Background

The Human Immunodeficiency Virus (HIV) remains a significant public health problem, with women accounting for the largest HIV disease burden [1, 2]. In 2021 alone, 54% of the 38.4 million people living with HIV (PLWH) worldwide were women and girls, with pregnant women inclusive, and 15% of these were not aware of their HIV status [1]. In sub-Saharan Africa, about half of the 33 million PLWH were women of reproductive age (15–49 years), with HIV rates ranging from 15–40% among pregnant women [3, 4].

HIV testing during pregnancy is crucial in preventing child-maternal transmission of HIV, as it enables timely detection of HIV, rapid initiation of treatment, and support during and after childbirth [5]. For pregnant women, testing and knowing their HIV status helps early linkage to care for those diagnosed with HIV, and this reduces the risk of transmitting HIV to the fetus and newborn [6]. According to Osório et al. [7], mother-to-child transmission (MTCT) of HIV is the main mode of HIV transmission in children under the age of 15 years. Over 80% of children living with HIV live in sub-Saharan Africa where this problem is significant [7].

In sub-Saharan Africa, over 180,000 children are infected with HIV during pregnancy, childbirth, and breastfeeding by mothers aged 15–49 [8–10]. Several studies have reported a great risk of MTCT of HIV during pregnancy ranging from 15–45% without antiretroviral therapy (ART), but this can be reduced to less than 5% with prenatal testing of pregnant women for HIV and early linkage to HIV care [11–13]. In sub-Saharan Africa, the rate of MTCT of HIV decreased from 27.2% in 2010 to 16.9% in 2019, which decline is largely attributed to early detection and linkage to HIV care during antenatal care (ANC) [14]. However, the rate of HIV testing among pregnant women is still very low in most sub-Saharan African countries [15].

Several factors increase pregnant women’s susceptibility to HIV acquisition and its impact, including biological, behavioral, socioeconomic, cultural, and structural risks [16]. In most African countries, there are high rates of sexism where men dominate in cultural and societal affairs, which aggravates women’s marginalization, and in most cases, women do not play a role in sexual decision-making [17]. Besides, high rates of poverty, gender-based violence, and inequality collectively pose a high risk for HIV infection among pregnant women in Africa [18, 19]. This vulnerability further solidifies the importance of prompt HIV testing among pregnant women. Studies conducted among adolescent girls and young women in Rwanda and other sub-Saharan African countries reported that failure to acquire permission from the husband, fear of stigma and discrimination, perceived lack of secrecy from service providers, and inability to access the health facility hindered pregnant women from testing for HIV [9, 20].

The government of Rwanda, through the Ministry of Health (MoH), adopted strategies to promote HIV testing services among pregnant women through the National Strategic Plan (NSP) of July 2013-June 2018, including mandatory HIV testing during antenatal care (ANC), community-based testing, self-testing, and door-to-door testing [20, 21]. The National Strategic Plan aimed at zero new HIV infections, zero HIV-related deaths, and zero stigma and discrimination due to HIV [22]. Although HIV testing remains a common component of ANC, only 13.1% of women in Rwanda receive all the components of ANC [23, 24]. Indeed, 47.2% of pregnant women in Rwanda utilize at least four ANC contacts, which limits the opportunities for access to HIV testing services for pregnant women [23, 24].

Previous studies in Rwanda evaluated HIV testing among the general population and other groups such as the male population [20, 25], with limited accessible studies focusing on pregnant women. Consequently, the level of utilization of HIV testing services and associated factors among pregnant women in Rwanda remains unclear. Previous studies elsewhere showed that pregnant women with a higher educational level, married, high wealth index, living in urban areas, and being exposed to media had higher rates of HIV testing [26–29]. These factors were considered in the present study to evaluate their relevance among Rwandan pregnant women.

Therefore, this study aimed to determine the prevalence and factors associated with HIV testing among pregnant women in Rwanda using the most recent 2020 Rwanda Demographic and Health Survey. Understanding the factors associated with HIV testing among this specific group is crucial in addressing the reasons for the unmet need for HIV testing in Rwanda and other sub-Saharan African countries.

