Knowledge about mother-to-child transmission of HIV (MTCT) and its determinants among reproductive age (15-49 years) women in Ethiopia: multi-regional based study

¹Debre Tabor University, College Health Sciences, Ethiopia

^&Corresponding author
Solomon Demis, Debre Tabor University, College Health Sciences, Ethiopia

Introduction    

Mother-to-child transmission (MTCT) of the Human immune deficiency virus (HIV) is the transmission of HIV infection from HIV-infected mothers to their infants [1]. Globally, progress has been made towards ending Acquired Immune Deficiency Syndrome (AIDS) as a public health threat. Based on World Health Organization (WHO) 2020 HIV report, about 38.0 million people living with HIV worldwide, and an estimated 17.8 million were women, constituting 51% of all adults living with HIV. In the absence of any intervention, transmission rates of MTCT range from 15%-45% [2,3]. The lowest MTCT rate was in Botswana, and the highest MTCT rates were in Congo (34%) and Ethiopia (25%) among sub-Saharan African countries [4].

The burden of MTCT is high in Low and Middle-Income Countries (LMICs). Sub-Saharan Africa is a highly affected region; with an estimated 25.6 million people living with HIV in 2015, 59% represent reproductive age women [1], and 90% of HIV positive pregnant women worldwide [5]. There were nearly 1.2 million HIV-exposed infants as per the report of United Nations International Children's Emergency Fund (UNICEF) [6]. Ethiopia is among the ten countries in the world with the highest burden of HIV infections in children [6,7]. In Ethiopia 65% of people living with HIV and 92% of pregnant women living with HIV have been accessed Active Retroviral Therapy (ART), preventing 3,700 new HIV infections among newborns [8].

Several factors contribute to increasing the transmission rate such as facing at least one pregnancy, lack of awareness on HIV status, failure to access to ART prophylaxis, poor adherence to ART, lack of clinic-based HIV education and counseling , and factors decreasing the rate of transmission are higher education level, higher household wealth level, urban residency, being exposed to mass media, being exposed to HIV/AIDS education, knowledge on HIV/AIDS. Having taken HIV test and living with HIV have been identified as contributing factor for knowledge increment of pregnant women about MTCT [9-12]. Moreover, advanced disease (stage 3 and 4), vaginal delivery, mastitis, nipple fissures, breast abscess, mixed breast and bottle feeding, living in the rural, long duration of breastfeeding (>12 months), failure to receive antiretroviral therapy (ART) during pregnancy or breastfeeding, and home delivery were factors that increase risk of MTCT [13-17]. Expanded access to and uptake of ART during pregnancy has helped to drive significant global reductions in mother-to-child HIV transmission (MTCT) [18,19]. Currently, there is an increment in the number of facilities providing prevention of mother-to-child transmission of HIV (PMTCT) services in Ethiopia. In 2014 a total of 2,542 government and 153 private health facilities were implementing PMTCT, reaching a 97% target achievement at the national level [20].

However, evidence from 2011 EDHS data showed that the overall knowledge of pregnant women about MTCT was very low at 34.9% [11]. Besides, studies in a different part of Ethiopia identified that knowledge of pregnant women about MTCT ranges from 93.6% in southeast Ethiopia [21], 65.9% in the Benchi-Maji zone [22], 19% in Mekaten [23], and 57.5% in Assossa [11]. Prevention of HIV transmission from HIV-infected women to their offspring is one of the four prongs of PMTCT HIV. Hence, antiretroviral treatment and other effective PMTCT interventions can reduce this risk below 5% [24]. As a result, Ethiopia had launched option B+ in 2013 by which lifelong antiretroviral treatment is provided to all pregnant and breastfeeding women living with HIV regardless of CD4 count or WHO clinical stage [5]. Despite the achievement, MTCT of HIV has remained a challenge for the country. One reason could be related to poor knowledge of the mother on MTCT, and its preventive strategies. So, the current study was intended to assess reproductive-age women's knowledge on mother-to-child transmission of HIV and its determinant factors in Ethiopia.

Methods     

Data source, study population, and sampling technique: a secondary data was analyzed from Stratified two-stage cluster sampling conducted among nine regional states in Ethiopia from January 18 to June 27, 2016. In Ethiopia, there are nine regional states (Afar, Amhara, Benishangul-Gumuz, Gambelia, Harari, Oromia, Somali, Southern Nations, Nationalities, and People´s Region (SNNP) and Tigray) and two city administrations (Addis Ababa and Dire-Dawa). Each region was stratified into urban and rural. Stratified two-stage cluster sampling was performed. Samples of Enumeration areas (EAs) were selected independently in each stratum in two stages. Firstly, a total of 645 EAs (202 in urban areas and 443 in rural areas) were selected with probability proportional to EA size. The target group was all reproductive-age women (15-49 years) in the selected enumeration areas [25]. Data was extracted from 14,599 reproductive age (15-49 years) women. An approval letter was obtained from the measure DHS and the data set was downloaded from the DHS website. (http://www.dhs program.com).

