This study will hopefully add evidence to the already existing body of knowledge on South Africa’s HIV epidemiology, especially among pregnant women in rural communities. It is a study which highlights a high HIV antenatal prevalence, high antenatal HIV testing rates, lack of expectation of spousal attendance in antenatal care and challenges experienced with condom compliance. In univariable analysis, multigravidity, being older than 30 years and having an unemployed spouse was associated with higher HIV prevalences, confirming findings that have previously been established in literature [5, 9, 18-20, 22, 30]. The study 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 [15, 16].
Of the 10.2% of teenagers interviewed in the study, 94.3% were high school students and 22.9% (n=8) were HIV positive. 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 . The HIV prevalence among teenagers is comparable to a prevalence of 17.2 to 22.5% reported in a 10 year cohort in a neighbouring South African province of KwaZulu-Natal . 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 [31, 32].
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 . The fact that self-employed women were less likely to be HIV positive in the multivariable analysis (p-value<0.0001) is consistent with findings suggesting that economic independence could improve the capacity to negotiate safer sexual practices . The results have to however be treated with caution given that self-employed participants only accounted for 10 (2.9%) of participants in the study.
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 [13, 14, 22, 34-36]. 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 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 [15, 16]. 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 [17, 18, 30].The HIV status of participants was not dependent on the facility from which they were recruited, and this was not statistically significant (p-value = 0.672). Findings from this study contrast the 2015 South African National Antenatal Sentinel HIV and Syphilis survey results which reported a declining HIV prevalence for the Eastern Cape Province .
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 [39, 40]. Future retrospective cohort studies should seek 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 .
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 epidemiology of HIV in a rural environment amongst women attending antenatal care. Secondly, the strength of the association between women older than 40 years and those between 20 to 29 years is weak due to the borderline p-value and the wide confidence interval.
Thirdly, 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. 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.