WHO South-East Asia Journal of Public Health
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 Table of Contents  
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 268-278

Knowledge of antiretrovirals in preventing parentto-child-transmission of HIV: a cross-sectional study among women living with HIV in Tamil Nadu, India

1 MPH, Senior Research Fellow, Knowledge for Health Initiative, AIDS Prevention and Control Project- Voluntary Health Services, Chennai, India
2 MBBS, MSc, Project Director, AIDS Prevention and Control project- Voluntary Health Services, Chennai, India
3 PhD, Program Manager– Research, AIDS Prevention and Control project- Voluntary Health Services, Chennai, India

Date of Web Publication25-May-2017

Correspondence Address:
Saumya Rastogi
MPH, Senior Research Fellow, Knowledge for Health Initiative, AIDS Prevention and Control Project- Voluntary Health Services, Chennai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2224-3151.207023

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Background: India is amongst the top 10 countries in the world currently with the highest burden of pregnant women living with HIV and nearly 80% of these women do not receive antiretroviral (ARV) drugs to prevent parent-to-child transmission (PTCT) of HIV. The aim of this study was to estimate HIV-infected women’s awareness on PTCT and knowledge of ARVs as a measure to prevent PTCT.
Methods: This was a descriptive, cross-sectional study in which a total of 986 women with HIV aged 18 years and above were interviewed in 13 high HIV prevalence districts of Tamil Nadu, South India. Data were analysed using descriptive, bivariate and multivariate methods.
Results: Nearly one fifth (18.8%) of the women with HIV had not heard of PTCT and 40% did not know that ARVs could prevent PTCT. In addition, 39.3% were not aware of the timing of PTCT; 50.4% reported intrauterine and intrapartum and 13.7% mentioned breastfeeding period as the possible timings of PTCT of HIV. Multivariate analysis showed that single/never married women had lower knowledge of PTCT. Also, those who had undergone a prior training on reproductive and child health (RCH) and those who discussed RCH issues with their partners were more likely to have higher knowledge.
Conclusion: Considering the risk of HIV transmission from HIV-infected women to their children, the knowledge level of PTCT among them is low. Appropriate strategies to generate awareness among women with HIV need be introduced to help them make informed decisions.

Keywords: Parent-to-child transmission, HIV, prevention, antiretrovirals, knowledge, predictors.

How to cite this article:
Rastogi S, Charles B, Sam AE. Knowledge of antiretrovirals in preventing parentto-child-transmission of HIV: a cross-sectional study among women living with HIV in Tamil Nadu, India. WHO South-East Asia J Public Health 2012;1:268-78

How to cite this URL:
Rastogi S, Charles B, Sam AE. Knowledge of antiretrovirals in preventing parentto-child-transmission of HIV: a cross-sectional study among women living with HIV in Tamil Nadu, India. WHO South-East Asia J Public Health [serial online] 2012 [cited 2022 Dec 2];1:268-78. Available from: http://www.who-seajph.org/text.asp?2012/1/3/268/207023

  Introduction Top

An overall reduction in adult HIV prevalence was reported in India from 0.41% in 2000 to 0.31% in 2009. Also, nationally, the prevalence of HIV in pregnant women has been declining and is currently 0.7%. In spite of these encouraging trends in HIV prevalence in the country, some areas of Maharashtra, Andhra Pradesh and Tamil Nadu, have recorded an HIV prevalence of as high as 3% among pregnant women which far exceeds the national estimate.[1],[2] In terms of burden, India is amongst the top 10 countries with the highest number of pregnant women with HIV.[3] Additionally, HIV prevalence among children below 15 years of age is nearly 3.5% of the total HIV burden in the country. With a population of 2.4 million individuals with HIV, this amounts to as many as 84 000 children living with HIV infection in India.[4],[5]

