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Abstract
Objectives Antenatal screening for HIV remains low in Nepal. Identifying factors associated with the uptake of antenatal screening is essential to increase uptake and prevent mother-to-child transmission (MTCT). This study investigated the effects of individual-level and district-level characteristics on the utilisation of antenatal screening for HIV in Nepal and how these effects changed between 2016 and 2022.
Design We used publicly available cross-sectional data from 2016 to 2022 Nepal Demographic and Health Surveys.
Setting Stratified, multistage, random sampling was used to collect nationally representative data.
Participants 1978 and 2007 women aged 15–49 years who gave birth in the 2 years preceding the surveys.
Primary and secondary outcome measures We used multilevel models to estimate associations between antenatal screening and potential factors influencing it in 2016 and 2022. We used districts as a random effect and looked at the intraclass correlation coefficients to disentangle the geographical effects. To distinguish barriers to HIV screening from barriers to accessing antenatal care (ANC) services, we performed similar analyses with whether the woman attended at least one ANC visit as the dependent variable.
Results Factors associated with antenatal screening have not changed significantly between 2016 and 2022. Higher uptake of HIV screening was found among women with higher education, the pregnancy being desired later and women who had four or more ANC visits. Being from a poorer family and having low knowledge of MTCT and the medicines to prevent transmission were associated with lower uptake. From the supply side, no factors had a significant effect on antenatal screening. Factors associated with antenatal screening and those associated with any ANC were different. Our results also showed a partial importance of geographical factors on screening uptake.
Conclusions Our results supported that antenatal screening could be improved by enhancing access to information and improving the availability of free screening.
- Antenatal
- Sexually Transmitted Disease
- Public health
Data availability statement
Data are available in a public, open access repository. The data that support the findings of this study are openly available in the NDHS programme at https://dhsprogram.com/methodology/survey/survey-display-472.cfm.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study used cross-sectional data from 2016 to 2022 Nepal Demographic and Health Surveys (NDHS), ensuring nationally representative results.
The use of multilevel models to explore factors associated with antenatal HIV screening in this study makes it possible to explore characteristics at individual and district level, to improve the depth of the analysis and to take account of geographical effects.
The cross-sectional design means that causality between potential influencing factors and HIV testing or antenatal care coverage cannot be inferred.
The lack of information on supply-side barriers in the NDHS data means that associations with supply-side barriers could not be found, leaving potential areas for further research.
Although the multilevel model makes it possible to disentangle some geographical effects, the lack of more detailed geographical information in the NDHS data does not allow for further geographical analyses to be carried out at the municipality level.
Introduction
HIV is a sexually transmitted disease (STD) that can be transmitted from infected mothers to their children during pregnancy and childbirth. According to UNAIDS, 6 million people were living with HIV in the Asia and Pacific region in 2021.1 Prevention of mother-to-child transmission (PMTCT) interventions such as antenatal screening play a key role in the improvement made.2 However, antenatal screening for HIV (and other STDs) remains low in Asia.3 According to the WHO, 10 of the 17 countries in Asia and the Pacific have achieved over 80% coverage of knowledge of pregnant women’s HIV status.2 A number of studies conducted in Asia have looked at the barriers to antenatal screening for STDs (Sabin L., Haghparast-Bidgoli H., Miller F. and Saville N., A systematic review of barriers and facilitators to antenatal screening for HIV, syphilis or hepatitis B in Asia: perspectives of pregnant women, their relatives and healthcare providers). From the supply side, common barriers identified include limited availability to antenatal screening services4–10 and low support and knowledge about STDs among health workers.6 11–13 Demand-side factors are numerous and include socioeconomic and demographic factors,4 7–9 12 14 15 knowledge about STDs,4 11 13–15 fear of husband’s reaction and stigma6 11 12 16 and low risk perception.9 11 12 14 However, no study, to our knowledge, has investigated factors associated with HIV antenatal screening in South Asia using data collected after 2015.
The Joint United Nations Programme on HIV/AIDS (UNAIDS)17 estimated HIV prevalence in Nepal to be 0.12% in 2020 for the population aged 15–49. However, this figure might be underestimated due to low screening coverage despite improvements after the implementation of the elimination of the vertical transmission strategy.18 HIV screening of pregnant women increased from 43% in 2016 to 57% in 2019.17 Screening for HIV during pregnancy in Nepal is included in the National HIV Testing and Treatment Guidelines19 and it is mandated to be offered free of charge to all pregnant women during their antenatal care (ANC) visits. In the event of a positive result, women are entitled to free access to treatment. In addition, according to the 2030 roadmap for safe motherhood and newborn health in Nepal,20 HIV and syphilis screening should be routinely carried out together during ANC visits for pregnant women.
