Overall, although Uganda had a significant increase in the proportion of women who came to ANC1 with known current HIV status during 2012-2016, this increase was small. There was also regional variation in trends of women coming with known HIV status at ANC1. The proportion of women who came to ANC1 with a known HIV status was low over the years of study, with fewer than 10% of women knowing their current status nationally. The proportion of KHIV+ is slightly higher than that of women that were newly tested HIV positive at ANC1 in 2015 and 2016 nationally.
National surveys show that most Ugandans have been tested for HIV at some point in the past. The 2011 Uganda AIDS Indicator Survey showed that 83% of women and 70% of men had ever been tested and had received the results of their last test [17], and information from the National HIV Testing Services showed that 42-51% of the population aged 15-49 years knew their HIV status in 2016, and that about 60% of these were women [8]. However, for purposes of early identification of all the HIV positive women so as to implement timely PMTCT interventions in Uganda, one is considered to be KHIV- when the documented test was done within four weeks of the visit [18]. This stringent measure of the known HIV negative status at ANC1 is likely to have skewed the overall proportions of women that came with known HIV status at ANC1 towards the unknown. Thus it is possible that more than 5-10% of the women attending ANC1 knew their HIV status, but either did the test outside the required window of time or attended ANC1 without any document verifying their status, and so were considered to be of unknown HIV status.
The proportion of KHIV+ is slightly higher than that of women that were newly tested HIV positive at ANC1 in 2015 and 2016. This could be due to the nationwide progress towards achieving UNAIDS first 90 which is 90% of the HIV-positive persons in a given population knowing their HIV- positive status [13]. In Uganda, between July 2015 and June 2016, 69% of persons living with HIV (PLHIV) knew their (HIV-positive) status [19] and this had increased to 73% between July 2016 and June 2017 [20]. Thus, the nationwide progress possibly also included the women of reproductive age.
However, the yield of those newly testing HIV positive at ANC1 was less than that observed in the general population of 3.5% [8]. This contradicts evidence that a big proportion of new HIV infections in Uganda are among women of reproductive age [7]. However, it is possible that some women do not attend ANC and thus may miss HIV testing. This therefore calls for innovative measures to identify all new HIV positive individuals especially women of reproductive age to achieve elimination of mother-to-child transmission of HIV (EMTCT).
The variations in trends in proportions of women that come with a known current HIV status at ANC1 regionally may be attributed to the differences in the HIV prevalence in the different regions. The 2016 Uganda Population-based HIV Impact Assessment puts the highest prevalence at 7.7% in South Western region, 6.6% in Kampala and the lowest at 2.8% in West-Nile [7]. This regional variation of prevalence is similar to the one of the 2011 Uganda AIDS Indicator Survey [17]. The fact that the more highly-prevalent regions also had higher proportions of women attending ANC1 with known current HIV status could be because HIV testing campaigns and services are more emphasized in these regions. This is because testing goals are shifting to places/populations with a high yield of HIV-positive persons [8].
Limitations and strengths
Our findings should be interpreted with the following limitations. We used DHIS2 data which is aggregate data and so we could not look out for individual effects such as repeat pregnancies in the same woman during the study period. Also, some variables were new and could not be assessed over the whole study. Relatedly, the new variables (data elements) are initially not very accurate because the health workers that often double as data entrants take some time getting accustomed to looking out for and reporting them.
Our estimate of the proportion of women who knew their current HIV status at ANC1 is likely an underestimate due to the documentation required to determine a known HIV status at ANC1. In addition, ANC data in DHIS2 have potential selection biases such as: distribution of public and private ANC services, misrepresentation since not all women attend ANC in DHIS2 reporting facilities and a small proportion opts not to attend professional ANC at all [21,22,23]. Nevertheless, a large proportion of Uganda’s population attends public health facilities [24] and so the results can be generalized to the entire country.
Finally in countries with a mature and generalized HIV epidemic such as Uganda, ANC indicators are important sources of data in HIV surveillance and provide good data on epidemic trends over time [21,22,23]. Our findings therefore can be used as proxy indicator of adult Ugandan women’s seeking behavior to know their HIV status, thus reflecting the national and sub-national trends of women of reproductive age who know their HIV-positive status in Uganda.