Luận văn knowledge, attitudes and practices regarding hiv aids prevention among pregnant women attending antenatal care at the setthathirath hospital in vientiane capital, lao people’s democratic republic

MINISTRY OF HEALTH UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH and MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH HANOI UNIVERSITY OF PUBLIC HEALTH PHOUNGEUN PHON

MINISTRY OF HEALTH UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH

and

MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH

HANOI UNIVERSITY OF PUBLIC HEALTH

PHOUNGEUN PHONGXAY

Knowledge, attitudes and practices regarding HIV/AIDS prevention among pregnant women attending antenatal care at the Setthathirath Hospital in Vientiane Capital,

Lao People’s Democratic Republic

MASTER THESIS

MASTER OF PUBLIC HEALTH

CODE: 8720701

Hanoi, 2019

MINISTRY OF HEALTH

UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH

and MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH

HANOI UNIVERSITY OF PUBLIC HEALTH

PHOUNGEUN PHONGXAY

Knowledge, attitudes and practices regarding HIV/AIDS prevention among pregnant women attending antenatal care at the Setthathirath Hospital in Vientiane Capital,

Lao People’s Democratic Republic

MASTER THESIS MASTER OF PUBLIC HEALTH

ACKNOWLEDGEMENTS

This work has been a long journey with a lot of support and input from lecturers, tutors, friends and my family members No journey is undertaken alone This master‟s thesis would not have been successful without them Thus, I owe my utmost gratitude to all the individuals who participated in making this study and who supported me during the study process

First of all, I would like to thank very sincerely the Ministry of Health, University of Health Sciences and Faculty of Public Health in Laos, the Hanoi University of Public Health in Vietnam, and the LEARN project for granting me the scholarship and opportunity to participate in this Master of Public Health course

I would like to thank my supervisors, Dr Duong Minh Duc, Ph.D (Hanoi University of Public Health) and Dr Somphou Sayasone, Ph.D (Lao Tropical and Public Health Institute) for their invaluable support, guidance and patience Without their encouragement, I would not have continued my study and come to the end of this journey

I present my deepest thanks to the honorable teachers, staff, coordinators and organizations that advised and helped me to conduct this thesis study Their kindness will always be in my cherished memories

I would also like to offer my warmest thanks to the leaders, doctors and nurses of the Setthathirath Hospital in Vientiane Capital for giving me permission to collect data in their hospital and for their encouragement during the data collection period

I also sincerely thank all patients who willingly participated in my study Finally, I would like to thank my classmates and my family, particularly my parents and my brothers and sisters, for supporting me spiritually and for their unconditional love, patience and encouragement throughout my study This accomplishment would not have been possible without them Thank you very much

