The acceptability , knowledge and perceptions of pregnant women toward HIV Testing in pregnancy at Ilembe District

This research study aimed to investigate the acceptability, knowledge and perceptions of pregnant women toward HIV testing in pregnancy in Ilembe District. An exploratory research design guided the study. A systematic random sampling was used to select pregnant women who were attending the ante-natal clinic for the first time in their current pregnancy. Self-administered questionnaires with close-ended questions were used in the collection of data. The questions included the women's demographic details, their views of HIV testing, knowledge and as well as their acceptability of HIV testing. Forty questionnaires were distributed and they were all returned. A quantitative method was used to analyse the data. The findings of the study revealed that 45 % of the women in the sample were relatively young (18-25 years) and most of them (90%) were unmarried .The majority of women (92.5%) said testing was a good idea and 85% said it was necessary. However only 52.5% said they would opt for HIV testing. The uptake of HIV testing was found to be low. Eighty-seven and a half percent (87.5%) of the women in the sample were of the opinion that HIV testing in pregnancy was of benefit to the mother and her baby. Women in the study were generally found to have a good understanding and good perceptions towards HIV testing in pregnancy, but this was not consistent with their behaviour.


Background
Correspondence address: Ms ZZ Nkosi School of Nursing University of KwaZulu-Natal Howard College Campus Durban 4001 Tel (031)260-2901 Fax:(013)260-2855 E-mail: nkosizz@ukzn.ac.zaAIDS is regarded as a serious health crisis because o f the large number of people who are dying o f complications related to HIV/AIDS.Globally there are 33 million people who are infected with HIV and the number o f people living with HIV in Africa has skyrocketed to 22 million (UN AIDS, 2008).South Africa is now faced with the largest and fastest growing HIV epidemic in Africa and the world.At the end o f2007, there were 5.7. million people living with HIV in South Africa and almost 1000 deaths occurring everyday ( UNAIDS, 2008).This number is higher than in any other country in the world and is expected to double over the next decade.The country estimates that 18.3% of adults (15-49 years) are living w ith HIV (D epartm ent o f H ealth, 2008).More than 55% of all South African infected with HIV reside in KwaZulu-Natal and Gauteng provinces (Dorrington et, al, 2006).
KwaZulu-Natal province has recorded the highest HIV infection rate amongst antenatal clinic attendees in South Africa in 2006 with a rate of 39% as compared to eight other provinces.The statistics show that an estimated 38 % of pregnant women aged from 25-29 are HIV infected, making this age group the group with the highest prevalence rate (Department of Health, 2008:4).
The HIV epidemic is also having a severe impact on maternal deaths in South Africa (Dilraj, Abdool Karim and Pillay, 2007:42).HIV data from antenatal clinics in South A frica su g g est th at the c o u n try 's epidemic might be stabilizing, but there is no evidence yet of major changes in HIV-related behaviour (UN AIDS, 2008).It is estimated that 91,271 babies were infected with HIV via Mother to Child Transmission during 2002 (Department of Health, 2003:2).The findings reveal that every day in Africa, 1900 children acquire HIV infection from their mothers.(Ekoveri, Leroy and Viho, 2004:697).
In light o f these high statistics, it becomes im perative that all pregnant women atten d in g antenatal clinics receive voluntary HIV testing and counselling (VCT).Uninfected women also benefit from such programmes because they provide them with information to reduce the risk o f acquiring HIV.For infected pregnant wom en, interventions can enable them to receive appropriate and timely help for their own health and to reduce the risk of passing the virus on to their babies (Semprini and Fiore, 2004).

Problem statement
Despite the rapid implementation o f pilot health program m es, the uptake o f services for the prevention o f HIV infection from mother to child remains low in South Africa (Ekoveri 2004:698).Many pregnant women believe that they are not at risk o f HIV infection and do not know about the benefits o f treatm ent and interventions available to prevent HIV transmission to their infants (Berer and Ray, 1993:239).
Studies reveal that there is a correlation between levels of knowledge about HIV testing and the chances of accepting the test.Fernandez et al. (2000: 467), found that acceptance was related to strong beliefs about the benefits o f testing, knowledge about vertical transmission and the woman's perception that she is at risk o f HIV infection (Kiarie et al. (2000(Kiarie et al. ( :1468)).Data from multitude of KAPB (knowledge, attitudes, practices, and behaviour) studies, demonstrate that most women have only a superficial knowledge of HIV testing (Goldman and Hatch 2000:424).

