs of young women and girls within the context of their local communities, emphasizing their empowerment, and addressing institutional obstacles. However, there is a lack of nationally representative data to examine women’s attitudes and knowledge levels in these nations, and this study represents the first of its kind in SSA. One of the significant objectives of this study is to bridge the knowledge gap by exploring factors, empirical evidence, populations, and up-to-date information for relevant stakeholders. Monitoring the uptake, adherence, and retention of PrEP programs is crucial for scaling up treatment in SSA countries through national health systems. Specifically, our focus was on the five countries included in the Demographic and Health Survey (DHS) report from 2021 to 2022, as they were the only SSA countries with available data on HIV PrEP knowledge and attitudes among women. Furthermore, gaining insights into the factors that influence patients’ decisions to initiate PrEP will contribute to the development of more affordable PrEP therapies and enhance HIV prevention efforts in the region. Therefore, using data from the most recent nationwide health survey, this study aimed to investigate women’s knowledge and attitudes, considering both individual- and community-level characteristics, in five African countries.
Discussion
This study aimed to investigate women’s knowledge and attitudes toward PrEP for preventing HIV infection in five countries in SSA while considering individual- and community-level factors. The final model identified several factors associated with the outcome variables. At the individual level, maternal age, education, wealth index, ANC follow-up, place of delivery, sex of the household head, knowledge about modern contraception, media exposure, and awareness of STIs were found to be independently associated with women’s knowledge and attitudes toward PrEP. In terms of community-level factors, community illiteracy, community mass media exposure, community ANC coverage, community wealth, and rural/urban residence were significantly related to women’s knowledge and attitudes toward PrEP. These findings highlight the importance of considering both individual and community contexts when examining knowledge and attitudes regarding PrEP in the study population.
In this study, older women were shown to be more knowledgeable and had a positive attitude toward HIV PrEP than adolescent women. According to the search results, there is no clear evidence that older mothers have better knowledge of and attitudes towards HIV PrEP than young females. However, a study conducted in rural Western Kenya found that there is an interest and willingness to take PrEP among a substantial minority of older individuals at an elevated risk of HIV [
39]. Women and girls comprise nearly half of HIV-infected individuals globally and 20% of new infections, indicating an urgent need to optimize HIV prevention options, including PrEP, in this population [
40,
41]. PrEP is highly effective in preventing HIV when taken as indicated, and there are two Food and Drug Administration (FDA)-approved daily oral medications for PrEP [
42]. Thus, older mothers may have better knowledge and perspectives based on their experiences. Therefore, since the disease affects the youth more, these young females should have a better understanding of the disease and different programs should take them into consideration.
Primary and secondary/higher-level educated women have revealed a higher level of knowledge and good attitude about HIV PrEP compared to formally uneducated women. Educated mothers may have better knowledge and attitudes towards HIV pre-exposure prophylaxis (PrEP) because of their access to health information, awareness programs, and possibly higher health literacy [
42]. Research suggests that health professional education plays a crucial role in increasing awareness and knowledge of PrEP for HIV prevention [
43,
44]. Additionally, educational attainment is often associated with better access to healthcare services and the ability to understand and effectively utilize health information [
44,
45]. This can lead to improved awareness and understanding of preventive measures, such as PrEP. Furthermore, education may also be linked to a higher socioeconomic status, which can provide better access to healthcare and health-related information [
45]. Overall, the combination of access to information, awareness programs, and higher health literacy due to education may contribute to better knowledge and attitudes towards HIV PrEP among educated mothers.
Rich women, and those from rich communities may take HIV PrEP more often than poor mothers due to socioeconomic inequalities. Research has shown that wealthier individuals have better access to healthcare services including HIV testing and prevention. For example, a study in East Africa found that women of higher socioeconomic status utilized more HIV testing services than their counterparts, indicating pro-rich inequalities in prenatal HIV test service uptake [
46,
47]. Another study in South Africa reported that early HIV testing appeared to be higher in the lower 40% wealth group than in the higher 40% wealth group [
48]. Additionally, a study in the United States, and SSA highlighted how factors such as poverty, unemployment, and inadequate access to healthcare can contribute to women’s increased vulnerability to HIV [
49‐
51]. These findings suggest that socioeconomic factors play a significant role in the implementation of HIV prevention measures, with wealthier individuals having better access to such services. Therefore, policies and strategies should focus on inequalities and disparities in access to healthcare.
Those who have received ANC follow-ups, delivered in health facilities, and have knowledge about modern contraception have shown a positive association for HIV PrEP knowledge and attitude as compared to their counterparts. Mothers who received ANC, delivered in health facilities, and had knowledge about modern family planning were more likely to have better knowledge and a positive attitude towards HIV PrEP than those who did not. This is because of several factors: maternal and child health visits provide opportunities for healthcare providers to educate and counsel women about HIV prevention, including the use of PrEP [
52]. This education can lead to increased knowledge and awareness of PrEP [
53]. Healthcare providers play a critical role in delivering PrEP in maternal health service settings. Their knowledge and positive attitudes toward PrEP can influence its acceptance and uptake among pregnant women [
53,
54]. Furthermore, integration of HIV services into maternal health settings has been shown to improve the uptake and retention of services related to prevention of mother-to-child transmission (PMTCT) [
55,
56]. This integration can lead to increased awareness and acceptance of HIV prevention strategies including PrEP. In summary, ANC, contraceptives, and institutional delivery provide opportunities for education, counseling, and the integration of HIV services, which contributes to increased knowledge and positive attitudes towards HIV PrEP among women.