However, there is an unequal coverage of HIV screening services across regions. The availability of services for PMTCT of HIV in facilities offering ANC services ranges from 0.8% of facilities in the mountain region to 1.6% in the hill region.21 Among facilities offering ANC services, only 3% can test for HIV and public facilities are more likely to have the capacity to test than private ones.21
There is currently no nationally representative study investigating individual-level and district-level factors associated with HIV antenatal screening in Nepal. Understanding potential barriers to antenatal screening for HIV is essential to ensure the implementation of appropriate interventions to PMTCT of HIV and allow early diagnosis of infections. It will also contribute to achieving the global target of MTCT elimination.22 Understanding barriers to the screening of HIV during pregnancy will also inform the screening of other STDs screened through blood tests such as hepatitis B or syphilis. HIV antenatal screening can be an entry point for other blood tests and represent an opportunity to develop integrated antenatal screening.2
The objective of this study is to answer the following research question: what are the effects of individual-level and district-level characteristics on the uptake of antenatal screening for HIV and how do they evolve between 2016 and 2022? Different hypotheses to be tested include:
Hypothesis 1: Predisposing characteristics, enabling factors and need factors are associated with antenatal screening for HIV. These factors are different from those associated with ANC visits.
Hypothesis 2: Women who were not screened despite attending an ANC visit were not screened because of supply-side barriers such as the health facility not having the necessary equipment or the ANC health worker not being sufficiently qualified to do so, rather than because she refused screening.
Hypothesis 3: Given the geographical constraints and unequal provision of antenatal screening across Nepal, the cluster and the district of residence play a key role in whether or not women receive HIV screening during pregnancy. Women living in districts where more ANC services offer antenatal screening are more likely to be tested. Living in hills is positively associated with HIV screening during pregnancy because it is in this region that the capital, Kathmandu, is located. The opposite effect is expected for the plains and mountains.
Hypothesis 4: Factors associated with the utilisation of antenatal screening for HIV changed between 2016 and 2022.
Methods
Study setting
Nepal is a landlocked country in South Asia with a population of around 30 million in 2021.23 The country is characterised by a predominantly rural population that is more or less geographically isolated due to a range of geographical terrains from the plains of the Terai to the peaks of the Himalayas.
Since 2017, after the establishment of the federal state in 2015, the health system in Nepal has been decentralised, with health services provided by health facilities at the municipality level.24 Previously decided by public health and health offices at the district level, decisions concerning Nepal’s health system have now been entrusted to health coordinators at the municipal level, thereby decentralising healthcare decision-making. This decentralisation has led to variations in health infrastructure and services between provinces and districts.25 ANC services are available in different types of health facilities across the country, from primary healthcare centres and health posts to district and zonal hospitals and private clinics.26 ANC visits are a crucial entry point for prenatal HIV screening. There are no laboratory services up to health post level. ANC provided from primary healthcare level to health postlevel does not cover any laboratory services.
Data sources and samples considered
We used publicly available cross-sectional data from Nepal Demographic and Health Surveys (NDHS) collected between June 2016 and January 201727 (subsequently named NDHS 2016) and between January and June 202228 (subsequently named NDHS 2022). Sample design has been detailed elsewhere.21 Stratified, multistage, random sampling was used to collect data. Nepal was divided into different strata based on geographical regions and other relevant factors, such as urban and rural areas. Within each stratum, clusters defined as neighbourhoods were randomly selected. In a second step, households to be interviewed were randomly selected from these clusters, ensuring national representativeness of the survey. For NDHS 2016 and NDHS 2022, respectively, the total sample is a representative cohort of the total prenatal population including 1978 and 2007 women aged 15–49 years who gave birth in the 2 years preceding the survey and with information on antenatal screening for HIV during ANC.
Outcome variable
The main outcome variable is a variable coded ‘1’ if a woman was tested for HIV and got the results as part of an antenatal visit and ‘0’ otherwise.
Exposure variables
We identified potential factors influencing antenatal screening for HIV through a literature review of factors influencing antenatal screening for HIV, syphilis or hepatitis B in Asia and organised potential factors using Andersen’s conceptual model.29 This theoretical framework for understanding how individual and environmental factors influence health behaviours identified three categories of predictors: (1) predisposing characteristics including demographic factors, social structure and health beliefs that influence health services use; (2) enabling factors allowing the individual to seek health services if needed and (3) need factors including perceived needs of healthcare services use (figure 1). Table 1 provides a description of the variables used in the analysis. We conducted multicollinearity tests between these potential variables using Cramer’s V and the variance inflation factor. Subsequently, women’s literacy was not included in the econometric analysis. Due to missing values, we did not include variables on discriminatory behaviour (465 missing observations), occupation (708 missing observations) and husband education (708 missing observations).
