Introduction

It has been well established that mother to child transmission accounts for the majority of HIV infections in children in developing countries.₁ The rate of transmission from an untreated HIV positive pregnant woman to her newborn is high.₂,₃ However, tremendous medical and public health achievements have been made in the prevention of mother-to child transmission (PMTCT) of HIV. ₄ The risk for infant infection has been reduced from approximately 25% to less than 2% by the use of currently recommended prenatal ARV and obstetric interventions for a woman who is aware of her HIV infection in pregnancy. ₄ Ideally, all women should be screened for HIV before delivery, during an initial prenatal care visit so that potent combination antiretroviral treatment can be given to women who are HIV-infected. However, approximately 40% of the mothers of the estimated HIV infected infants born in the year 2000 were not screened for HIV infection before delivery.₄ Globally, HIV testing and counseling is recognized as a priority in national HIV programmes because it forms the gateway to HIV/AIDS prevention, care, treatment and support interventions but this has not become entrenched in peripheral health facilities in developing countries.₅ It is critical to increase the prenatal detection rate of HIV-infected pregnant women in these countries, so that effective interventions can be delivered.

Furthermore, the availability of affordable, accurate, reliable, simple and rapid HIV tests providing results within the time frame of a single brief antenatal visit for single or a small number of clients significantly facilitates PMTCT programmes by reducing traveling time and expenses, and by virtue of their feasibility in peripheral primary health services.₄ The sensitivity and specificity of these tests are greater than or equal to 99% and similar to those of ELISA.₄ The rapid HIV tests are most suitable in developing countries where the majority of pregnant women are attended by traditional birth attendants (TBAs), the pregnant women use the formal health sector only as a backup arrangement.₆,₇ If pregnancy and labour progress as expected, the pregnant woman attends a local formal health post once at booking which mostly may be late in pregnancy. In these circumstances, rapid HIV tests afford the opportunity to screen for HIV in women attending peripheral units and provide results during same visit.₈,₉

The present study sets out to determine the prevalence of HIV seropositivity among pregnant women attending primary health services and factors influencing utilization of PMTCT services in Ilesa Local Government maternity centres in South Western Nigeria.

Methods

Subjects

Ethical considerations

Testing procedure

Statistical analysis

Results

A total of 518 pregnant women were tested for HIV infection. Table 1 shows the socio-demographic characteristics. The ages of subjects ranged from 15 to 40 years with a mean age of 25.99 ± 4.98 years. Majority, 298 (50.8%) were in the age group of 25 - 34 years. Four hundred and seventy three subjects (80.6%) were currently married, 344

(58.6%) had secondary education and as many as 449 (76.5%) were in the low socio -

economic class. Sixty-nine women (9.5%) had positive results to the double rapid tests. There was no discordant result. Thirteen (18.8%) of the women accepted to utilize PMTCT facilities.

At the focus group discussion, the women expressed their mind on the possibility of transmitting HIV to the unborn child despite their status.

One of them submitted that:

‘Me, it is impossible. I reject it in Jesus name! I don't have HIV and I can not give it my child. I am sure this HIV thing is not as bad as you people are making us to believe'

One of the women who accepted to use PMTCT services hinged her decision on the provision of the facilities at no cost. Said she:

‘As long as the service will be provided free, I will make use of it. This is because my husband can not afford to pay for extra service. Even, it was a tug-of-war before I could collect the transport fare to the clinic this morning'

Figure 1

Table 1: Socio-demographic characteristics of the pregnant women

Discussion

The prevalence of HIV of 9.5 % obtained in this study is much higher than the prevalence rate of 1.2% reported for Osun State (where the study sites are located) and the national prevalence of 4.4% in the 2005 sentinel survey conducted by the Nigeria's National Agency for AIDS Control.₁₁ The difference may be explained by the fact that the sentinel survey made use of pregnant women in tertiary health centres whereas our study focused on women accessing ante-natal care (ANC) in primary health facilities. Previous studies have reported low ANC uptake in tertiary centres while many pregnant women in Nigeria attend peripheral health facilities. ₆,₇

Our study supports the documented fact that the prevalence of HIV is high in the reproductive age group during which sexual activity is maximal. It also agrees with an earlier finding that young adults, especially females are at the centre of the epidemic in Nigeria.₅

Marital status was found to have significant association with HIV status of the study participants. This is in keeping with study reported by Hope et al.₁₂ It was demonstrated in the study that women married to spouses whose jobs take them away from homes for long periods tend to engage in unsafe sex, thereby predisposing them HIV infection. Furthermore, traditional gender roles often promote sexual practices that put women at risk of contacting HIV even in a stable relationship. In Nigerian patriarchal society, women especially of the lower social class, can not influence their husbands' behaviour and have limited ability to negotiate safe sex. ₁₁

This study also shows that HIV infection is more common among pregnant women who did not go to school or complete secondary school education. This agrees with study that reported that women with higher education have better knowledge of HIV transmission whereas low level of female education promotes ignorance about HIV transmission and its prevention, especially to the unborn child₁₃. This was aptly demonstrated in the focus group discussion. Most of the women were in school when they had the index pregnancy and therefore could not complete secondary education. This may also explain why most of them were unemployed and they belonged to low socio-economic class. Unemployment is associated with poverty, and this has been linked with unsafe sex for money thereby increasing the risk of HIV infection.₁₃,₁₄

We also found that majority of those that attended the maternity centres were multigravida, while primigravida who might be at a higher risk of HIV infection by virtue of relatively younger age and the associated risky sexual behaviours, do not utilize formal antenatal services . Furthermore, those that utilized the services presented late in third trimester, when interventions could be late to address some adverse trends of HIV on pregnancy especially in resource limited settings. Financial constraint was cited as reasons for late and/or poor utilization of antenatal services. This is in agreement with other studies. ₁₅, ₁₆

The acceptance rate of VCT was high among the subjects but utilization of PMTCT was remarkably low. Ekanem et al ₁₅ reported similar findings in Ibadan while de Paoli and co-workers ₁₇ reported that perceived high personal susceptibility to HIV/AIDS, barriers related to confidentiality and partner involvement were associated with willingness to accept VCT. The women's acceptance of VCT seems to depend upon their perception that VCT and PMTCT strategies provide clear benefits, primarily for them and not for the unborn child. This is influenced by a set of social and psychological factors which determine the health-seeking behaviour of the women.

Conclusion

In this study, the acceptance rate for VCT was high among the pregnant women attending maternity centres in Ilesa, Nigeria; the uptake of PMTCT strategies was remarkably low. There is a need to develop innovative information and health education techniques to provide HIV positive mothers with knowledge and skills that will enable them to make informed choices about PMTCT strategies.