Parent-to-child-transmission (PTCT) of HIV is the transmission of HIV from an HIV-positive mother to her child during any stage of pregnancy, labour, delivery or breastfeeding. It is the most significant route of transmission of HIV worldwide, among individuals below 15 years of age; nearly 90% of the newly infected children with HIV are due to PTCT.[3] In the absence of any intervention, the risk of PTCT ranges from 20% to 45%.[6] This risk can be decreased to 2% and 5% in non-breastfeeding and breastfeeding women respectively with antiretrovirals (ARVs).[7],[8],[9] Without such intervention, it is estimated that about a third of HIV-infected children would die before the first year of life, and a half would die before two years.[10] In India, only about 20% of the estimated number of pregnant women with HIV received ARVs in 2008, which, in all likelihood, would not have fulfilled the UN General Assembly Special Session (UNGASS) goal* of ensuring ARVs to 80% of pregnant women by 2010.[3]

Awareness and knowledge about health services are indirect indicators of utilization of services for the population in question. According to the PRECEDE-PROCEED model, it is regarded as one of the predisposing factors for behaviour or utilization of Prevention of Parent to Child Transmission (PPTCT) of HIV services in the present context.[11] Research studies focusing on the knowledge level of PPTCT have been performed worldwide, but are mostly concentrated in the African continent.[12],[13],[14],[15],[16] Among studies performed elsewhere, Luo et al. in China found that about 60% of pregnant women were aware of PTCT.[17] In another instance, a study in USA found that only 58% of women of childbearing age knew about the availability of a prophylactic intervention for PPTCT.[18] In the Indian context, a study carried out among women attending an antenatal clinic in Kolkata reported that just 6.8% of participants had heard of PTCT of HIV.[19] In rural South India, 48% pregnant women did not know of means to prevent PTCT.[20] It is of note here that most of the research studies had pregnant women as the participants and never has a study been conducted among women living with HIV. HIV-positive women who are pregnant or lactating are at risk of transmitting HIV to their offspring. Moreover, there is a dearth of such research work in the Indian context. Keeping these needs in view, the purpose of this paper is to throw light on the awareness on PTCT and knowledge of antiretrovirals in preventing PTCT and the factors associated with it.

  Method Top

This was a cross-sectional study conducted in Tamil Nadu between May to October 2009 by the AIDS Prevention and Control Project in collaboration with Tamil Nadu Positive Women’s Network (TPWN+) and Tamil Nadu State AIDS Control Society (TANSACS) among women living with HIV. In recent years, the prevalence of HIV in the general population has shown encouraging trends in the state. The adult HIV prevalence declined from 0.93% in 2002 to 0.33% in 2009 in the state which, however, is higher than the national estimate of 0.31%.[4],[5] Tamil Nadu has 22 districts categorized as high HIV prevalence (‘A’ category‡) districts.[21] Out of these, 13 districts were selected on the basis of their geographical representativeness and active presence of TPWN+. The sample size in each district was decided by the probability proportionate to size method, using the number of women with HIV registered with the NGO (TPWN + ). A refusal rate of about 10% was observed, with 102 women either refusing to participate in the study or withdrawing from the study before the interview reached acceptable completeness. A total of 986 interviews were completely conducted among these women [Table 1].
Table 1: Selection of sample from 13 districts in Tamil Nadu

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Thus, a sample size of 986 provided us with a precision/margin of error of ±4% at 99% confidence interval.

Drop-in-centres (DIC) and community- care-centres (CCC) run by TPWN+ which catered only to HIV-positive women were chosen as the focal points from where the sample was recruited via purposive sampling in the selected 13 districts. The inclusion criteria of the respondents were that the women should have completed 18 years of age, they should be aware of their HIV-positive status and should have consented to being interviewed. It was realized that sample selected by this method would not be representative of those women with HIV who did not attend the DIC and CCC. Despite it, difficulty in recruiting the women living with HIV outside the NGO’s network and ethical considerations attached with using probability sampling techniques compelled the use of purposive sampling at these centres frequented by HIV-positive women registered with the NGO. Based on the inputs from respondents, semi-structured interview-schedules were designed, pilot tested and revised. These were originally drafted in English and later translated into Tamil, the regional language. Socio- demographic variables such as age, education, monthly family income, number of children borne and variables related to knowledge of ARVs in preventing PTCT were assessed by open-ended questions. Close-ended questions were used to assesse the rest of the variables in the study. The interviews were conducted by investigators trained in research methods, research ethics and about modes of HIV transmission in a two-day training workshop. Oral informed consent was obtained from all the participants after explaining the purpose of the study. The participation was voluntary and the women had the freedom to refuse to answer specific questions and withdraw from the interview at any point of time. The study protocol conformed to the Declaration of Helsinki and Indian Council of Medical Research (ICMR) ethical guidelines. Ethical approval was obtained from the Institutional Review Board of the Christian Medical College and Hospital, Vellore, Tamil Nadu, India.