Purpose
The purpose o f this study is to establish the know ledge and percep tio n s o f pregnant women about HIV testing and to ascertain the level o f HIV testing acceptability amongst these women Objectives The objectives for conducting this study were:

•
To ascertain women's knowledge of HIV testing

Significance of the study
The significance o f this study is to find strategies that will make HIV testing in pregnancy more acceptable to pregnant women.There is hope that increased knowledge of HIV testing in pregnancy will allay anxiety in pregnant women thus in creasin g the num ber o f wom en accepting HIV testing.The health sector may be able to plan and allocate the appropriate resources.This will serve as a way o f evaluating health promotion programmes when the level of knowledge and perceptions o f pregnant women are known.

Theoretical Framework
The researcher used the Health Belief Model (HBM) and the Reasoned Action Theory to support the rationale for conducting the study.Research around health-related issues has indicated that people need to take reasoned action in order to stay healthy.Maiman and Becker (1974)  This is illustrated diagrammatically in figure 1.

Literature Review
Pregnant women endorse the offer of HIV testing, but they are uncertain about p ersonal uptake (Johnson and Johnstone, 1993:21).This means that women offer to take HIV testing but they are not sure whether they really want to take the HIV test.They are also not sure how are they going to cope with the results if they are positive.
HIV testing and counselling in pregnancy HIV counselling is a confidential process that enables individuals to examine their knowledge and behaviour in relation to their personal risk o f acquiring or transmitting the HIV virus.Counselling helps them to decide whether or not they should be tested.One in three babies bom to HIV infected mothers will be infected with HIV during pregnancy, delivery and via breast milk without intervention.All mothers should be offered voluntary counselling for HIV during antenatal care (Department of Health, 2008).Karim (1999), are o f the opinion that individual health related behaviour is influenced by the knowledge o f the disease and necessary promoting actions to prevent or improve the condition, as well as their beliefs, which may be positive or negative towards the disease or health promoting actions.

Perceptions on HIV testing
HIV risk perceptions are not stationary and can vary depending on the context, tim e and know ledge o f the person

Methodology
T his is a q u an titativ e study.The researcher used an exploratory survey to obtain facts in an attempt to learn about and describe the p ercep tio n s and knowledge pregnant women have on HIV testing.An exploratory survey explores the c h a ra c te ristic s o f the target population and identifies what issues are important to their understanding o f the topic (Katzenellenbogen, et. al 1999:170).

Setting
The antenatal clinic where the study was co n ducted is The eN dondakusuka Municipality, Northern KwaZulu-Natal.This Community Health Centre is in the Ilembe District.The clinic conducts a weekly ante-natal clinic, which is held on a Monday.Out o f 200 pregnant women who are seen per month, only 10% opt for HIV testing.

Population
The population surveyed was made up o f p reg n an t w om en atten d in g the antenatal clinic at the selected clinic for the first time in their current pregnancy.The reason for testing pregnant women for HIV, according to Johnson and Johnstone (1993:16) is that reproduction and ch ild b ea rin g d ecisio n -m ak in g focuses on women.

Sampling method
This study used systematic sampling to draw its sample from the population.The inclusion criterion for the study was that the pregnant woman should be attending antenatal clinic for the first time in her current pregnancy.All pregnant women who come to the clinic are entered in the register for statistical purposes.The antenatal re g ister was u sed as the sampling frame.The population elements for the day were listed in consecutive numbers.In the list, the research selected every third name and 20% was selected each M onday over a period o f four weeks.This means that there were 10 respondents each week making a total of 40 respondents in four weeks.

Data collection
Data was collected each Monday over one month in Novem ber 2004.The re searc h er used self-ad m in istered questionnaires for collecting data with close-ended questions.No names were written on the questionnaires.Anonymity was maintained and participants were guaranteed confidentiality

Instrument
The questionnaire was translated into Zulu since the majority of participants were Zulu speaking .The translated questionnaire was tested by an expert in the School of Nursing for content validity .Section A of the questionnaire covered dem ographic data such as age, educational level, parity and marital status.Section B contained questions to ascertain the know ledge levels o f respondents regarding HIV.Section C and D dealt w ith the resp o n d en t's perception towards testing for HIV.

Data collection process
The researcher waited for the pregnant women to receive health education, group counselling and the antenatal examination.Informed written consent was obtained before questionnaires were administered.Data was collected in a private room adjacent to the waiting area.Only one participant was allowed in the room at any one tim e to m aintain confidentiality.

