Our study on the magnitude of repeat HIV testing in the third trimester and its associated factors found that 8.1% of pregnant women received repeat HIV testing in the third trimester. The uptake of repeat HIV testing was associated with age and parity. The barriers to receiving a repeat HIV test included unfamiliarity with the intervention, perceived low risk of acquiring HIV, fear, delay in initiating antenatal care, intervention characteristics, clinic operations and inadequate resources. On the other hand, motivators included a need to have a healthy baby, conducive environment, and HIV status confirmation.
We found a lower proportion of women (8.1%) being retested for HIV during pregnancy than previously reported in Kenya (32%), Zambia (24.6%), South Africa (62%) and United States of America 28.4% (9, 20–22). The differences in the prevalence of repeat HIV testing among countries could be related to the extent to which repeat HIV testing is implemented and rolled out in specific countries. Additionally, the differences in social demographics across the countries can also contribute to the variations on the prevalence rates of repeat HIV testing among pregnant women (1). Specifically for Malawi, the low uptake of repeat HIV testing could arise from the low attendance of the successive antenatal visits by most pregnant women (36) which impedes the majority of women from receiving a repeat HIV test in the third trimester, which was also observed in Kenya (22). Our findings differ with previous findings (37, 38, 39) in that more women from the rural facility received a repeat HIV test that those from the urban facility as reported. This difference be explained by the lack of competing interests that people in the rural areas may have unlike the urban counterparts who have other commitments to meet such as work obligations. Furthermore, the volume of work in rural health facilities could be less than in the urban one due to disparities in catchment area population which made health providers encourage women to have repeat test. In our study the catchment population for the urban and rural facilities were 150,096 and 33,019 respectively with 35 health care providers in the urban facility and 14 health care workers in the rural facility. In support of the foregoing, previous studies have reported that perceptions of extra workload by health care providers as a factor that discourages the implementation of repeat HIV testing in the third trimester (22, 21, 40, 19)
Our findings that older age and higher parity were associated with increased uptake of repeat HIV testing remain congruent to findings from studies done in Uganda, Haiti, Malawi and Tanzania (6, 41, 42, 43, 44). This may be attributed to the fact that advanced age may lead to high parity which may enable women to have a greater exposure to information and knowledge about mother to child HIV transmission including benefits of repeat test. This could increase women’s motivation to be retested for HIV. In contrast other studies have indicated younger age as a determinant factor for uptake of HIV testing (44, 45). This could be because young age is associated with engaging in risky sexual practices that could lead to HIV infection forcing them to know their HIV status (40, 41)
Unfamiliarity with the intervention secondary to a lack of sensitization about the need for it was reported as a barrier for the uptake of repeat HIV testing in the third trimester. The lack of emphasis could be due to health care providers avoiding more responsibilities that come with offering of a repeat HIV test (19). This finding corroborates with results from previous studies in Kenya that reported inadequate information on the significance of repeat testing among health workers and pregnant women as a deterrent for uptake of repeat HIV testing among pregnant women (19, 22, 45). Cognizant that Provider initiated testing and counselling is a known strategy that increases uptake of HIV testing (38, 39) there is a need to train healthcare providers on their role in promoting awareness of the relevance of a repeat HIV test may enhance uptake of the test by pregnant women in the third trimester. Going forward, considerations may be undertaken to make repeat HIV testing in late pregnancy mandatory just like initial HIV testing during pregnancy for provider-initiated testing and counselling to be effective.
Although some women were aware of repeat HIV testing in the third trimester, they reported that it was not possible for them to demand for the service from health care providers. This resonates well with what studies have reported that negative attitude of health care providers displayed in disrespectful behaviors prevent women and their families from accessing health services (22, 46, 47). Health systems should develop mechanisms to empower its clientele through awareness of the prevention of mother to child HIV transmission services available and clients’ rights as far as utilization and accessibility of such services is concerned. In the same vein, healthcare providers should be oriented to other models of care such as human centered design which provides room for recipients of care to demand services basing on their needs (48).