Three variables were used to measure the knowledge on PTCT–awareness of PTCT, knowledge of ARVs as a measure to prevent PTCT and knowledge of timing of transmission of HIV from parent-to-child. In the bivariate and multivariate analysis, independent variables examined were age, education, monthly income, marital status, type of family, prior education/training on reproductive and child health and discussion about reproductive and child health issues with partner. The dependent variable was knowledge of ARVs as a measure to prevent PTCT of HIV. Data analysis was performed using statistical software SPSS 17.0. In addition to descriptive analysis, inferential statistics such as Pearson’s chi-square and logistic regression analysis were carried out. Logistic regression was performed to calculate the net effect of the independent variables on the outcome variable. P-values of less than 0.05 were considered to be significant.

  Results Top

Sample characteristics

The mean age of the study participants was 32.3 years; majority of them in the age group of 25–34 years. A small proportion of women were illiterate (3.4%) and nearly 63% had up to 10 years of education. The mean monthly income in the sample was INR 1381.80 with most of them earning in the range of INR 0–1000 per month (48.3%). Majority of them were married and living with spouse (56.1%) and about 37% were divorced or separated or widowed. A small proportion was never-married single women (6.8%). A total of 80% of women bore children, with the majority having two children (49.4%) and 27.4% having one child. Median number of children borne by a woman with HIV was two. Additionally, three-fourth of the sample lived in nuclear families, the rest lived in joint families.

Knowledge of timing of PTCT and of ARVs in preventing PTCT

[Table 2] indicates the knowledge about the timing of PTCT and of ARVs as a measure to prevent PTCT. The study found that almost a fifth (18.8%) of the participants were not aware of PTCT. In addition, about 40% did not know that ARVs could prevent PTCT. A similar proportion (39.3%) of the women was unaware of the timing of PTCT. About half of the respondents mentioned intrauterine and intrapartum as the possible timings and 13.7% mentioned breastfeeding period as the possible time of PTCT of HIV. [Table 3] provides details on the questions asked for each of the above mentioned variables.
Table 2: Awareness of PTCT among women living with HIV

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Table 3: Questions posed to assess the study participants' awareness and knowledge on PTCT of HIV

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Determinants of knowledge of ARVs as a measure to prevent PTCT

[Table 4] provides information on the factors associated with the knowledge of ARVs as a possible measure to prevent PTCT of HIV. Pearson’s chi-squared test (χ2) was employed as the statistical test of significance. Among socio-demographic factors, almost all variables showed an association with the knowledge of ARVs. Specifically, higher education was associated with a higher proportion of the respondents having knowledge on the role of ARVs in preventing PTCT (P<0.001). Similarly, those women who were either married and living with spouse or divorced/separated/ widowed were more likely to know about ARVs as compared with single or never-married (P=0.001). Income in the sample showed an erratic trend with respect to knowledge of ARVs. Women with lower and higher monthly income were more likely to have knowledge as compared to women with medium income (P=0.002). Other factors like prior training on reproductive and child health by NGOs and healthcare providers also indicated a positive association with knowledge of ARVs (P<0.001). Moreover, those women who discussed RCH issues with partners were more likely to know about ARVs as a measure to prevent PTCT of HIV (p<0.001).
Table 4: Knowledge of ARVs as a measure to prevent PTCT by the background characteristics of HIV-positive women

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[Table 5] represents the results of the multivariate analysis which showed that never-married women did not have adequate knowledge on ARVs. Women who were divorced, separated or widowed had significantly higher knowledge of ARVs. (OR=2.39; 95% CI=1.3–4.4; p=0.01). Also, those women who had undergone educational training on RCH were significantly more likely to know about ARVs (OR=2.19; 95% CI=1.6–2.9; p< 0.001). Similarly, those respondents who discussed reproductive and child health issues with their partners were nearly two times more likely to know about ARVs as a method to prevent PTCT as compared with those who did not discuss these issues (OR=2.15; 95% CI=1.6–2.8; p< 0.001).
Table 5: Logistic regression estimates of knowledge of ARVs as a measure to prevent PTCT among HIV-positive women