Variables: the main outcome of interest was knowledge of reproductive-age women on Mother-to-Child Transmission of HIV (MTCT). Each reproductive-age woman was asked whether HIV can be transmitted from mother-to-child with multiple options with: (1). During pregnancy (Yes, No), (2). During delivery (Yes, No), (3). During breastfeeding (Yes, No) (4). During pregnancy, delivery, and breastfeeding (Yes, No) (5). Reduce the risk of transmission by taking certain Antiretroviral drugs (ARDs) (Yes, No). Those questions were added and dummy coded so that respondents who reported "Yes" to three of the five questions were categorized as having good knowledge of MTCT, others to poor knowledge of MTCT coded as “No” [26].

Independent variables: socio-demographic variable includes: age, residence, marital status, educational status, wealth index, ever tested for HIV, know a place to get HIV test, media exposure. Comprehensive knowledge was expressed as: 1) Know the two primary prevention methods (use of condoms and having just one uninfected faithful partner that reduce the chance of getting HIV; 2) Know that a healthy-looking person can have HIV; 3) Reject the two most common local misconceptions about HIV/AIDS transmission or prevention (HIV cannot be transmitted by mosquito bites, HIV cannot be transmitted by supernatural means, a person cannot become infected by sharing food with a person who has HIV). Finally, dummy coded as having Comprehensive knowledge if the answer "Yes" to the 3 questions, otherwise "No". Risky sexual behavior on women who had multiple sexual partners, higher-risk sexual partners, condom use with multiple partners, and condom use at last high-risk sexual intercourse.

Statistical data analysis: the data was obtained from national survey Data from 2016 EDHS using previous validated demographic and health survey 2011, EDHS 2009 tool the extracted data were cleaned, recorded, and analyzed using SPSS statistical software version 24. Sampling weight was applied for all analysis procedures to account for complex survey design and unequal probabilities of selection. Rao-Scott chi-square test that adjusts for complex sample design was used to examine the association of two variables (Exposure with the outcome). Data which is hierarchical and clustering nature, sampling weight was applied for all analysis procedures to account for complex sample survey design and unequal probabilities of selection. Rao-Scott chi-square test that adjusts for complex sample design was used to examine the association of two variables. Due to the fact that varies from cluster to cluster, interclass correlation was calculated and found to be 9.2% since it is lower than the expected (10%), we used binary logistic regression model All variables with a p-value ≤ of 0.25 in the bi-variable analysis were entered into the final model for multivariable analysis. Variables with p values ≤0.05 in multivariable binary logistic regression model analysis were considered statistically significant. Finally, the result was presented using tables and texts. The ethical approval letter was obtained from The Demographic and Health Surveys (DHS) Program written on January 03, 2021.

Results     

Socio-demographic characteristics of women: a total of 14,599 reproductive-age women were involved in this study. Around 5,750 (39.4%) of reproductive age women were in the age category of 15-24 years old. More than three quarters, 11,162 (76.5%) of the participants were from rural areas. The education status of the participants advocated that 6,633 (45.4%) had no formal educational background (Table 1). The current study showed that more than three quarters, 12,673 (86.8%) [95% CI; 86.3, 87.3] of reproductive age women had good knowledge of MTCT. Less than half of the respondents, 6,699 (45.9%) had media exposure to MTCT. Furthermore, around 6,930 (47.5%) of the participants were ever been tested for HIV (Table 2). Factors associated with knowledge of women on MTCT: binary logistic regression analysis was used to determine associated factors of knowledge of reproductive age women towards MTCT. Bi-variable analysis showed that age, residence, marital status, educational status, wealth index, media exposure, know a place to get HIV test, ever been tested HIV and comprehensive knowledge of HIV were associated with awareness of reproductive age women on MTCT. However, in multivariable analysis factors such as educational status, exposure to media, wealth index, know a place to get HIV test, ever been tested for HIV, and comprehensive knowledge of HIV were significantly associated (Table 3). Hence, reproductive-age women who had an educational level of primary, secondary and higher education were 1.55 ,1.97 and 2.73 times more likely of having good knowledge on MTCT [AOR = 1.55, 95% CI; 1.28,1.88, AOR = 1.97, 95% CI; 1.28, 3.04] and [AOR = 2.73, 95% CI; 1.52, 4.88] than no formal education respectively. On the other hand, reproductive age women with a wealth index of the middle were 1.31, and 1.9 times more likely knowledgeable than the poor, [AOR = 1.31, 95% CI; 1.02, 1.67] and richest [AOR = 1.9, 95% CI; 1.22, 2.95]. In addition, women who had media exposure were 1.41 times more likely to have good knowledge than women who had not media exposure [AOR = 1.41, 95% CI; 1.16, 1.71]. Besides, reproductive-age women who knew the place to get HIV test were 1.34 times higher odds of knowledge on MTCT [AOR = 1.34, 95% CI; 1.09, 1.66] than those who did not know. Reproductive age women who had comprehensive knowledge about HIV were 2.48 times more knowledgeable than women who had not comprehensive knowledge [AOR = 2.48; 95% CI; 2.04, 3.01]. Furthermore, women who had ever been tested for HIV were 1.5 times more likely to have good knowledge of MTCT than women who never tested [AOR = 1.5: 95% CI; 1.24, 1.82].

