Abstract

Background: Globally, Human Immunodeficiency Virus (HIV) continues to be a major public health burden. Transmission occurs by several means including the transmission from mother to child mostly happening during labor and delivery. The objective of this study was to determine the prevalence and factors associated with HIV infection in women who delivered at Soroti Teaching/Regional Referral Hospital.

Methods: A cross-sectional study was conducted from April to June 2023. A total of 422 mothers who delivered in Soroti Regional Referral and Teaching Hospital were sampled by systematic random sampling.

A structured data extraction tool was developed and data were collected using the Kobo Collect mobile application.

Data was analyzed using STATA 15 and modified Poisson regression model was used for inferential statistics. Statistical significance was accepted for a value of p < 0.05.

Results: The average age of the population was 26 years (SD = 0.5). The HIV prevalence was 5.3%. Associated factors were Gravidity ≥ 5 (PR- 95% CI = 1.54 to 1.57, P = 0.007), previous miscarriage ≥ 3 (PR = 0,266 (0.11, 0.642) CI 95%, P = 0.003), Hepatitis B PR-19.429 (2.613, 144.43) CI 95% p = 004 and residing in a rural setting (PR = 2.506 (1.05, 1.593) CI 95% p = 0.038).

Conclusion: HIV prevalence among women who delivered at Soroti Teaching Hospital during the study period was 5.3%. Gravidity above 7, Hepatitis B infection, miscarriages more than or equal to 3 and living in a rural setting were significantly associated with HIV infection. Prevention of subsequent pregnancies and sexually transmitted diseases like hepatitis B are key factors in the prevention of HIV.

Keywords

HIV; Seroprevalence; Factors associated

Introduction

According to United Nations Programme on HIV/AIDS (UNAIDS) data show that there are 39 million [33.1 million-45.7 million] people living with HIV globally [1]. The prevalence varies from one continent to another and from one region to another within the same country [2,3]. Sub-Saharan Africa carries the biggest burden of the disease. In 2023, an estimated 1.4 million adults and children were living with HIV in Uganda; with 50000 new infections and 2800 deaths during the same year [1].

Uganda, for the period 2000-2020, recorded tremendous improvement in the fight against the HIV and AIDS epidemic. It is among the eight countries in the world that had fully achieved the 90-90-90 targets by the end of 2020 [4]. The AIDS-related deaths significantly reduced hence reducing AIDS- related orphans. Also, as a result of EMTCT (Elimination of Mother to Child Transmission) HIV prevention programs the country realized a reduction in the numbers and proportion of children who contract HIV from their HIV infected mothers [4]. According to Ministry of Health estimates, 2020, HIV prevalence among adults (15-49 years) in Uganda is 5.4%. Mother-to-child transmission (MTCT) of HIV in Uganda decreased by 77% from 23,000 in 2010 to 5300 in 2020. This is good progress towards the global goal of eliminating MTCT of HIV [4]. It was estimated that 5.8% children got infected due to MTCT in the year 2020 [4]. The prevalence is higher among females (6.8%) as compared to the males (3.9%). There is variation of prevalence per district the highest being Kampala at 18% whereas Soroti District where this study was conducted stood at 5.2% [4].

Prevention of Mother to Child HIV Transmission (PMTCT) is a four -pronged approach comprising of a package of interventions summarized as 1) primary prevention of HIV infection; 2) prevention of unintended pregnancies among women living with HIV; 3) prevention of HIV transmission from women living with HIV to their infants; and 4) provision of treatment, care and their families [5]. There has been an increase in the proportion of women tested during pregnancy in Uganda, with 98% of pregnant women who attended Antenatal Care (ANC) in 2019 knowing their HIV status. Antiretroviral therapy provision to the public and private sector in Uganda has also increased. This has been accelerated by the test and treats policy which was adopted in Uganda in 2016 [5].

Despite the high ANC testing rates, there is limited data about prevalence of HIV among women in labour since some of them are referrals to the regional hospital and there are lacunae in knowledge about the factors associated with the mothers who are found HIV positive therefore the need for the study. Knowledge of the HIV status of pregnant women could reduce the risk of vertical transmission of HIV through the interventions of PMTCT. Our objective was to determine the prevalence and factors associated with HIV infection among pregnant women delivering at Soroti Regional Referral Hospital in Eastern Uganda.

Materials and Methods

Study design and setting

This was a cross-sectional study that used quantitative approaches to data collection and analysis. The data were extracted from a large study titled ’Situational analysis and capacity building for health research Soroti University’ that was conducted at a regional referral and teaching hospital in Eastern Uganda from May to July 2023. The hospital is located in Soroti City which is 326 kilometers east of Kampala the capital city of Uganda. The hospital serves the Teso SubRegion comprising of ten districts with a population of 2.5 million. Women have an average of 5.4 children in their lifetime according to the 2023 Uganda Demographic and Health survey. Most of the surrounding districts are rural.

