Title : The association between antenatal care and HIV testing and treatment during pregnancy: A cross-national analysis of high-burden African settings
Abstract:
Antenatal care (ANC) participation is critical for HIV testing and antiretroviral therapy (ART) initiation to prevent mother-to-child transmission (MTCT), yet significant disparities persist across African nations with high HIV prevalence. With new threats to funding for broad HIV-related prevention interventions, understanding where disparities exist and how to best consolidate care has never been more critical. The purpose of this analysis is to explore the link between participation in ANC and prompt HIV testing in high-burden African nations and to compare ART initiation among HIV-positive pregnant women in these nations. Data from the 2020–2022 Population-Based HIV Impact Assessment (PHIA) from seven African nations with high HIV prevalence were used for this analysis. The prevalence of HIV among pregnant women in each nation ranged from 4.81% in Uganda to 30.1% in Eswatini. The relationship between ANC and HIV testing was highly variable between nations, with the strongest associations observed in Zimbabwe (OR 8.96, 95% CI 5.74–13.99) and Tanzania (OR 7.76, 95% CI 5.33–11.29). The relationship between ART initiation and ANC among pregnant women living with HIV was equally variable, with Malawi, Uganda, and Zimbabwe showing no significant association between ANC participation and ART initiation among HIV-positive pregnant women, while Mozambique (OR 3.71, 95% CI 1.49–9.20) and Lesotho (OR 3.24, 95% CI 1.11–9.51) demonstrated stronger linkages. These findings underscore the urgent need to strengthen ANC-HIV service integration, particularly in nations where fragmented care models contribute to delayed testing and treatment initiation. Consolidated ANC-HIV programs not only improve testing rates but also facilitate earlier ART initiation by embedding HIV services within routine maternal care. This study highlights the critical role of ANC as a gateway to HIV care and the importance of patient-centered, integrated service delivery. In the face of escalating threats to foreign aid-such as recent suspensions of PEPFAR funding, which supports ART for millions in sub-Saharan Africa-consolidating HIV services within ANC becomes even more vital. Countries like Malawi, where PEPFAR funds constitute a substantial portion of HIV program budgets, are particularly vulnerable to funding disruptions, which could reverse gains in MTCT prevention. Strengthening domestic health systems to deliver integrated care ensures continuity of services while mitigating reliance on external funding. Furthermore, involving women in care planning and addressing structural barriers such as stigma, transportation costs, and clinic wait times can improve engagement. Proactive strategies, including community-based ANC outreach and peer-led counseling, must be prioritized to sustain progress toward eliminating MTCT in an era of uncertain donor support.