Methods

Results

Characteristics of participants

A total of 870 pregnant women were included in this analysis (Table 1). The majority were below 35 years of age (74.2%), married (84.7%), had attained a primary level of education (60%), were working (66.1%), and were rural residents (81.5%). In addition, most of the participants had ever given birth to less than four children (83.3%), had health insurance (81.9%), were from a household size of fewer than six members (77.7%), of which the majority were headed by males (82%), had exposure to media (82.6%), had no problem accessing the health facility (75.8%), and had visited a health facility in the last six months (84.4%). Furthermore, the majority had no multiple-sex partners (86.4%), no history of STIs (94.6%), participated in healthcare decision-making (67%), had comprehensive HIV knowledge (68%) and MTCT knowledge (68.4%), and had low HIV-related stigma (77.3%). Regarding HIV testing, 94.0% (95%CI: 92.3–95.4) had ever tested for HIV during pregnancy.

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Table 1. Background characteristics of pregnant women as per the 2020 Rwanda demographic health survey.

https://doi.org/10.1371/journal.pgph.0002728.t001

Factors associated with HIV testing among pregnant women

Results of the bivariable analysis are detailed in Table 2, with significant factors independently associated with HIV testing highlighted. After adjusting for all the included variables in the multivariable logistic regression model, the factors found to have a significant association included age, education level, working status, marital status, region, household size, visit to a health facility in the last 6 months, multiple sexual partners, and comprehensive HIV knowledge (Table 2, see AOR).

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Table 2. Factors associated with HIV testing among pregnant women, as per the 2020 Rwanda demographic health survey.

https://doi.org/10.1371/journal.pgph.0002728.t002

Pregnant women aged 25–34 years were 1.54(95%CI: 1.54–4.42) times more likely to test for HIV compared to those aged 35 and above. Compared to those with tertiary education, pregnant women with secondary, primary, and no education were 8.07(95%CI: 2.15–11.43), 5.53(95%CI: 1.28–9.74), and 6.07(95%CI: 1.21–10.44) times, respectively, more likely to test for HIV. Similarly, compared to working pregnant women, those not working were 4.29(95%CI: 1.52–12.08) times more likely to test for HIV. Those from households of 6 members and above were also 2.96(95%CI: 1.01–8.61) times more likely to test for HIV compared to their counterparts from households of less than 6 members. Moreover, pregnant women with no multiple sex partners were 4.16(95%CI: 3.01–5.74) times more likely to test for HIV compared to those with multiple sex partners.

However, unmarried women (AOR = 0.28, 95%CI: 0.19–0.86) and those from the western region (AOR = 0.20, 95%CI: 0.63–0.66) were 0.28 and 0.20 times less likely to test for HIV, compared to married pregnant women and those from Kigali, respectively. Similarly, pregnant women who had not visited a health facility in the last 6 months (AOR = 0.22, 95%CI: 0.10–0.48) and those with no comprehensive HIV knowledge (AOR = 0.68, 95%CI: 0.30–0.55) were 0.22 and 0.68 times less likely to test for HIV compared to those that had visited a health facility and had comprehensive HIV knowledge, respectively.

Discussion

In this study, the prevalence and factors associated with HIV testing among pregnant women in Rwanda were assessed. The study identified potential factors influencing HIV testing among pregnant women and these have a great impact on both mother and baby if not addressed. The prevalence of HIV testing among pregnant women was found to be 94.0%. This is higher than the prevalence of HIV testing in Zambia (80%) among women of childbearing age and the overall prevalence reported from 11 East African countries (67.13%) and 85.74% specifically for Rwanda [27, 29]. The variations in quality and access to HIV testing facilities, as well as knowledge related to HIV/AIDS, including mandatory HIV testing during ANC, community-based testing, self-testing, and door-to-door testing, may be the reasons for the reported variations [21, 26, 29]. Additionally, the observed difference in HIV testing among pregnant women may be attributed to the differential efforts and resources put into HIV prevention programs, as well as differences in socio-demographics across countries [10, 37].

Pregnant women aged 25–34 years were more likely to test for HIV compared to their older counterparts (35 years and above). This could be attributed to the fact that sexual education tends to be focused on young women who may be involved in high-risk sexual behaviors and that older women do not perceive themselves to be at risk for HIV [27, 38, 39]. These findings are consistent with studies from Vietnam, Ethiopia, and 11 East African countries, which also reported older age to be associated with less HIV testing [40, 41]. Nonetheless, further studies should be conducted to critically identify reasons why older women (35 years and above) are less likely to test for HIV during pregnancy in Rwanda.