Women who had information about STIs and mass media exposure showed a positive impact on HIV PrEP knowledge and attitude as compared to those who did not have information about STIs and mass media exposure. Exposure to mass media can increase the awareness and knowledge of HIV PrEP among women. Women’s low level of awareness of HIV PrEP has been linked to the lack of PrEP advertising in places where women seek healthcare [
57]. Studies have shown that mass media campaigns can be effective in increasing knowledge and behavioral changes related to HIV prevention [
58]. Social media platforms, such as television, radio, and books, other social media platforms can also be used to provide PrEP information to women [
59,
60]. Therefore, mass media campaigns and social media platforms can be used to increase awareness and knowledge of PrEP among women, which can lead to better attitudes towards PrEP and increased uptake of medication. Moreover, if countries use social media according to the culture and lifestyle of their people and their level of education, they can reduce the spread of the disease by instilling preventive measures, such as PrEP.
Women from rural areas showed a lower likelihood of knowledge and attitudes about HIV PrEP than urban dwellers. Rural women in Africa may not take HIV PrEP compared to urban women due to several factors. Rural women often face challenges in accessing healthcare services, including HIV testing and prevention, due to factors such as distance to healthcare facilities, lack of transportation, and limited resources [
46], however, wealthier individuals, including urban women, have better access to healthcare services, including HIV testing and prevention [
47]. Rural women may struggle to afford the costs associated with PrEP such as transportation, consultation fees, and medication [
46]. Furthermore, rural women may experience higher levels of stigma and social exclusion due to their HIV status, which can discourage them from seeking healthcare services and accessing PrEP [
46], and have lower levels of awareness about HIV prevention methods, including PrEP, due to limited access to information and resources [
46]. Similarly, integrating HIV PrEP into family planning services for women in sub-Saharan Africa has faced several challenges, including difficulties in translating policy into practice, optimizing access, uptake, and effective use among populations at risk of acquiring HIV [
47,
61]. Despite these challenges, studies have shown that providing universal access to PrEP in rural settings can be associated with lower HIV incidence among persons who initiate PrEP compared with matched recent controls [
62]. Efforts to improve access to HIV PrEP among rural women in Africa should focus on addressing socioeconomic inequalities, improving access to healthcare services, and addressing stigma and social exclusion.
Empowered women in Africa are more likely to receive HIV PrEP because of their increased ability to make decisions about their sexual behavior and negotiate safe sex practices. Research has shown that women’s empowerment is strongly associated with their ability to ask their partners to use a condom, refuse sex, and make decisions about their sexual behavior, which are all important factors in HIV prevention [
63,
64]. Additionally, women’s empowerment has been linked to better health behaviors and outcomes, including HIV testing. This is significant in the context of SSA, where fear of a partner’s reaction is a major barrier to HIV testing in many women. Therefore, empowering women and young girls has the potential to contribute to better health outcomes and to reduce the risk of HIV transmission. The “DREAMS” initiative of the United States [
65]. The Agency for International Development also aims to empower adolescent girls and young women to reduce their HIV risk through various interventions, including social asset building and reproductive healthcare [
63,
64].
Strength, and limitations of the study
The utilization of nationally representative surveys from five African nations to evaluate knowledge and attitudes toward HIV PrEP to prevent HIV infection among key segments of the population (women) and related individual- and community-level factors is a fundamental strength of this study. Therefore, we believe that our findings are applicable to these countries. Another significant strength of this study was the incorporation of various possible factors of the outcome variables using an advanced mixed-effect model approach. Furthermore, the study data were gathered using conventional and verified data-gathering procedures, which could be another strength of this study. Finally, since this study is the first in its kind, it will serve as a foundation for future researchers, policymakers, and health professionals. However, the study has the following limitations. First, a cause-and-effect link cannot be demonstrated due to the cross-sectional nature of the study. Second, there might be recall bias, because it depends on self-reported statistics. Issues including accessibility to treatment, sociocultural-related factors, issues pertaining to health professionals, and support programs were not included in the analysis. Ultimately, due to limitations in data availability and constraints, we had to depend on surveys conducted in different countries within the selected countries. Therefore, more country specific studies might reveal the real scenario. This was necessary because of the data constraints we encountered and the availability of information from various sources.
Conclusions and the way forward
This study found that women knowledge, and attitude to HIV PrEP among five SSA countries women was low. Women’s knowledge, and attitude to HIV PrEP was determined by several individual, and community level factors. Generally, less than one-seventh of women of reproductive age have shown knowledge, and attitude to HIV PrEP. Factors like maternal age, educational attainment, wealth index, exposure to the media, knowledge of modern contraceptives, ANC, health facility delivery, hearing about STIs, employment status, sex of household heads, giving birth, community level ANC coverage, community institutional delivery, community exposure to the media, illiteracy in the community, community wealth, and place of residence were found to be associated with knowledge and attitude toward HIV PrEP to prevent HIV infection among women from five SSA countries after confounders were considered.
Thus, efforts must be made to overcome the barriers that prevent women from using HIV PrEP in order to slow the spread of HIV/AIDS. Therefore, all parties active in HIV/AIDS prevention and control, regardless of nationality, ought to take into account the aforementioned variables. There will be benefits from assisting economically disadvantaged women and improving HIV PrEP education in the workplace and educational settings. Additionally, improving maternal health services, including institutional delivery, contraception, ANC, and women’s empowerment, as well as transforming the media and seizing these changes, will increase the nation’s understanding of and attitude toward HIV PrEP. Consequently, women’s health will be preserved and the prevalence of HIV/AIDS would decline.
When HIV prevention programs are implemented, considering young women, expanding access to health coverage, involving uneducated and rural women in community-wide programs, and creating awareness skills through the mass media that respects the culture and tradition of the people, and providing free drugs in large quantities, it is possible to increase women’s knowledge and improve their attitudes. We urge other countries to add information to the national population and health survey and to conduct other studies. It is advisable to consider cultural-related variables and to explore the use of spatial epidemiology approaches.