This study will hopefully add evidence to the already existing body of knowledge on South Africa’s HIV epidemiology, especially among pregnant women. It is a unique study that does not only provide an update of the antenatal HIV prevalence but also seeks to use epidemiological data to inform health promotion practices in a rural South African environment. Lessons from this high HIV burden country will hopefully also be applicable to other LMIC and their planners. The major difference between this study and the South African antenatal surveys is that this study includes all pregnant women and not exclusively primigravidas [16, 20].
This study has also been able to show that the HIV epidemic is maturing, characterised by an almost 40% antenatal HIV prevalence; a 100% proportion of women who know their HIV status; a higher HIV prevalence in older women, those who are unemployed, those who have had a previous pregnancy and those whose partners are locally employed. This study is also unique in that it has assessed the support provided by the male partner during antenatal care visits in public health facilities.
Of the 10.2% of teenagers interviewed in the study, 94.3% were high school students. This teenage pregnancy rate is lower than that described by Mchunu et al.  in a similar South African population wherein 19.2% of women reported to have fallen pregnant during their teenage years . In that study, 74.1% of teenage pregnancies were attributed to lack of knowledge, and 55% claimed that they did not fully understand the risks involved with sexual intercourse . Teenage pregnancy is known to be highly associated with a poor socio-economic status, risky sexual behaviours, violent behaviours and substance use . Regardless of the percentage of teenagers who were pregnant, it cannot be ideal for school children who are themselves dependent on adults to be pregnant as this often has an impact on their long-term progress [21, 22].
This is a poverty-stricken community with more than half of the women interviewed being unemployed (57.7%), never married (71.4%) and multiparous (63.9%). Almost 45% of the women’s partners were employed locally, suggesting that there were economic opportunities locally that favour males. These compare to other antenatal care survey results such as that in another South African province (Limpopo), where 808 pregnant women were recruited, 51% from rural areas and 28% from peri-urban areas . In that study both rural and peri-urban pregnant women had a high rate of being unemployed and being unmarried .
Encouraging is the fact that 50% of women had their first antenatal care visit at 16 weeks. This is good as it allows adequate time for identification of congenital abnormalities, maternal or foetal risks and the suppression of the viral load if HIV positive, thus reducing the probability of Mother-to-Child-Transmission [5, 6, 24–27]. This compares to antenatal care survey results of a Cameroonian study , of 293 pregnant participants, where 34% had started antenatal care in the first trimester . The explanations most commonly offered for a late antenatal presentation were financial difficulties and living a long way from the health facility .
The fact that all participants knew their HIV status and were open to disclose is positive and moves us closer to the goals of the 90-90-90 strategy [14, 29]. This compares favourably with other similar studies where the HIV testing rate in antenatal care was was up to 99.0% . Disclosure of HIV test results to sexual partners in a group of Ugandan women was relatively high and the findings suggest that having a sexual partner who had also tested for HIV probably made it easier for women to disclose their HIV status . The study also suggested the following as key factors in promoting disclosure: the need for promotion of sexual partner HIV testing; furthering of knowledge about HIV in women; and encouraging women to attend antenatal care . The high testing rate is also a sign that health professionals were complying with HIV policies to encourage testing of all pregnant women so that they can be initiated on HAART without delays .
The data shows that antenatal HIV prevalence is increasing and higher than that presented in previous studies for same area . The crude antenatal HIV prevalence of 38.2% is higher than the 31.9% (95%CI: 27.4–36.8) and the 33.3% (95%CI: 30.4–36.4) antenatal prevalences previously reported for Chris Hani and OR Tambo Districts respectively . The differences could be attributed to the inclusion of multigravida women in this study [16, 20]. The high prevalence could be a result of an increasing incidence most probably related to poor condom compliance and the concurrent reduction of HIV related mortality due to an improved antiretroviral programme . There was no statistical difference in HIV prevalence between health facilities.
The 2015 South African National Antenatal Sentinel HIV and Syphilis survey reported a declining HIV prevalence for the Eastern Cape Province . This contrasts with findings from this study. The prevalence in the Eastern Cape province has stabilised since 2005, having increased by only 0.7% from 1990–2015 . Over the 5-year period (2011–2015), the point prevalence estimate reached a peak in 2013 and 2014 at 31.4 (95%CI: 29.4% -33.5%); and declined by 1.2% in 2015 to 30.2% .
