In this study, the prevalence and factors associated with HIV testing among pregnant women in Rwanda were assessed. The prevalence of HIV testing among pregnant women was found to be 94.0%. This is higher than the overall prevalence reported from 11 East African countries (77.5%) and that from Nigeria (42.7%) [28, 29]. 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 [13, 19].
Pregnant women aged 25–34 years were more likely to test for HIV compared to their older counterparts (35 years and above). This may be attributed to the fact that sexual education tends to be focused on young women who may be involved in high-risk sexual behaviours [29, 30]. These findings are consistent with studies from Vietnam and Ethiopia which also reported older age to be associated with less HIV testing [31, 32]. 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. These findings are supported by other studies in Rwanda and Senegal which also reported differential rates in HIV testing among regions [8, 9]. Kigali as the capital and predominantly urban city has more widespread and multi-service health infrastructures which offer more opportunity 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 of access to health services including sexual and reproductive awareness. 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 [22, 33]. 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 [14].
Surprisingly, lower levels of education (secondary, primary and none) were associated with more 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 [24, 34, 35]. 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 right decisions regarding attendance and utilization of health services [29, 36]. However, the probable reason for the lower odds of HIV testing among pregnant women with tertiary education could be attributed to the stigmatizing attitudes highly educated people hold towards HIV-positive people hence they may fear utilizing HIV testing services [37]. Therefore, this study finding warrants further exploration to establish why women with tertiary education 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. 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 counselling 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 visit and HIV testing [15]. Pregnant women who visit a health facility are more likely to be attending antenatal care, of which health education and HIV testing are compulsory components [19], 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 [38]. 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 the unmarried. This is similar to a study from Thailand [19] and that from East Africa [24] 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. Moreover, since married women tend to have premarital HIV testing with their partners, they, thus, tend to be more receptive to regular HIV testing. 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 done in East Africa which showed that women with multiple sexual partners had lower odds of HIV testing [24]. However, the finding is contradictory to studies in Ethiopia which 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 [15, 39]. 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. This deviates from study findings in Vietnam and Ethiopia which reported employed pregnant women being more likely to test for HIV [31, 40]. Although employment is a vital component of women's empowerment for making healthy decisions and choices, it has also been reported to have a negative effect on other women's health aspects, predisposing women to sexual violence [41] and reducing antenatal and postnatal care attendance [42, 43] 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.
Strengths And Limitations
We used the most-recent data from the 2020 Rwanda Demographic and Health survey, with a large sample size and standardized data collection protocols. Moreover, we weighted the dataset making our results generalizable to all pregnant women in Rwanda. However, this study also had some limitations such as the risk of information and recall bias due to the sensitivity of the HIV topic (prone to social desirability effects) and data was self-reported, without verifying with health records. All this could have affected the true estimation of HIV testing prevalence. In addition, the cross-sectional design of this study limits inferring causality but rather only association.