According to the hospital records, the teaching and regional referral hospital has a bed capacity of 274 and the total about 60,000 patients per annum. This registers about 20,000 admissions and 40,000 outpatients annually while. The unit handles about 2000 first ANC visits and average 300 deliveries per month. It receives referrals from seven hospitals, 10 health centre four and 62 health centre three in the region. The hospital provides free HIV services including PMTCT for clients and comprehensive HIV care. It receives referrals from seven hospitals, 10 health centre four and 62 health centre three in the region. The hospital provides free HIV services including PMTCT for clients and comprehensive HIV care.

Study population and sample size determination

This data was part of the prevalence of pregnancy related complications study among mothers who delivered at the teaching hospital in the year 2022 whose sample size was calculated as 422. The sample size was estimated using Kish and Leslie formula [6]: where n is the sample size recommendation, Z = 1.96 (value from the normal distribution), p is the assumed 50% pregnancy related complications prevalence in order to achieve a bigger sample size, q = 1-p and e is the level of precision which is set at 5% We then took the sample size of 384 and adjusted for non response by 10%, to give a minimum sample size of 422 which was used. The sampling units were selected by the systematic random sampling technique by reviewing the clients’ record archives of labour and delivery, a logbook for year 2022, and by calculating k value as 8, after the first chart was selected by the lottery sampling method. Whereas, the study population of this study was all mothers delivered in 2022 should have fulfilled the eligibility criteria of this study. This cross-sectional study recruited 422 participants.

Inclusion and exclusion criteria

All women who delivered in the hospital during the study period were eligible for the study. Women who had complete documentation in the registration book and patient charts were included, whereas women who had incomplete data like age, HIV and Hepatitis B results were excluded.

Laboratory diagnosis and quality control: Antenatal care service provides routine laboratory diagnostic tests for all pregnant women and results are recorded in the hospital chart. Five milliliters of venous blood were drawn using a sterile needle and syringe. Three drops of blood were taken from the sample for ABO and Rhesus testing and the rest was centrifuged at 300 revolutions per minute for 5 minutes. The serum sample was tested for HIV, Syphilis and Hepatitis B. These tests are routine antenatal tests currently in Uganda. Syphilis was tested using the Rapid Plasma Regain (RPR) test. All RPR positive sera/plasma were further confirmed by Treponema pallidum hemagglutination (TPHA) test. Those who tested positive for both RPR and TPHA were diagnosed to have syphilis infection. ABO and Rh groups were determined using commercially prepared antisera according to manufacturer’s instructions. All tests were run using controls according to laboratory standard operating procedures. HIV testing was done in accordance to the Uganda Ministry of Health testing algorithms [7]. Determine kit used for HIV 1 and 2 as screening test and stat pak as second test being confirmatory for positive samples and SD Biolineas a tie breaker in case of any discrepancy between the first two tests. When the Duo kit was available it could be used as a screening both HIV and Syphilis. All samples that tested negative on the first test were considered negative [7].

Data collection and analysis: Research assistants collected and entered data using the Kobo Collect mobile application preloaded with a structured data extraction tool. The Kobo Collect application was preinstalled on android-based mobile phones and data were collected using the devices. Data was uploaded to the server daily. The questionnaire elicited data on the socio-demographic characteristics of the pregnant women, obstetric characteristics and laboratory findings. Data were collected from mothers’ hospital charts who delivered from labor ward. Data was cross-checked for completeness, and entered into STATA 15, software for analysis. The results were presented in tables. Descriptive statistics such as means, frequencies and proportions were used to summarize the data. Bivariate analysis was done to determine associations between the predictor and outcome variables. Multivariable logistic regression was used to assess the strength of the association between the independent/ predictor variables and the outcome variables. Both bivariate and multivariate binary logistic regression models were fit to identify factors associated with HIV and Hepatitis B. A p-value < 0.05 in the multivariable binary logistic regression analysis was considered to be statistically significant. The dependent variable for this study was HIV prevalence which was obtained from the chart laboratory results. The independent variables for this included socio-demographic characteristics such as, age, respondent’s education level, marital status, respondent’s employment status, obstetric characteristics such as parity, gravidity, and ever had induced abortion; and ANC factors. Gravidity was defined as the sum of all pregnancies, including all live births and pregnancies that were terminated at less than 6 months or did not result in a live birth. Parity was defined as pregnancies that resulted in the delivery at greater than 6 months gestation, of either a live birth or a stillbirth.