In our study inadequate resources such as health workers and test kits deterred women from accessing repeat HIV testing in the third trimester, as was reported in earlier studies as well (21, 22, 49). Lack of health workers made the clinical operations to be unfavorable for pregnant women to access repeat HIV testing because it meant that they had to access the service from another department outside of the maternity department (3, 45, 50). Clinic operations need to be well organized alongside with adequate health care workers to attract clients as these may prevent delays and stigma which is associated with low uptake of interventions such as HIV testing (22). We propose that repeat HIV test during third trimester should be given prominence through provision of synchronized or integrated care (46). This can be achieved by offering all subsequent antenatal care services including PMTCT under one roof, isolating one visit from the visits which are made in the third trimester to be a specific visit for repeat HIV testing in addition to the antenatal subsequent care(45). In addition, task shifting might be employed to fill the gap of health providers by training and encouraging midwives to perform HIV testing alongside their regular duties (3, 18, 21).
Lack of test kits has also been reported as a hindrance for uptake of initial HIV testing in other studies (51, 52, 53). Lack of test kits for repeat HIV testing could also have been fueled by the facilities priorities and rationing of resources which might have led to giving preference to initial HIV testing rather than repeat HIV testing during pregnancy (42). Investing in resources to strengthen national stock buffering capacity and use of electronic ordering systems by institutions should be a priority (3). Intervention characteristics such as needle pricks associated with blood draw was mentioned as one of the factors preventing women from demanding repeat HIV testing a similar finding in studies done elsewhere (7, 52, 53). This is because rapid HIV testing which demands a finger prick to obtain sample for HIV testing is the main mode of HIV testing in antenatal clinics in Malawi (54). Employing other innovative interventions such as oral HIV self-testing may be essential in improving uptake of repeat HIV testing as reported in other studies (53, 55, 56)
Our findings that a perceived low risk of being infected with HIV and fear of consequences following seropositive as individual barriers for repeat HIV testing have been reported in previous studies (3, 57, 55). A perceived low risk may result from lack of knowledge on HIV issues as evidenced by the study participants in this study and other studies conducted elsewhere which have highlighted individual’s view that initial HIV negative status remains forever (50, 52). In our study women were afraid of HIV positive result as it could lead to divorce and loss of source of their income which has also been reported by other studies (1, 50). Fear of the outcome of repeat HIV is influenced by the level of knowledge of individuals and male partner support (58, 59, 60). In the study the fear associated with repeat HIV testing may be associated with the fact that male partner involvement is not encouraged during repeat test as reported by some participants in our study. Literature has revealed that participation of male partner in PMTCT yield good health outcomes and improves uptake of HIV services including HIV testing (1, 52)
In the study, preterm births were a hindrance for uptake of repeat HIV testing, a factor which has not been reported in other studies in the region (20–23). This factor may have been mentioned by the participants because preterm births are common in Malawi with a prevalence of 19.7% (58). While causes of preterm births are multiple and complex, late antenatal booking may predispose women to preterm birth (59) .This is because the first antenatal care contact is an essential opportunity to assess the pregnancy and identify women who may need additional care and support (59, 60). By adhering to the first contact interventions, midwives can identify and address potential risk factors earlier on, which can help to improve maternal and neonatal outcomes (37, 60). In addition late antenatal booking contributes to inadequate antenatal contacts which, coupled with substandard care due to unavailability of essential equipment and human resource deprive pregnant women from receiving interventions which may assist in preventing pregnancy related complications such as preterm birth (60). In Malawi only 24% of pregnant women initiate antenatal care in the first trimester while 50.6% attain four antenatal contacts (37, 60). Shortage of nursing and midwifery personnel stands at 63%, which is far below the WHO recommendation of 1 per 175 people (61). Therefore promotion of early antenatal initiation among women through social and behavior change communication campaigns should be urgently employed. Furthermore, health facilities particularly antenatal clinics should have adequate personnel and supplies to enhance adherence of health care providers to the antenatal care standards (59, 37).These interventions are likely to prevent preterm births. Strengthening antenatal care by employing other models of prenatal care such as group antenatal care may also assist in reducing preterm births which impedes uptake of repeat HIV testing in the third trimester. Motivators for uptake of repeat HIV testing included HIV status confirmation, need for better outcome and conducive environment as reported elsewhere (38, 39, 22, 62). Understanding these motivators may inform strategies to facilitate uptake of repeat HIV test among pregnant women. Furthermore, adherence to the repeat HIV testing will ultimately enhance HIV diagnosis and linkage of seroconverted women to antiretroviral treatment which will contribute to the eradication of pediatric HIV.