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  Discussion Top

The present study has highlighted the level of awareness about PTCT, its timings and knowledge related to the role of ARVs in reducing parent-to-child transmission of HIV among HIV-positive women who attended DIC/CCC. Since this was a cohort of HIV-positive women registered with an NGO working for HIV-infected women, who learned their status at integrated HIV counselling and testing centres attached to antenatal clinics and may have undergone prior interventions on HIV awareness the knowledge level was expected to be higher than the general population. Our study reports that over 80% of study participants had heard of transmission of HIV from mother to child§. The awareness level in the present study seemed to be better than that reported in China[17] and Nigeria[16] where only 64% and 68% of pregnant women respectively had heard of PTCT. On the other hand, in the present study, a much smaller proportion (40%) knew about the possible treatment modality ie. ARVs.These results were better than the estimates in Nigeria, where only 17% pregnant women knew of ARVs.[12] Also, a study done in Kolkata, India reported that nearly 91% of pregnant women did not know of the prevention methods of PTCT.[19] However, the present results resemble those of a South Indian study which estimated that 48% pregnant women did not know about the measures of PTCT.[20] Correct timing of transmission of HIV to infants was also not known to many women as reported in the present study. Transmission during intrauterine and intrapartum period was quoted by nearly 50%, whereas breastfeeding period was answered only by 13.7%. Though the knowledge about timing of PTCT during intrauterine and intrapartum periods was comparable to other studies,[12],[15],[16] knowledge on transmission during breastfeeding was lower than most other instances.[15],[16],[17] Even though some of the estimates in the present study are relatively better than those found in other similar literature, it is necessary to outline that women living with HIV are at risk of transmitting HIV to their offspring during intrauterine/intrapartum phase or during breastfeeding; even a slight gap in knowledge should be a cause of concern to the policy-makers.

The multivariate analysis found that never-married or single women possessed significantly lower knowledge about ARVs as compared with ever-married women. Nearly 62% of never-married women were less than 35 years of age in our study. This reveals that the young and never-married women did not have adequate knowledge on the role of ARVs in preventing PTCT, they possessed the highest probability of giving birth, although being in the reproductive age group. Thus, efforts to create awareness on PTCT among this vulnerable group are warranted. Divorced/ separated/widowed women reportedly had higher knowledge of ARVs than the never- married women. One possible explanation could be that these women were either widowed because of spouse’s death due to HIV or, in other cases, marital dissolution happened due to wife’s positive status. In both scenarios, it is likely that these women received HIV counselling and advice by an NGO that resulted in higher knowledge. In accordance with similar studies,[22],[23] this study too highlighted a positive association between prior training on RCH issues by either NGOs or health workers and higher knowledge of ARVs. This is an encouraging finding, because it showed a high recall of the messages already received by these women. It indicates that a quality intervention addressing the knowledge gaps in PTCT would be well-received and would have a high impact among these women. It is also well established that open communication regarding reproductive and sexual health between partners is an effective way of making responsible and healthy decisions.[24],[25] In compliance with these, our study also found a positive association between discussing RCH issues such as birth-spacing, family planning methods, pregnancy, delivery and breastfeeding with the spouse and higher knowledge level of ARVs which calls for appropriate family counselling strategies for HIV-positive women and their partners.

  Limitations Top

The present study suffers from some limitations which should be considered while interpreting the results. Information on income was not disclosed by a large proportion of women living with HIV. Even those who gave this information seem to have given it inaccurately as evident from the erratic trend shown in the bivariate and multivariate analyses.

However, as ‘monthly income’ is an important socio-demographic indicator, it has been used as an independent variable, in spite of its questionable nature. Another limitation of the study is that the sample may not be representative of all the women living with HIV in the community, as only those respondents could be recruited who attended drop-in-centres or community care centres. Women with HIV outside these centres could not be recruited because of the feasibility and ethical issues attached with identifying them in the general population.