In women, the HIV risk has always been known to be decreasing with increasing age [1–3, 6, 16, 20, 31]. According to Stats SA , approximately 20% of South African women in their reproductive years (15–49 years) are HIV positive; however, HIV prevalence among those aged 15–24 has declined over time from 7.3% in 2002 to 4.6% in 2017 .
Several studies [1–3, 6, 16, 20, 31] have previously described a higher HIV incidence among teenage women since they had sex with both their peers and much older men [1–3, 6, 16, 20, 31]. Another South African study  previously reported a ‘recent partnership’ in 32% of young women aged 15–24 years to involve a partner five or more years older than them . Another 42% reported at least one age-disparate partner either in any of their three most recent partnerships or in their first-ever partnership . HIV prevalence was 29% among these women .
Pregnancy in early adolescence has been found to be associated with an increased incidence of HIV infection among South African women . The higher risk is associated with sexual risk behaviour such as multiple partners and a greater age difference with partners . This study, however, found a different phenomenon: the prevalence is higher amongst older women which suggests changes in the epidemiological characteristics possibly since the HIV infected women were infected many years previously but only knew their HIV positive status in the index pregnancy or it could well be a mark of an increasing incidence among older women. The aim of PMTCT programs is to improve the wellbeing of expectant mothers and to reduce the incidence of HIV among newborns [9, 10]. It is therefore of interest to quantify the HIV MTCT trends among newborns in the same study population, especially since multigravidas were associated with a higher prevalence than primigravidas.
It is of little surprise that unemployed women had a significantly higher risk of being HIV positive than self-employed women. HIV is a disease of poverty , which further explains the increasing HIV prevalence in this community where more than 50% of the participants were unemployed . Poverty may drive some women into risky sexual behaviours such as transactional sex and an inability to negotiate safer sexual practices with their partner . Participants who reported to always use condoms during intercourse were possibly not being honest. After all, they were pregnant at the time of interview, making it unlikely that they always used condoms.
One participant reported her sexual debut to have consensual, without a condom and is the one that resulted in the index pregnancy which was unplanned. This kind of behaviour suggests an opportunity for the South African Department of Health to have more health promoters who can assist such women. The results further suggest that health promoters could help dispel myths about condoms. They should also advocate for latex free condoms for people who are allergic to latex condoms . Plastic or polyurethane condoms are an effective barrier against HIV as well as bacterial sexually transmitted diseases while at the same time allowing better transfer of heat . They are thinner than latex condoms and increase sensitivity . However, plastic condoms are more expensive than latex condoms and less flexible so more lubrication may be needed .
Women need to be empowered to be the ones who decide on the choice of condom use . As evidenced in this study, 45.8% of women reported not using a condom because of the partner’s preference. Women should therefore not blindly trust their partners but should instead take control of their sexual decisions and be empowered through interventions that encourage them to negotiate safe sex. They need to understand and acknowledge their own bodies, wishes and desires, in addition to being stimulated to participate in social movements to combat gender inequalities . All these roles can be fulfilled by qualified health promoters .
Most women did not have an expectation for their partners to accompany them during their antenatal care visits. Spousal support during antenatal care can help improve acceptance and utilisation of preventive strategies in general and to an increased uptake of interventions to prevent vertical and sexual transmission of HIV . Partner/couple counselling in the antenatal setting may have further benefits to individual VCT . In a Kenyan study, male antenatal care attendance was found to be associated with improved infant HIV-free survival . Promotion of HIV testing in men and engagement in antenatal care services may improve outcomes in infants .
The non-involvement of partners in antenatal care services could discourage women in their ability to disclose their HIV-positive status due to fear of rejection, stigma and discrimination. It could also serve as a barrier to women beginning treatment and adhering to it and may disrupt HIV prevention services which could in turn result in poor HIV outcomes.
Even though attempts were made to reduce limitations the study encountered a few. Firstly, findings from this study are not representative of the Eastern Cape Province as participants were recruited from only four health facilities. Findings from this study do, however, give a reasonable idea of the changing epidemiology of HIV in a rural environment amongst women attending antenatal care.
Secondly, the limited privacy during the interviews that occurred as a result of infrastructure challenges could have resulted in a social desirability bias, especially in questions pertaining to sexual behaviour and the use of condoms. Where this bias was noted results are reported truthfully. Lastly, only a few participants’ CD4 cell counts and viral loads were included in the clinical records, as such these measures are not reportd altogether in this article. It is however unlikely that these limitations could have distorted the findings on the epidemiology of HIV in this population especially since medical information was triangulated from clinical records.