Paper:Antenatal HIV Testing in Sub-Saharan Africa During the Implementation of the Millennium Development Goals: A Systematic Review Using the PEN-3 Cultural Model

Antenatal HIV Testing in Sub-Saharan Africa During the Implementation of the Millennium Development Goals: A Systematic Review Using the PEN-3 Cultural Model

Sarah R. Blackstone, Ucheoma Nwaozuru, Juliet Iwelunmor

First Published December 22, 2017 Research Article 

https://doi.org/10.1177/0272684X17749576tract

This study systematically explored the barriers and facilitators to routine antenatal HIV testing from the perspective of pregnant women in sub-Saharan Africa during the implementation period of the Millennium Development Goals. Articles published between 2000 and 2015 were selected after reviewing the title, abstract, and references. Twenty-seven studies published in 11 African countries were eligible for the current study and reviewed. The most common barriers identified include communication with male partners, patient convenience and accessibility, health system and health-care provider issues, fear of disclosure, HIV-related stigma, the burden of other responsibilities at home, and the perception of antenatal care as a “woman's job.” Routine testing among pregnant women is crucial for the eradication of infant and child HIV infections. Further understanding the interplay of social and cultural factors, particularly the role of women in intimate relationships and the influence of men on antenatal care seeking behaviors, is necessary to continue the work of the Millennium Development Goals.

INTRODUCTION

eywords antenatal HIV testing, sub-Saharan Africa, PEN-3 cultural model, perceptions, enablers

Sub-Saharan Africa is disproportionately affected by HIV/AIDS, which has impacted the health-care system dramatically, as health-care providers have struggled to provide care to all those in need.^1,2 Given that over 60% of adults with HIV are women, and the total fertility rate in sub-Saharan Africa was approximately 4.7 in 2015,³ mother-to-child transmission (MTCT) of HIV is a serious concern.⁴ MTCT is almost nonexistent in high-income countries, due to effective antenatal care (ANC) and HIV testing and counseling.⁵ However, in sub-Saharan Africa, 60% of HIV infections are borne by women, and as many as 1.4 million women with HIV in the region become pregnant. Rates of MTCT range from 5% to as high as 30% in sub-Saharan Africa.⁶ More than 90% of HIV infections in young children and infants occur through pregnancy, delivery, and breastfeeding, and as many as 90% of HIV infections in infants and children worldwide occur in sub-Saharan Africa.⁶ Without proper prevention and intervention, one in three children born to a mother with HIV will become infected, but through proper use of prevention of mother-to-child transmission (PMTCT), thousands of children can be saved every year, thus improving birth outcomes by reducing infant and maternal mortality.⁶

Proper ANC is part of essential interventions to reduce maternal and infant mortality and MTCT of HIV.⁷ The World Health Organization (WHO) recommends a minimum of four antenatal visits to ensure a healthy pregnancy and optimal birth outcomes. These visits should ideally begin in the first trimester to maximize their effectiveness.^8,9 Timely ANC is beneficial for several reasons, including that it provides an early point of entry for HIV testing among pregnant women. Several countries have expanded upon this, enforcing the recommendation of provider-initiated HIV testing during pregnancy, which is essential for early identification of high-risk pregnancies.^8,10 Early identification of HIV infection in pregnant women leads to earlier initiation of antiretroviral therapy (ART), thereby reducing the risk of MTCT. Furthermore, longer duration of antenatal ART is associated with lowered risk of MTCT.¹¹ Many steps have been taken to improve maternal health, reduce infant mortality, and combat HIV since the inception of the Millennium Development Goals in 2000.

As part of the Millennium Development Goals and the Global Plan for Elimination of new HIV infections, UNAIDS recommended routine testing for HIV among pregnant women.⁶ This can lead to early detection of HIV and treatment initiation to reduce the likelihood of transmission to a child; however, many pregnant women do not regularly get tested.^7,12–14 Millennium Development 6 aimed to halt and reverse the spread of HIV by 2015.¹⁵ During the implementation period of 2000–2015, the rate of new HIV infections dropped by 38%, and access to ART increased.¹⁶ While great strides were made in combating HIV worldwide, MTCT in sub-Saharan Africa continues to be a problem. As the Millennium Development Goals agenda has ended as of 2015, the Sustainable Development Goals (SDG) have begun, to complete and build upon the goals set for world health in 2015. The purpose of this review is to systematically explore the barriers to antenatal HIV testing in sub-Saharan Africa, during the implementation of the Millennium Development Goals to improve maternal and child health, reduce infant mortality, and combat HIV/AIDS between 2000 and 2015.¹⁷Because rates of MTCT, child mortality, and HIV infection are still high in sub-Saharan Africa, the question guiding this review is “what are the prominent barriers and enablers to antenatal HIV testing in sub-Saharan Africa?” Reviewing factors that influence pregnant women's decision to test for HIV can be used to develop future interventions to improve PMTCT, as we work toward achieving the SDG for health and wellness.

Figure 3. Summary of findings.

Figure 1. The PEN-3 cultural model.