Quality control and assurance

The principal investigator recruited and trained third year medical students with prior research knowledge. Prior to data collection training research assistants happened for two days. They were trained on the data collection tool, ethics and study protocol. The data entry form was designed with skips and restrictions to ensure quality data collection. Pretesting of study tools was done at the nearest health centre IV by administering the data collection tool to selected charts retrieved from labor ward achieves in order to ensure familiarity of the team with the tool and also identify any errors. Also, to ensure compliance to the study protocol, research assistants were supervised during data collection.

Sampling technique and study variables

The study subjects were selected by the systematic random sampling technique by reviewing the clients’ records of labor and delivery, a logbook for the year 2022, and by calculating k value as 8, after the first chart was selected by the lottery sampling method. The dependent variable is HIV/AIDS seropositive status. Whereas, the independent variables assessed were age, educational status, gravidity, marital status, place of residence and obstetric characteristics.

Results

Seroprevalence and sociodemographic characteristics

The overall prevalence of HIV infection among mothers who delivered in labor ward was found to be 5.3% 10 mothers had no HIV results as they were unbooked and came in as emergencies. Majority 97.6 % of the mothers had their results on files (patient charts). Uganda national guidelines promote all pregnant mothers who visit the ANC unit to test for HIV infection [7]. The majority of the mothers who delivered were found in the age interval of the highly productive age (18-31 years). Out of the 422 mothers 59 (14%) had never gone to school. The educational status of HIV-seropositive mothers who attended formal education was 95% among those found HIV positive. Around 78.9% of the sampled mothers were married, while the rest proportion was either widowed or divorced. More than half (59.1%) of the mothers came from rural settings. The contribution of the urban dwellers towards HIV seropositivity was less than the rural dwellers. The majority of HIV-seropositive mothers were in the age group of 18 to 31 years (Table 1).

Variable	Characteristics	n(%)
Sex of household	Female	420 (99.5)
head respondent: n=442	Male	2(0.5)
Religion: n= 422	Anglican	178(42.3)
	Catholic	159(37.8)
	Others	13(3.1)
	Pentecostal	71(16.9)
Place of residence (n=422)	Rural	249(59.1)
	Urban	172(40.9)
Age group (years)(n ) of respondents	<20	101(23.9)
	20-24	94(22.3)
	25-29	118(28)
	30-34	69(16.4)
	35-39	30(7.1)
	≥40	10(2.4)
School attendance (n=422)	None	59(14)
	Primary	190(45.1)
	Secondary	144(34.2)
	Tertiary	28(6.7)
Employment status	Employed	46(11)
	Self employed	365(86.9)
	Not Employed	9(2.1)
Marital status	Not married	89(21.1)
	Married	332(78.9)
Number of marriage partners	1	388(91.9)
	2	30(7.1)
	3	1(0.2)
	None	3(0.7)
Income level	Less than 3000 UGX	162(38.7)
	5000 UGX- per day	88(21)
	More than 5000 UGX /day	36(8.6)
	No income	133(31.7)
Have health insurance	Yes
	No
Distance to government health unit	Less than 5 km	225(53.6)
	More than 5 km	195(46.4)

Table 1: Characteristics of study participants-Hospital Survey N = 422.

HIV positive by Maternal Obstetric Characteristics. The majority (90.5%) of mothers attended ANC at least once. Most mothers attended more than 3 times during the entire period of ANC. Prime gravidity were almost equally represented as the multigravidas (Table 2).

Variable	Characteristic	n(%)
Number of births (including index birth)
	0	136(32.2)
	1	113(26.8)
	2	63(14.9)
	3	41(9.7)
	4	31(7.4)
	≥5	38(9)
	Yes	373(90.5)
	No	39(9.5)
Number of ANC visits: (N=373)
	None	39
	1	1(0.3)
	2	17(4.6)
	3	59(15.8)
	4	161(43.2)
	≥5 visits	135(36.19)

Table 2: Obstetric table N=422.

There is a significant association between the dependent variables (HIV seropositive status among mothers) and hepatitis B infection, Parity greater than seven, miscarriages greater than 3 and living in a rural area (Table 3).

Table 3: Factors associated with HIV among women who delivered at a regional referral hospital in Eastern Uganda.

After Poisson regression factors associated with HIV among the women who delivered at the teaching hospital included living in a rural setting, gravidity, miscarriages above 3 and having tested Hepatitis B (Table 4).

Table 4: Poisson regression.

Discussion

In our study HIV prevalence among mothers who delivered at the teaching hospital in the specified study period was 5.3%. Women are particularly susceptible to HIV infection for both biological and sociocultural reasons like the use of alcohol or chewing the psychotropic plant during sexual intercourse, history of multiple sexual partners, and low awareness about the use of condoms during sexual intercourse, transactional sex, inefficient coverage of testing, poor HIV counselling, and testing during pregnancy and low habit of sharing the test results among couples [8-12]. The prevalence we reported in our study was lower compared to other similar studies which reported 20% for example done in South Africa and Ethiopia [11-13].