Ethical consideration
Permission for the study was sought from the following bodies:

Content Validity
The research q uestions in the questionnaire covered the content of the research in terms knowledge, perception and acceptability o f HIV testing.

Reliability
A pilot study was conducted on a group of five pregnant women who did not form part o f the study.They were given a questionnaire to complete before HIV counselling at the clinic.An appointment was made with the respondents to come to the antenatal clinic a week later so that they could complete the questionnaire again with the same questions.The responses from the first questionnaire and the second questionnaire were the same and there was correlation.

Distribution of respondents by Age
The results in figure 1. revealed that most women were relatively young, between the age of 18-25 (45%, n = l8).Twenty seven and a half percent (n=l 1) of women were between the ages of 31-40.17.5% (n=7) were between 26-30.7.5% (n=3) were between 13-17 and with a relatively small number o f women who were 41 years or older which is 2.5% (n= 1).

Distribution of respondents by Marital Status
The highest proportion of respondents were unmarried (90%.n=36).There were only 7.5% (n=3) married women in the sample.Many women were single and young.According to Baylies and Bujra (2000:10).these young patients have limited information about reproductive and sexual health including HIV/AIDS and they engage in sexual relationships at an early age.Ho and Loke(2003: 822). in their study found that unm arried women were more likely to be tested for HIV

Distribution of respondents by parity
Seventy percent (n=28) of respondents were of parity between p0-p2.20%(n=8) were of parity' between p3-p5.Only 10% Seventy percent (n=28) o f women said they w ould convey the m essage regarding the importance o f testing to another person while 17, 5% (n=7) said they would not be able to tell another person and 12.5% (n=5) were not sure.In order to increase the percentage of people who felt able to convey the message of the im portance o f HIV testin g in pregnancy, all health sectors providing VCT services must make every effort to provide VCT services that women see as clearly beneficial.
Have you ever had an HIV test?
Eighty five percent (n=34) o f women

Educational standard
The results revealed that only 10% (n=4) o f respondents had tertiary education.The highest, 62.5% (n=25) proportion of the sample had secondary education .There was only one (2.5%)respondent with no formal education.The sample consisted mostly o f women with low levels o f education.The researcher is of the o p in io n th at w om en w ith less ed u catio n have little access to information

Knowledge of HIV testing
Who should test for HIV?
Forty percent (n=16) of women were of the opinion that testing should be done by all women together with their partners .Only 7.5% agreed that testing should be done by all women.Women studied by M atinga (2003:1 1), felt th at HIV counselling and the testing process would be m eaningful if couples are involved.
When should a person test?
Fifty five percent (n=22) of respondents, responded by saying a woman should take a test when she wanted to.Twenty seven and a half percent (n=l 1) said she should test during pregnancy and only 15% (n=6) said she should test when asked by a health worker.

Age and Marital Status
The sample in this study was found to be mostly young women between the ages of 18-25 (45%) and most of them were unmarried (90%).The reason why there are such a high proportion o f single pregnant women is that the area where the study was conducted is an industrial area.The other reason is that, during these years (18-25) young women learn, explore and make decisions that will affect the rest of their lives including early and unintended pregnancies (USAID 2004).Enosolease and Offor ( 2004) further found that older women were more likely to accept HIV testing than the young ones.This may be due to the fact that older women see themselves at risk of contracting HIV infection.

Educational Standard
Most women in the study had attained secondary school education (62,5%) and only 10% had attained tertiary education.This is in line with the findings of Baylies and Bujra (2000:6) where they found that, women's lack of access to education and lower levels o f literacy contribute to their limited access to information about HIV testing.

Unemployment
The majority o f young women migrate from their homes to seek employment in the low paid industries.Because they are financially dependent, they fail to control their sexual lives and they engage in unprotected sex.Enosolease & Offor (2004:88), in their study found that young women had multiple sexual partners and regularly practised unprotected sex.This increases their vulnerability to HIV/AIDS and the death toll among economically pro d u ctiv e people is in creasin g (Davhana-Maselesele, Lalendle & Useh, 2007:17)