PHOUNGEUN PHONGXAY

LIST OF CONTENTS

ACKNOWLEDGEMENTS i

ABBREVIATIONS vi

LIST OF TABLES vii

LIST OF FIGURES .vii

ABSTRACT viii

Introduction 1

Research Objectives 3

Chapter 1: Review of Literature 4

1.1 Definitions 4

1.1.1 HIV 4

1.1.2 HIV/AIDS prevention from mother to child 4

1.1.3 Prevention of mother to child transmission 4

1.2 Global burden of HIV infection 4

1.3 Situation of HIV infection in the Lao PDR 6

1.4 HIV infection among women 8

1.5 Transmission of HIV from mother to infant 9

1.6 Prevention of Mother-to-Child Transmission (PMTCT) 10

1.7 Knowledge regarding HIV/AIDS prevention of pregnant women 11

1.8 Attitudes regarding HIV/AIDS prevention of pregnant women 14

1.9 Practices regarding HIV/AIDS prevention of pregnant women……… 15

1.10 Conceptual framework 18

Chapter 2: Subject and Methodology 19

2.1 Subject 19

2.1.1 Inclusion criteria 19

2.1.2 Exclusion criteria 19

2.2 Setting and duration 19

2.3 Study design 19

2.4 Sample size 20

2.5 Sampling method 20

2.6 Data collection 21

2.7 Variables 21

2.7.1 Key variables 21

2.7.1.1 Independent variables 21

2.7.1.2 Dependent variables 21

2.8 Definition(s)/Concept(s), measures and assessment 22

2.8.1 Definition(s)/concept(s) 22

2.8.1.1 Demographic characteristics 22

2.8.1.2 Knowledge 22

2.8.1.3 Attitudes 22

2.8.1.4 Practices 22

2.8.1.5 Maternity 22

2.8.1.6 Pregnant women 23

2.8.2 Measures and assessment 23

2.8.2.1 Knowledge regarding HIV/AIDS prevention among pregnant women 23

2.8.2.2 Attitudes regarding HIV/AIDS prevention among pregnant women 24

2.8.2.3 Practices regarding HIV/AIDS prevention among pregnant women 24

2.8.2.4 Socio-demographic characteristics among pregnant women 24

2.8.2.5 Psychological factors among pregnant women 24

2.8.2.6 Reproductive history of pregnant women 24

2.9 Data quality and analysis 25

2.10 Ethical issues 25

2.11 Limitations and bias and how to minimize these biases 26

Chapter 3: Results 27

3.1 Socio-demographic factors 28

3.2 Psychological factors 29

3.3 Reproductive health history 30

3.4 Knowledge regarding HIV/AIDS prevention among pregnant women 31

3.5 Attitudes regarding HIV/AIDS prevention among pregnant women 35

3.6 Practices regarding HIV/AIDS prevention among pregnant women 39

Chapter 4: Discussion 43

4.1 Demographic characteristics 43

4.2 Reproductive health history 44

4.3 Knowledge regarding HIV/AIDS prevention among pregnant women 44

4.4 Attitudes regarding HIV prevention among pregnant women 46

4.5 Practices regarding HIV/AIDS prevention among pregnant women 48

Conclusions 50

Recommendations 51

REFERENCES 52

LIST OF ANNEXES 58

Annex 1: Pregnant woman consent form 58

Annex 2: Key variables factors 60

Annex 1: Key individual factors 61

Annex 2: Research questionnaire presented to the pregnant women 65

Annex 3: Research questionnaire presented to the pregnant women 64

- Questionnaire form section 1: Socio-demographic data of pregnant women 64

- Questionnaire form section 2: Psychological factors of pregnant women 66

- Questionnaire form section 3: Reproductive history of pregnant women attending ANC service 67

- Questionnaire form section 4: Knowledge of pregnant women regarding HIV/AIDS prevention 68

- Questionnaire form section 5: Attitudes of pregnant women regarding HIV/AIDS prevention 72

- Questionnaire form section 6: Practices of pregnant women regarding

HIV/AIDS prevention among pregnant women attending ANC 73

Annex 4: Ethical Approval 75

Annex 5: List of research team members 76

Annex 6: Curriculum Vitae of Researcher 77

Annex 7: Thesis comments 80

Annex 8: Minutes of Explanation 90

AIDS ………Acquired Immunity Deficiency Syndrome

AMR ………Ambulatory Medical Record

ART ……….Anti-Retroviral Treatment

GARP………Global AIDS Response Progress

HCWs ……… Healthcare Workers

HIV.……….Human Immunodeficiency Virus

JICA………Japan International Cooperation Agency

KAP Knowledge, Attitudes and Practices

PMTCT Prevention of Mother-to-Cchild Transmission of HIV MTCT Mother-to-Child Transmission

SPSS Statistical Package for Social Sciences

STIs Sexually Transmitted Infections

TPB Theory of Planned Behaviour

UNAIDS United Nations Programme on HIV/AIDS

WHO World Health Organization

ANC Antenatal Care

PLHIV People living with HIV

VTC Voluntary testing and counseling

LIST OF TABLES

1 Table 3.1: Socio-demographic characteristics of study respondents………… 27

2 Table 3.2: Psychological perceptions among study respondents of HIV

Infection……… 29

3 Table 3.3: Reproductive health history of study respondents ……… 30

4 Table 3.4.1: Knowledge of pregnant women regarding HIV/AIDS prevention.31

5 Table 3.4.2: Multiple logistic regression association between knowledge and influencing factors……… 33

6 Table 3.5.1: Attitudes of pregnant women regarding HIV/AIDS prevention

ABSTRACT

Introduction: In Laos it is estimated that there are 12,000 people living with HIV

and 570 new infections yearly The number of HIV positive pregnant women during 2015-2018 was 423 cases, but among children aged 0-4 years during 2010-2018, there were 7,410 recorded as HIV positive New HIV infections amounted to 1,016 cases, and the total number of deaths was 779 HIV positive children

Objectives: This study is to assess the knowledge, attitudes and practices regarding

HIV/AIDS prevention and to identify the associated factors among pregnant women attending antenatal care at the Setthathirath Hospital in Vientiane Capital, Lao PDR,

in 2019

Methods: This study applied a cross-sectional design The target population was

pregnant women attending antenatal care (ANC) in 2019 The calculated sample was 215 mothers using simple random sampling All were interviewed by use of a self-administered questionnaire Independent variables (socio-demographic, psychological symptoms and reproductive history) were tested for association with the dependent variables (knowledge, attitudes and practices regarding HIV/AIDS prevention) The statistical significance was a P-value of ≤ 0.05

Results: Out of the 215 respondents, more than half had a poor knowledge

regarding HIV/AIDS prevention and more than half of the respondents (53.0%) had

a negative attitude towards HIV/AIDS prevention Only 17.2% had a highly positive attitude towards HIV/AIDS prevention Similarly, more than half of the respondents (55.8%) had poor practices, while less than a quarter of the respondents (23.7%) had good practices regarding HIV/AIDS prevention There was no association between the socio-demographic variables with the knowledge, attitudes, and practices towards HIV/AIDS prevention among mothers attending the ANC services (p > 0.05)

Conclusion: The knowledge, attitudes and practices towards HIV/AIDS prevention

amongst pregnant women were poor There was a lot of misunderstanding amongst pregnant women regarding HIV/AIDS prevention We have not found any socio-demographic factors with significant association with their knowledge, attitudes and practices regarding HIV/AIDS prevention