Description of the independent variables
Flow chart of potential influencing factors based on the Andersen’s conceptual model. ANC, antenatal care; PMTCT, prevention of mother-to-child transmission; STIs, sexually transmitted disease.
Descriptive analyses
We conducted descriptive analyses to investigate the completeness of key variables and to describe characteristics of women tested and untested for HIV during pregnancy using proportions and their CIs (table 2 and online supplemental table 1).
Supplemental material
Pregnant women counselled and tested for HIV in 2016 and 2022
Econometric analyses
Taking into account the possible correlation that may exist within and between clusters and districts, the hierarchical structure of the data with women (level 1) nested within clusters (level 2) nested within districts (level 3) and given that the dependent variable is binary, we used a two-level random intercept multinomial logistic regression model. We chose the 75 districts as level-2 units of analysis for NDHS 2016 and the 77 districts as level-2 units of analysis for NDHS 2022.
We estimated a series of multilevel multivariable logistic models with potential associated factors mutually adjusted to test the hypotheses and answer the research question30 31 using NDHS data 2022 and 2016 in separate models. To test hypothesis 1 and determine factors associated with antenatal screening, we performed mutually adjusted multivariable analyses containing potential predisposing characteristics, enabling factors and need factors (model 1, online supplemental table 2). We hypothesised that these elements could be combined using the Andersen framework, and therefore, decided a priori to test them all simultaneously and adjust them mutually. To investigate the first hypothesis and distinguish barriers to HIV testing from barriers to accessing ANC services, we performed the same analyses using NDHS data 2022 and 2016 with the dependent variable being a dummy variable indicating whether women attended at least one ANC visit and the results were compared (model 2, online supplemental table 2). We tested the second hypothesis, that is, women were not screened despite attending an ANC visit because of supply-side barriers, by running the same multivariable multilevel logistic models as those used to test hypothesis 1 but on a sample composed only of women who attended at least one ANC visit (model 3, online supplemental table 2). To test hypothesis 3, a logistic multilevel model without any explanatory variables was estimated to determine the existence of variability by clusters and districts.
Given oversampling of certain populations and as recommended to make data more nationally representative, we used individual weight.32 We approximated level-1 weights using the method recommended by DHS.33 Given the method used to sample the NDHS data, districts have a chance of being included in the sample that is proportional to the size of their population. We estimated the level 2 weights by aggregating the individual weights at district level and normalising them.33 We used the svy command on Stata for all econometric analyses. We conducted all analyses using STATA V.18 and package melogit.
Patient and public involvement statement
As this study uses publicly available data, it was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.
Results
Descriptive analyses
Table 2 reports on HIV counselling and screening during pregnancy. Twenty per cent of women who gave birth in the last 2 years reported being tested for HIV during ANC and receiving the results. This percentage did not change between 2016 and 2022 (table 2).
Online supplemental table 1 shows the characteristics of the study participants. They are similar between the NDHS 2016 and NDHS 2022 samples. The majority of the participants were between 15 and 30 years old and were literate, although they had not necessarily completed their education. Among women with a high level of education, an equal proportion had or had not undergone antenatal HIV screening. Among pregnant women from wealthy households, almost 80% did not get tested. More than 90% women were not aware of HIV. The vast majority of women in the sample had at least one problem accessing health services. Among pregnant women who attended at least one ANC visit, most of them attended more than four visits with a skilled ANC provider. Most of the women tested attended an ANC visit at a public health facility.
Econometric analyses
Online supplemental table 2 presents the estimated OR of the potential factors influencing HIV screening during pregnancy.
Hypothesis 1 was partially supported by the results. Only certain predisposing characteristics, enabling and need factors were significantly associated with HIV screening. Model 1 (online supplemental table 2), which contains variables at the individual and district level, showed that women with incomplete secondary, complete secondary or higher education were respectively 2.616, 4.456 and 4.660 times more likely to be tested during pregnancy than women with no education. Women with knowledge of MTCT (OR 1.903, 95% CI (1.24 to 2.91)) and knowledge of the availability of medicines to avoid it (OR 1.473, 95% CI (1.04 to 2.08)) had significantly higher likelihood of being tested during pregnancy. Among the enabling factors, all had a significant impact on the likelihood of being tested, except the variable indicating barriers to accessing healthcare services and the variable about access to healthcare. Pregnant women who had four or more ANC visits were (OR 2.190, 95% CI (1.30 to 3.67)) more likely to be tested than women who had fewer visits. Pregnant women from wealthier households were more likely to be tested for HIV than women from poor households (OR 2.772, 95% CI (1.33 to 5.75)). Finally, among the need factors, women wanting the pregnancy later had significantly higher likelihood of being tested (OR 1.575, 95% CI (1.09 to 2.26)).