Africa is inhabited by over 14.7% of the world’s population, but shouldering more than 90% of all HIV/ AIDS-related mortality [11,14]. By cascading from the global plan, Uganda set a goal of universal access and raised the capacity for the delivery of HIV counselling and testing, PMTCT, and provision of ARVs [7]. Uganda reported a decline of 39% in new HIV infections recorded over the past decade though the magnitude is still very high [2,4,10,15].

In our study the factors that were associated with HIV seropositivity among the mothers included testing positive Hepatitis B, Parity greater than seven, miscarriages greater than two and living in a rural area. Other sociodemographic factors and maternal factors were not statistically significant as per our study. The explanation for the association is depends on the variable identified. Firstly, hepatitis B infection is also sexually transmitted just like HIV. This means the factors that affect transmission of the two diseases are similar being that they can both be sexually transmitted. Multiparty and having had two or more miscarriages could be that they are having greater exposure to the source of infection. Similar studies have reported- Whereas many previous HIV prevention studies have reported that living in urban area is associated with a higher risk of HIV acquisition due to lifestyle in our study we revealed that it was the opposite [14,16]. The most likely explanation for this finding is that most of the clients that came to the hospital live in the rural areas. It appears that town dwellers have many options where to deliver from including private clinics. The other possible explanation could be that the urban dwellers have found a way to protect themselves since there are better services in town.

In contrast to the other studies [17,18], marriage, age education level, socioeconomic status, gestation age and distance to nearest health unit were not associated with testing HIV positive. In the current study, the highest proportion of the women was married, which is in agreement with a study from Ethiopia in Gondar that reported the majority of women (94%) who were found seropositive for HIV tests were married [11,13,19]. No comparison was made by computing straightforward between the married and un- married categories of women. Again, according to the Zimbabwean study, like that of the Nigerian study marriage was protective against HIV infection, as married women were two times less likely to be HIV positive compared to unmarried women [11].

Limitations

This study was hospital based so the findings may not be a true reflection of the general population and may not be representative of lower health units. As we used secondary data from the hospital patient charts in the labour ward, it was difficult to control for missing data and inconsistencies. Partner related sociodemographic information was not adequately captured in the charts therefore could not be analyzed yet it is equally important.

The fact that such important values could not be captured may have affected generalization of the findings. Despite these limitations, to the best of our knowledge the study presented primary results of prevalence and associated factors of HIV/AIDS among mothers who delivered at the referral and teaching hospital.

Conclusions

There is still a high prevalence of HIV/AIDS among mothers delivering at Soroti Regional Referral and Teaching Hospital. The risk of testing HIV positive was higher among women with hepatitis B infection, parity greater than seven and miscarriages greater than 3. The findings of this study will provide valuable information for policy makers in the hospital particularly in the area of PMTCT.

Ethical Approval

Ethical approval for this study was sought from Clarke International University Research Ethics Committee, approval number, CLARKE-2023-704. Administrative clearances were sought from the office of the Chief Administrative officer Soroti District and the Hospital Director. Participant informed consent was waived as this was retrospective document based study and individual patients could not be readily accessible.

Authors Contributions

SK: Conceptualization, proposal development, Methodology, funds acquisition and management, data collection, data analysis, supervision and report writing. DA, AJF, CA, JMO, MI, JE, AS, MC: Proposal development, data collection and report writing.

Conflict of interest Declaration

The authors declare no conflict of interest.

Funding

This study was funded by the Government of Uganda through Soroti University Research and Innovation Fund (SUNRIF), Round1. Grant No. SUNRIF-2022/.

Acknowledgement

The authors would like to acknowledge the contribution of the Vice Chancellor Soroti University Prof Ikoja Odongo who acquired the funds for the research activities and the Soroti University Director of Research and Innovation Professor Francis Ejobi, for his administrative support. We also thank Mathew Muwanguzi for coordinating the study.

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Article Information

Article Type: RESEARCH ARTICLE

Citation: Kabwigu S, Ronald O, Emmanuel O, Achoroi D, Amonya C, et al. (2024) Prevalence and Factors Associated with HIV Infection among Mothers Who Delivered in a Resource Limited Teaching Hospital: A Cross-Sectional Study. J HIV AIDS 8(1): dx.doi.org/10.16966/2380-5536.187

Copyright: © 2024 Kabwigu S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Publication history: 

Received date: 16 Apr, 2024

Accepted date: 15 May, 2024

Published date: 24 May, 2024