Willingness to test
In this study, 52, 5% o f women were willing to be tested out o f the 85% who had not been previously tested.This is considered as a low HIV testin g acceptance.In a study conducted by Ho and Loke (2003:823), they found that pregnant women refused the HIV test mainly because they have only one sexual partner who they believe is trustworthy and they feel that being infected with HIV is out o f question.The majority of young women migrate from their homes to seek employment in the low paid industries.Because they are financially dependent, they fail to control their sexual lives and they engage in unprotected sex.Enosolease and Offor (2004:88), in their study found that young women had multiple sexual partners and regularly practised unprotected sex.This increases their vulnerability to HIV/ AIDS.
A cco rd in g to th is study, the poor response appeared in the population where only 15% reported to have ever been tested for HIV.This low figure is likely to be influenced by past exposure to HIV testin g in th eir previous pregnancies and by the acceptability of the voluntary counselling and testing provided.

Perceptions
The findings showed that 93 % o f women said testing was a good idea and 85% said it was necessary.However, not all w om en who said HIV testin g in pregnancy was a good idea thought it was necessary because 52, 5% said that they would opt for HIV testing.Exner (2002:7) and Matinga (2003:7) found that women felt that being tested was a way to decrease their anxiety about HIV.This is further supported by the findings of this study where the highest population (55%) o f women felt that getting tested for HIV is emotionally stressful.
These findings highlight the importance o f using pre-test counselling to directly address patients' anxiety about testing.Most of the women felt that HIV testing should be routinely done.The findings of this study are similar to the findings of the study conducted by Kiarie et al (2000Kiarie et al ( :1469)), where most women felt that HIV testing should be routinely offered in antenatal clinic because it eliminates the need for a woman to be singled out for testing and therefore reduces the suspicion of spouses and friends.They further found that the contributing factor in the women's acceptance of HIV testing was based on the w om en's perception o f the benefit for their babies or their own health of having the test.

Future Reproduction for an HIV Positive Woman
For A frican w om en children are considered essential to self -fulfilment and to family happiness (Tallis, 1997:19) and the value placed on children are high.The majority of women in the study (62,5%) felt that an HIV positive mother should not bear children.The researcher argues that denying an HIV positive mother the right to bear children will be unconstitutional and it violates women's equality and their security as a person.
An individual w om an's reproductive choices should be respected, regardless o f her HIV status.It is their right to bear children but counselling is very important so that they make informed choices.
Women must decide on their own without pressure to have or not to have a test.

When should testing be done?
The problem with testing a woman during pregnancy is the uncertainty about whether pregnancy is the best time for a woman to find out she is HIV positive.Kennedy (2003:65) recommended that if testing is done during pregnancy, it should be done at an early stage it possible because this would allow those women diagnosed as HIV positive the opportunity to be offered advice and treatment during antenatal care for their own health and that o f their babies.

Testing Negative
Women (47.5%) in this study were of the opinion that a person needed to practise safe sex when tested negative and 35% said a person needed to retest to be sure and 7% said a person needed to be careful. It

Sharing the results with other people
The findings of this study reveal that the m ajority o f resp o n d en ts are not comfortable with informing relatives or partners about their HIV test results.Ekanem & Gbadegesin (2004:95) found that only few pregnant women would undergo the test if the results were to be shared with relatives.HIV positive women who communicated their results to partners often suffered violence from th eir p artn ers a fte r co u n sellin g (Temmerman, et al 1995:970).A different view was put forward by Sethosa and P eltzer (2 005:39) w ho stated that individuals who were aware that they arc infected with HIV and who engage in sexual relationship have a social and legal responsibility to disclose their infections to their partners.

Recommendations related to research
• A similar study need to be done on a larger scalc so that results will bcgcncralizable.

Conclusion
From the findings of this study it can be deduced that HIV testing acceptance is low in the setting where the study was conducted.The women's perceptions of HIV testing are good but they are not consistent with their behaviour.That means that the women's positive attitude towards HIV testing was not transformed into actual behaviour.Women showed a good understanding and knowledge of HIV testing in pregnancy but their knowledge did not increase the uptake o f testing.This might be due to the in crease in aw areness o f vertical tran sm issio n o f HIV.Increasing knowledge about HIV transmission may decrease the stigma surrounding HIV infection and help to improve acceptance rate to HIV testing in pregnancy.

Table 1 . Perceptions of pregnant women. (n=40)
If you have tested negative, what must you do?Most women responded by saying that about the w indow p erio d and the possibilities o f further exposure.Thirty five (87.5%) women were o f the opinion that testing does ben efit a pregnant woman.Only one (2.55%)respondent had a different view and said