Factors significantly associated with ANC visits and antenatal screening differed (model 2, online supplemental table 2). Factors associated with having any ANC visits were the caste, the presence of co-wives, the number of children, the agroecological zone of residence and the participation in decision-making within the household. Factors associated with antenatal screening for HIV included the education level of the mother, the number of ANC visits, the wealth, whether the pregnancy was desired later and knowledge of MTCT and of the availability of medicines to avoid it. None of these factors overlapped.
Contrary to the assumptions in hypothesis 2 assuming that women were not screened despite attending an ANC visit because of supply-side barriers, when considering only those women who attended at least one ANC visit (model 3, online supplemental table 2), having a qualified health professional and the type of facility when attending ANC visits were not significantly associated with antenatal screening.
The intraclass correlation coefficient (ICC) represents the proportion of the variation between districts in the total variation. In the empty model, the ICC indicated that 24.61% of the chance of being tested for HIV during pregnancy was explained by differences between districts and 75.39% by differences within the district. The ICC indicated that 27.00% of the chance of being tested for HIV during pregnancy was explained by differences between clusters. The cluster and the district of residence are partially associated with antenatal screening. Hypothesis 3 also assumed that living in hilly areas positively influenced antenatal screening and that women living in districts where such antenatal screening were more available in ANC services were more likely to be tested. This was not verified in the data. The environment of residence and the number of facilities offering PMTCT services in the district of residence did not have a statistically significant effect on the probability of women being screened (model 1, online supplemental table 2).
When comparing model 1 in online supplemental table 2 for 2016 and 2022 to investigate hypothesis 4, the factors associated with HIV screening during pregnancy have slightly changed between 2016 and 2022. The effect of education, wealth, knowledge of medicines and number of ANC visits on HIV antenatal screening remained positive and significant in both years. However, participation in household decisions and having genital discharge, sore or ulcer were significantly associated with HIV screening in NDHS 2016 but not in 2022. Moreover, knowledge of MTCT and the pregnancy being desired were not significant in NDHS 2016 but were in 2022. In 2016, 34.84% of the chance of being tested for HIV during pregnancy was explained by differences between districts and 43.80% by differences between clusters whereas in 2022 districts explained 24.61% and clusters 27.00% in 2022.
Discussion
This study contributes to the understanding of the effects of individual-level and district-level characteristics on the utilisation of antenatal screening. We found that the factors associated with antenatal HIV testing did not change significantly between 2016 and 2022. This suggests that the barriers to the use of antenatal screening have not changed and that the Nepalese health system and policy-makers continue to face difficulties in addressing them effectively.
Only 20% of women who gave birth in the last 2 years reported being tested for HIV and receiving the results. This is much lower than the 57% of women in Nepal tested for HIV during pregnancy reported by UNAIDS in 2019.17 This may be explained by the fact that UNAIDS data are collected from facilities so the denominator is women attending ANC in a facility, whereas NDHS data are reported by women, who may be unaware that they have been tested for HIV as part of their antenatal blood tests.
Nepal, like all WHO member states, is committed to the dual elimination of MTCT of HIV and syphilis. Screening for HIV and syphilis is based on simple blood tests. However, rapid diagnostic tests are common for HIV and no serological testing equipment is required. Although routine screening is recommended in the Safe Motherhood and Newborn Health Road Map 2030,20 antenatal screening for syphilis in Nepal remains low due to barriers likely to be similar to antenatal HIV screening. Only about one-fifth of facilities providing ANC visits offer syphilis tests.34 The experience gained in raising awareness and knowledge of HIV testing can be used as a basis for similar efforts to promote routine syphilis testing. Similarly, the results can be used as a basis for screening for hepatitis B, which also requires a blood test and is not yet included in Nepalese ANC programmes.
