Utilization of HIV testing services among pregnant mothers in low income primary care settings in northern Ethiopia: a cross sectional study

HIV continues to pose a major problem globally. More than 90% of new global pediatric HIV infections are in sub-Saharan Africa [1]. According to the HIV/AIDS estimates of the Central Statistical Agency of Ethiopia in 2014, 3886 children in the country acquire HIV infection every year [2]. Mother to child transmission (MTCT) is a major source for pediatric HIV infection. In the absence of any preventive measures, the risk of a baby acquiring the virus from an infected mother ranges from 15 to 45%, which occurs during pregnancy, childbirth or breast feeding [3].

HIV testing of women of child bearing age is an entry point for PMTCT (prevention of mother to child transmission). It is one of the primary prevention strategies for MTCT. HIV testing is an effective intervention to increase PMTCT [4]. However a significant number of women in HIV epidemic regions have not been tested for HIV [5]. Utilization of HIV testing services in sub-Saharan Africa is low; even where such services are available, women are not receiving the full benefits [1].

Previous studies have identified socio-demographic status [6‐13], knowledge of MTCT& PMTCT [14‐16] and attitude towards HIV/AIDS [17‐19] as factors that determine uptake of HIV testing. However, the relative contribution of these factors to HIV testing varies from study to study and from population to population. Studies conducted in Ethiopia on HIV testing of pregnant mothers were mainly on acceptance and refusal of the test offered by the counselors at PMTCT sites during antenatal care [20‐22]. Studies that identify proportions and factors associated with actual HIV testing among pregnant mothers are scarce. This study will contribute to identifying obstacles to take up HIV taking in pregnant women in order to develop a more comprehensive & multidisciplinary approach to scale up HIV testing services in resource limited settings. We aim to identify the proportion of and factors for HIV testing among pregnant women in Ethiopia.

In this study 67% of pregnant women were tested for HIV. It was lower than studies conducted in Vietnam (90%) and Cambodia (76%) [24, 25]. This could be due to differences of in knowledge and attitude towards HIV/ADIS, MTCT or PMTCT.

In our study women of older age were less likely to be tested for HIV. In contrast a study conducted in Cameron showed that pregnant women between the age range of 25 and 30 years were more likely to be tested for HIV compared with pregnant women age less than 20 years. On the other hand, a study conducted in Georgia showed that the age of the mother was not a determinant of opting for HIV testing [26].

Our study also showed that pregnant women who attended secondary education or above were more likely to be tested for HIV compared with pregnant women who did not attend formal education, consistent with previous studies in Nigeria and Tanzania that showed an association between higher educational level and HIV testing [7, 9]. However other studies level of education was a statistically significant factor for HIV testing [25, 26]. This could be due to variations in what is taught at schools.

The findings of this study showed that women from urban areas were more likely to be tested for HIV compared with women from rural areas and this is consistent with other studies [16, 17, 25]. This could be due to lower access of HIV testing centre in women from rural areas. Women who lived closer to the hospital were more likely to be tested for HIV [10].

A study showed that lower income was associated with a lower likelihood of pregnant women getting counseling for HIV testing [11]. Similarly our study indicated that women whose monthly expenditure was ≥30 USD were more likely to be tested for HIV compared with women whose monthly expenditure was <30 USD. HIV testing service in Ethiopia is free of charge for study participant as well as the general population. The observed association between monthly expenditure and HIV testing could be related to the capacity to afford transport and access to information such as having radio and television. Distance and transport costs were barriers to access PMTCT services [12].

HIV testing among women was negatively associated with parity. Compared to nulliparous women, parous women were more likely to refuse HIV testing after counseling [6, 13]. In this study, pregnant women who have not had any children were more likely to be tested for HIV compared with multiparous pregnant women who had five or more children.

Pregnant women attending antenatal care who had previous knowledge about prevention of mother-to-child transmission of HIV were more likely to be tested for HIV [14, 15]. In this study subjects who had comprehensive knowledge of mother to child transmission of HIV were more likely to be tested for HIV. Pregnant women with a high PMTCT knowledge score and knowing someone who receives antiretroviral therapy for PMTCT, were more likely to be tested for HIV [16]. Similarly in our findings respondents who had comprehensive knowledge of PMTCT were more likely to be tested for HIV. This could be due to higher perceived benefit of HIV testing among women who had better knowledge of MTCT and PMTCT. Studies have identified lack of HIV risk perception, perception of poor health care support, worry about husband’s disapproval, fear of knowing their HIV status, need to have their partner consent, stigma and poor perceived quality of post-test counseling for positive test result as some of the reasons women were tested for HIV [16‐19]. Some of the potential gaps for HIV testing for pregnant women are lack of knowledge, stigma and discrimination. According to guidelines on the prevention of mother-to-child transmission of HIV in Ethiopia, male partner involvement, community based mother’s support, involving PLWHIV (people live with HIV) in campaigns to reduce stigma and discrimination are strategies to increase the uptake of HIV testing and PMTCT service as a whole [3]. Efforts to increase knowledge on HIV testing amongst mothers, to decrease stigma of HIV, and to increase partner support have been in place after our study was conducted. These efforts could make HIV testing better today in our study population. However, studies identified that only 20% of male partners are involved PMTCT of similar settings in northern Ethiopia [27, 28].

In this study mothers who lack of HIV risk perception were less likely to be tested for HIV. On the other hand, mothers who had a favorable attitude towards HIV positive living were more likely to be tested for HIV. Many women were not tested for HIV because of perceived low risk of HIV. Among Ethiopian women HIV prevalence in 2013 was 1.7% [2].

One third of pregnant women had never been tested for HIV until the time of the study. Implementing information, education and behavioral change communication on HIV positive living, MTCT and PMTCT are very useful to scale up HIV testing. Enhancing mother’s HIV risk perception in resource limited setting is highly recommended (Additional file 1).