  Conclusion Top

The present study is one of the pioneers in exploring the awareness of parent-to-child transmission of HIV and knowledge of ARVs in preventing transmission among HIV-infected women. Though the awareness level of PTCT among these women can be considered relatively better than the awareness among non-HIV-positive women, some specific gaps in the knowledge of PTCT remained. These gaps were knowledge of methods to prevent PTCT and correct timings of HIV transmission from mother to child. As prior training on RCH issues was found to be associated with a higher knowledge on PTCT, so NGO- or health provider-led awareness generation programmes focusing at routes of transmission of HIV from parent-to-child and measures to prevent PTCT are imperative among this population. The content of the counselling services provided by the Integrated counselling and testing centres (ICTCs) should be revised to lay more emphasis on prevention of PTCT of HIV. Such programmes should also integrate couple counselling on RCH issues and encourage spousal communication on these should be paid to the needs of vulnerable women such as the young and the single more attention when devising such programmes.

  Acknowledgement Top

This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the AIDS Prevention and Control (APAC) project and do not necessarily reflect the views of USAID or the United States Government.

At the UN General Assembly Special Session (UNGASS) in 2001, governments committed to reduce by 50% the proportion of infants infected by HIV by 2010 by ensuring that 80% of pregnant women accessing antenatal care receive PPTCT services.

According to the model, health behaviour is regarded as being influenced by individual and environmental factors, and has two parts: an “educational diagnosis” (PRECEDE, an acronym for Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation) and an “ecological diagnosis” (PROCEED, for Policy, Regulatory and Organizational Constructs in Educational and Environmental Development). Knowledge is one of the predisposing factors that lead to behaviour change.

For the purpose of planning and implementation of NACP-III, all the districts in the country are classified into four categories based on HIV prevalence in the districts among different population groups for three consecutive years.

Studies to explore the awareness and knowledge regarding PTCT have never been performed among women living with HIV; most of the literature pertains to pregnant women who are not HIV-positive. Since this is the only comparable group available, we have compared awareness and knowledge levels obtained in our study with the ones obtained in the studies performed among pregnant women, not infected by HIV.

  References Top

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World Health Organization. PMTCT strategic vision 2010–2015: preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals. Geneva: WHO, 2010.  Back to cited text no. 3
National AIDS Control Organization. Technical report: India HIV estimates, 2006. New Delhi: Ministry of Health and Family Welfare, 2006.  Back to cited text no. 4
National AIDS Control Organization. Press Release: HIV declining in India: new infections reduced by 50% from 2000-2009. Sustained focus on prevention required. New Delhi: Ministry of Health and Family Welfare, 2009.  Back to cited text no. 5
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Dorenbaum A, Cunningham CK, Gelber RD, Culnane M, Mofenson L, Britto P, et al. Two-dose intrapartum/ newborn nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission: a randomized trial. JAMA. 2002; 288(2): 189–198.  Back to cited text no. 7
Lallemant M, Jourdain G, Le Coeur S, Mary JY, Ngo- GiangHuong N, Koetsawang S, et al. Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. N Engl J Med. 2004; 351: 217–228.  Back to cited text no. 8
World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a public health approach. Geneva: WHO, 2010.  Back to cited text no. 9
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Green L, Kreuter M. Health promotion planning: an educational and environmental approach. 2nd edn. Mountain View: Kreuter Mayfield Publishing, 1991.  Back to cited text no. 11
Adeleke SI, Mukhtar-Yola M, Gwarzo GD. Awareness and knowledge of mother-to child transmission of HIV among mothers attending pediatric HIV clinic, Kano, Nigeria. Ann Afr Med. 2009; 8(4): 210-214.  Back to cited text no. 12
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lgwegbe AO, Ilika AL. Knowledge and perceptions of HIV/AIDS and mother to child transmission among antenatal mothers at Nnamdi Azikiwe University Teaching hospital, Nnewi. Niger J Clin Pract. 2005; 8: 97-101.  Back to cited text no. 15
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Chen JQ, Dunne MP, Zhao DC. HIV/AIDS prevention: knowledge, attitudes and education practices of secondary school health personnel in 14 cities of China. Asia Pac J Public Health. 2004; 16(1): 9-14.  Back to cited text no. 22
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Santhya KG, Dasvarma GL. Spousal communication on reproductive illness among rural women in southern India. Cult Health Sex. 2002; 4(2): 223-236.  Back to cited text no. 25


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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