As found in other studies,7 35–40 we have shown that the more educated a woman is, the more likely she is to be tested for HIV during pregnancy. Our results are consistent with other studies36 39–43 which showed that knowledge of MTCT and the drugs to prevent it are significantly associated with antenatal screening. Educational programmes and information campaigns should be used to encourage screening.44 45
We found that women of wealthier households are the most likely to be tested for HIV during pregnancy. Although studies by Westheimer et al46 and Thierman et al47 showed an opposite effect of wealth, our results were consistent with the majority of studies on the subject.7 36 39 A programme to remove financial barriers, such as the cash transfers implemented in Nepal to encourage the use of ANC,48 could be considered for antenatal screening.49 50
Among the need factors, only wanting a later pregnancy is significantly associated with antenatal screening. This may be explained by the fact that women do not always have the necessary information to consider risk factors as an indicator of the need for screening and the fact that the prevalence of HIV in Nepal is relatively low.17 The literature has shown that higher perceived risk was associated with higher screening.38 42 51
Attending ANC services being a first step to accessing screening services, we found that pregnant women who attended four or more ANC visits were more likely to be tested. Attending fewer than six antenatal visits has been identified as a barrier in the literature52 and women who had more than one antenatal visit were more likely to have been screened.53 However, this study showed that the barriers to antenatal screening are different from those to ANC visits. Addressing the barriers to antenatal visits is not sufficient to improve access to screening.
In the Nepalese context, the shortage of equipment54 and healthcare workers55 suggest that the supply-side barriers are significant. According to the Nepal Health Facility Survey 2021, only 7% of facilities offering ANC had staff with up-to-date training in infection control guidelines and screening capacities were limited with less than 3% of the facilities offering ANC care able to conduct HIV screening.34 No factors on the supply side such as the type of health facility or the health workers qualification were significantly associated with antenatal screening. Rather than a real absence of barriers on the supply side, this may be explained by the nature of the data. The DHS data, while comprehensive, do not capture the variation and complexity of supply-side factors such as the knowledge and behaviour of health professionals and the quality of services, for example. In-depth qualitative studies should be conducted to better capture and understand these barriers.
Access to screening services is another factor associated with the decision to undergo antenatal screening identified in the literature.36 43 51 56 Despite the geographical constraints in Nepal and the uneven provision of antenatal screening across the country, which led us to assume that place of residence played an important role in screening uptake, we found that the district of residence is only partially associated with antenatal screening for HIV. We identified multiple factors associated with antenatal screening, which may explain why a relatively low chance of being tested for HIV during pregnancy was explained by differences between districts. Moreover, the number of PMTCT services in a district or the type of environment does not give an accurate picture of where a woman lives. It does not give information on the distance between a woman’s home and the nearest PMTCT service. A woman may be in a district with a low number of PMTCT services but be close to one. However, the nature of the NDHS data does not allow for an in-depth analysis of the geographic barriers.
These limitations aside, our results advanced the empirical literature on factors associated with antenatal screening for STDs. We used an econometric procedure that provided a measure at an appropriate level and disentangled the different effects, highlighting the importance of the geographical context in Nepal. This information is particularly relevant to develop interventions to increase antenatal screening uptake. The difference in the factors associated with screening and those associated with antenatal visits suggested that encouraging antenatal visits is not sufficient and specific interventions such as educational programmes and information campaigns or cash transfers interventions should be implemented to encourage antenatal screening.
Conclusions
Higher uptake of HIV screening was found among women from wealthier families, women who desired the pregnancy later and women with good knowledge of MTCT and the drugs available to prevent transmission. Lower education and having less than four ANC visits were associated with lower uptake. No supply-side factors, including the qualification of health workers and the availability of PMTCT services, were significantly associated with antenatal screening. Factors associated with antenatal screening have not changed significantly between 2016 and 2022 and were different from factors associated with ANC visits.
These findings inform the need for a comprehensive strategy targeting women with a higher risk of not receiving HIV screening during pregnancy and the implementation of the policy provisions. Further studies, respectively, those using approaches are needed to further explain the findings of this study and shed light on the contextual elements.
Data availability statement
Data are available in a public, open access repository. The data that support the findings of this study are openly available in the NDHS programme at https://dhsprogram.com/methodology/survey/survey-display-472.cfm.
Ethics statements
Patient consent for publication
Ethics approval
This study used publicly available data and was conducted in accordance with ethical guidelines, ensuring responsible and transparent use of the data. No specific ethical approval or consent procedure was required for this study.
References
Supplementary materials
Supplementary Data
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Footnotes
Twitter @naomi_saville, @HHaghparast
Contributors LS, NS and HH-B discussed the research and analysis strategy. LS conducted the analysis and submitted the paper. LS is responsible for the overall content as the guarantor. NS and HH-B supported LS throughout the process. NS, MD and HH-B proofread the final document. All authors have read and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.