In this secondary analysis of 2016 UDHS data, we found empirical evidence for significant differences in utilization of HTC services between disabled and non-disabled pregnant women in Uganda. Disabled women compared to their non-disabled peers were likely to be older, have no education, and come from poor households. They were, however more likely to be employed, which reflects some level of empowerment. Our principal finding shows that disabled women were less likely to receive pre-test HIV counselling, to be tested for HIV, and receive post-test HIV counselling.
Uganda has been one of the few countries in sub-Sahara Africa to promote disability-inclusive HIV prevention services. For example, Uganda’s HIV Counselling and Testing Policy  explicitly recognizes that people with disabilities are at higher risk of HIV infection, and may experience difficulty in accessing HIV services. Further, this policy document stipulates that all HIV counselling and testing services should address the unique needs of persons with disabilities to address the persistent inequities . Hanass-Hancock and colleagues  who studied eighteen national strategic plans for the inclusion of people with disabilities in HIV/AIDS services in Eastern and Southern Africa, found that Uganda’s national strategic plan represented the region's best practice in disability-inclusive response to HIV/AIDS. Disability advocacy and self-advocacy groups and organizations in Uganda have been very active and engaged in developing disability-inclusive national strategic plans to respond to the HIV/AIDS epidemic .
Despite these efforts, our study found significant differences in utilization of HTC services between disabled and non-disabled pregnant women in Uganda. Disabled women compared to their non-disabled peers were less likely to receive pre-test HIV counselling, to be tested and received HIV result, and receive post-test HIV counselling. Our findings of persistent disability-related disparities in antenatal HTC service utilization points to a gap between disability-inclusive policy development and implementation in Uganda. While the laws and policies in several African countries, including Uganda, explicitly protect disability rights, equality, and nondiscrimination in access HIV services including testing and treatment  , a study has documented several challenges and clear gaps in implementation of disability-inclusive HIV services, resulting in systemic inequities in HIV service utilization and care .
These persistent inequities in access to and utilization of HIV services among people with disabilities, among other things are rooted in assumption, misinformation and stigmatization about disability . Research reveals a tendency of misconceptions about exposure to risk of HIV among people with disabilities  , and also that the fear of stigma prevents people with disabilities from accessing HIV services, even when they consider that they may be HIV positive , This issue is compounded by the lack of disability awareness and training among health care providers, lack of accessible HIV and testing information and services, and communication barriers such as sign interpreters, making it difficult for people with disabilities to access and utilize HIV services [21,29]. Widespread misconceptions about lower HIV exposure among women with disabilities allegedly for being non-sexual and dismissing evidence on higher exposure to sexual violence often lead to exclusion from health promotion activities, including HIV campaigns, which make women with disabilities disproportionately vulnerable to HIV, particularly young women with disabilities .
To ensure access to HIV health services for individuals with disabilities in Uganda, there is a need to increase awareness among reproductive-age women with disabilities about the risk of HIV and the importance of seeking HIV services. Equally important is to provide continuous training for healthcare providers about the risks of HIV among people with disabilities by providing tools to meet the unique needs people with disabilities to have equitable access to sexual and reproductive health. For example, a study found that providing disability-related training among health care providers can be effective not only in sensitizing health workers to improve access to HIV services for people with disabilities, but also in providing knowledge and skills to implement needed changes . However, for a sustainable change, such endeavors require political will on the part of national and local governments and commensurate budget allocations.
The strength of the study lies in the use of nationally representative survey data and the large sample size. Notwithstanding, the study is without limitations. First, the UDHS does not include questions on the severity, duration, onset, and cause of disability—all of which may limit the sensitivity and accuracy of the data presented. Second, the use of the cross-sectional study design, as employed in the DHS, a cause and effect relationship could not be determined. Third, the study adopted self-reporting of past events (e.g. prenatal care uptake or HIV testing), which is subjected to social desirability and recall bias. Lastly, there are several other unmeasured confounders such as couple testing, availability of testing services and how testing is done, which could potentially influence the uptake of HIV testing during the ANC visits.