Discussion     

Prevention of mother-to-child transmission of HIV requires knowledge of reproductive-age women towards MTCT of HIV. Thus, this study was intended to assess the knowledge of reproductive-age women towards MTCT and associated factors in Ethiopia. In Ethiopia, the knowledge of reproductive age women towards MTCT accounts for 86.8% [95% CI; 86.3, 87.3] which is consistent with the finding from Kenya [27,28]. The consistency could be because both studies used national demographic analysis with nearly similar sample sizes. But, our finding is higher than the finding from small sample size in some parts of Ethiopia at Mecha District, 31.4% [29], Assosa district, 57.5% [10], Southern Ethiopia, and 11.5% [30]; and EDHS 2011, 34.9% [11], Cameroon, 79.3%, Zimbabwe, 70.5% [31], South Africa, 30.8% [32], India, 50.8% [33] and Pakistan, 14.3% [34]. This disparity could be explained because the sample size used in our study is larger than the aforementioned countries. In addition, the recent study period increases the health service quality and coverage including MTCT and access to information and education than earlier study period.

Similarly, another finding from Gondar, 88.5% [35], Tikur Anbessa and Zewditu memorial hospital, 89.8% [36], and Surat, 91% [37] showed better knowledge of reproductive age women on MTCT than our study. This clear difference could be because most of the studies were conducted at the institution level with probable higher access to education, information, and knowledge on MTCT. Beyond reproductive-age women's knowledge on MTCT, this study also assessed reproductive-age women's knowledge on MTCT and its association with different variables. Among the socio-demographic factors higher educational level of the women had a positive association with knowledge on MTCT. This finding is in agreement with previous findings from Gondar [35], EDHS 2011 [11], Surat [37], and Pakistan [33]. The positive association could be because; those who had a higher educational level might get information about MTCT by reading different sources like magazines and newspapers. The odd of knowing MTCT was higher among reproductive-age women with the increased level of wealth index. This is similar to the finding from EDHS 2011 [11]. A higher wealth index may increase the confidence of the women to get access to ANC and MTCT independently. They may also get the chance to learn from a health professional.

In our study, only 41% of reproductive-age women received information on MTCT from the media. This is similar to a finding from EDHS 2011 [11] and Kenya [30]. Different media may transmit information directly related to MTCT. Exposure to media increases the knowledge of reproductive-age women on MTCT. Similarly, reproductive-age women who knew the place to get HIV test were higher odds of knowledge on MTCT. Those women who know the place to get HIV test could have the confidence to get the service. This may heighten the information related to MTCT and increase the knowledge of reproductive-age women on MTCT. Comprehensive knowledge of HIV, ever been tested for HIV showed significant association with knowledge on MTCT. This is consistent with the study conducted in Zimbabwe (32). Ever been tested women may get post-tested counseling which may increase the knowledge of reproductive age women on MTCT.

Conclusion     

he awareness of reproductive-age women on MTCT is still low in Ethiopia. Higher educational level, higher wealth index, exposure to media, know a place to get HIV test, comprehensive knowledge of HIV, and ever been tested for HIV were significantly increased the knowledge of reproductive age women on MTCT. Strengthening HIV test coverage and post counseling testing service needs to be focused on to increase knowledge of reproductive age women on MTCT. It is highly recommended to increase the media coverage of MTCT using different media platforms.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Solomon Demis participated on the conception, design, data collection, analysis and interpretation of the study. Wubet Alebachew facilitated the data collection. Biniam Munye managed and wrote the first draft manuscript. Tigabu Munye has analysed the data and critically reviewed the manuscript. All authors read and approved the final version of the manuscript.

Acknowledgments     

The authors would like to appreciate the study participants, the data collectors and Debre Tabor University.

Tables     

Table 1: socio-demographic and economic characteristics of reproductive-age women

Table 2: knowledge of reproductive age women on MTCT, 2016 EDHS analysis

Table 3: factors associated with knowledge of reproductive age women on MTCT

References