The study results showed that pregnant women who lived in the western region of the country had lower odds of HIV testing compared to those who lived in Kigali. The study findings are supported by other studies in Rwanda and Senegal which also reported differential rates in HIV testing among regions [20, 21]. Kigali as the capital city of Rwanda and predominantly urban has more widespread and multi-service health infrastructures which offer more opportunities for its residents to access diverse health services. The western region of Rwanda, on the other hand, is 87.8% rural and relatively remote, making it less developed with fewer health facilities, and therefore lesser chances to access health services including sexual and reproductive awareness [25]. Further, compared to Kigali, rural Rwanda might have less variety of media exposure in the form of television, radio, billboards, and social media which are key sources of information about the importance of HIV testing during pregnancy [25, 42]. It is therefore imperative to ensure balanced efforts and resource allocation in HIV prevention programs across the country. Moreover, developing an appropriate and targeted community-based intervention such as community or home visits by health workers to test individuals in remote and hard-to-reach areas would increase access to HIV testing services among pregnant women [11].

Surprisingly, lower levels of education (secondary, primary, and none) were associated with higher odds of HIV testing compared to tertiary level of education. Notably, tertiary education was associated with fewer odds of HIV testing, a finding contrary to previous studies associating higher educational attainment with a higher likelihood of HIV testing [29, 31, 43]. Education is well established to be a potent tool that may be utilized to not only improve HIV knowledge but also to empower individuals, especially women, to make the right decisions regarding attendance and utilization of health services [44, 45]. However, the probable reason for the lower odds of HIV testing among pregnant women with tertiary education could be attributed to the stigmatizing attitudes more educated people tend to hold towards HIV-positive people; hence, they may fear utilizing HIV testing services [46]. In addition, it is argued that more educated women are likely to have demanding careers with tight work schedules and thus less free time for ANC/HIV testing. The actual reason remains inconclusive and therefore warrants further exploration to establish why more educated women were less likely to use HIV testing services.

Pregnant women in this study with no comprehensive knowledge about HIV were less likely to test for HIV compared to those with comprehensive knowledge. The study finding is consistent with a study among women in East Africa which reported high HIV education was associated with HIV testing [27]. This is not surprising and further highlights a need to strengthen the means of HIV information dissemination through the use of media campaigns and emphasis on HIV health education and counseling by health workers during antenatal care and community outreaches. This should consider addressing possible misconceptions among various education levels and needs.

Furthermore, it was observed that pregnant women who had visited a health facility in the last 6 months had higher odds of HIV testing compared to their counterparts who had not. This finding is supported by a similar study in Ethiopia which also reported a positive association between recent health facility visits and HIV testing [12]. Pregnant women who visit a health facility are more likely to attend antenatal care, of which health education and HIV testing are compulsory components [37], explaining the above observation. Pregnant women from large household sizes were also more likely to be tested for HIV compared to their counterparts from smaller households. This is in agreement with a study from Sudan, which also reported that women in extended families are more likely to test for HIV [47]. This may be because of the influence and concern of their older relatives, who may tend to encourage them to attend antenatal care where they can access and receive HIV testing services.

Married women were also more likely to test for HIV during pregnancy compared to unmarried. This is similar to a study from Thailand [37] and that from East Africa [31] which also reported a positive association between marital status and HIV testing. The possible explanation may be that married women are more likely to be reminded and encouraged by their partners to go for antenatal care where they can receive HIV testing services [48, 49]. Moreover, since married women tend to have premarital HIV testing with their partners, they, thus, tend to be more receptive to regular HIV testing [48, 49]. Additionally, it was also observed that pregnant women without multiple sexual partners were more likely to test for HIV compared to those with multiple sexual partners. This is in agreement with a study conducted in East Africa, which showed that women with multiple sexual partners had lower odds of HIV testing [31]. On the other hand, due to differences in the context, studies in Ethiopia identified women with multiple sexual partners as having higher odds of HIV testing compared to those with one sexual partner, due to a higher perceived risk of acquiring HIV [12, 50]. Nonetheless, further studies are needed to explore the association between the number of sexual partners and HIV testing during pregnancy.

Study findings also indicate that non-working pregnant women had higher odds of HIV testing compared to those working. The study finding is consistent with a study in Vietnam which reported employed pregnant women being more likely to test for HIV [41]. Although employment is a vital component of women’s empowerment for making healthy decisions and choices, it has also been reported to harm other women’s health aspects, predisposing women to sexual violence [51] and reducing antenatal and postnatal care attendance [52, 53] partly due to the busy work schedules. This implies a need to strengthen work-related policies, such as work leaves, to enable working women to attend to vital health aspects of pregnancy and child care without risking their jobs and careers.

Supporting information