Keywords: HIV/AIDS prevention, pregnant women, knowledge, attitudes,

practices, Setthathirath Hospital, Vientiane, Lao PDR

Introduction

The transmission of HIV from an HIV-positive mother to her child during pregnancy, labor and delivery or breastfeeding has been called mother-to-child transmission (GARP, 2015) Mother-to-child transmission (MTCT) in the present

is even more severe due to a lack of knowledge, attitudes and practices (KAPs) regarding HIV/AIDS prevention amongst pregnant women Having good KAP is a cornerstone in preventing MTCT (USAID, 2015)

Globally, since the beginning of the HIV epidemic, 75 million people have been infected with the HIV virus; 37.9 million people are living with HIV, while 32 million people have died from AIDS-related illnesses up to the end of 2018 (UNAIDS, 2019a) In 2017, about 18.8 million women were infected, 2.3 million of whom were HIV-positive pregnant women Furthermore, 1.7 million children under

15 years of age were infected (WHO, 2018b) Yearly, there are about 170,000 new cases amongst children (UNICEF, 2016) The WHO urges health authorities to strengthen all programs for the prevention of mother-to-child transmission (PMTCT) and to provide HIV/AIDS prevention services to all mothers and their infants, including antenatal services and HIV testing during pregnancy (WHO, 2018d)

There have been numerous efforts made to prevent MTCT Adequate knowledge about HIV/AIDS prevention has been a promising means of promoting positive knowledge and attitudes as well as engaging in safe practices amongst pregnant women Increasing knowledge of HIV/AIDS prevention helps to overcome misconceptions that could prevent behavioral change towards safe practices Stigmatizing is significantly associated with misconceptions about HIV transmission and negative attitudes towards people living with HIV Poor KAP on HIV/AIDS prevention not only affects the pregnant women‟s health but also the health of their husbands and children (UNGASS, 2017)

The Lao PDR has shown significant economic growth over the last few decades In 2016 the country moved up from a low-income economy to a lower‐

middle income economy (UNLaoPDR, 2017) From ambulatory medical records and the Spectrum programmed in 2018, there were approximately 12,000 PLHIV among the general population, with 570 cases of new infections PMTCT records from these sources at the end of year 2018 revealed that 48,005 pregnant women had been counseled before being pre-tested, 45,565 pregnant women had been tested for HIV at the ANC, and after the post-test, 69 pregnant women and 55 children were HIV positive From 2015 to 2019, the number of HIV positive pregnant women was 423 cases In addition, from 2010 to 2018, the number of HIV positive children 0-4 years of age was 7,410, with new HIV infections in 2018 alone numbering 1,016 cases and deaths totaling 779 HIV positive children (HIV Center, 2018)

Vientiane Capital accounts for nearly 50% of the cumulative HIV cases in Laos In 2015, 44,676 women in the capital tested for HIV at antenatal clinics, including those who already knew of their HIV positive status Of these, 106 women were found to be HIV positive with a prevalence rate of 0.24% (GARP, 2015) The Setthathirath Hospital is located in one of the most populated areas in Vientiane Capital with many migrants coming from other countries The hospital has the biggest clinic providing HIV services in Laos, including services for pregnant women (JICASurvey, 2016) In the new National Strategy and Action Plan (NSAP) for the period 2016-2020, one of the goals is to see an increase of 15% of pregnant women with correct KAP on HIV/AIDS prevention This is aimed at reducing the HIV prevalence to 3% or lower However, there has been no empirical data for this information in Vientiane Capital As such, this study aimed to explore the knowledge, attitudes, and practices regarding HIV/AIDS prevention among pregnant women attending antenatal care at the Setthathirath Hospital

This study sought to answer the two following research questions:

1 What are the attitudes, knowledge and practices of pregnant Lao women with regard to HIV/AIDS prevention?

2 What are the factors associated with the knowledge, attitudes and practices regarding HIV/AIDS prevention of these pregnant women?

Research Objectives

1 To assess the knowledge, attitudes, and practices regarding HIV/AIDS prevention among pregnant women attending antenatal care at the Setthathirath Hospital in Vientiane Capital, Lao PDR, in 2019

2 To identify the factors associated with the knowledge, attitudes, and practices regarding HIV/AIDS prevention among pregnant women attending antenatal care at the Setthathirath Hospital in Vientiane Capital, Lao PDR, in

2019

Chapter 1: Literature Review 1.1 Definitions

1.1.2 HIV/AIDS prevention from mother to child:

Human immunodeficiency virus (HIV) is one of the leading causes of mortality among children Mother-to-child transmission can occur during pregnancy, labor and delivery or breastfeeding The prevention of mother-to-child transmission (PMTCT) programmed aims to stop HIV transmission from infected pregnant women to their unborn/newborn babies (WHO, 2011)

1.1.3 Prevention of mother to child transmission:

The prevention of mother-to-child transmission (PMTCT, also known

as the prevention of vertical transmission), refers to interventions to radically reduce the transmission of HIV from an HIV positive mother to her infant during pregnancy, labor and delivery or breastfeeding (USAID, 2015)

1.2 Global burden of HIV infection

The global commitment to control the HIV/AIDS pandemic has been

initiated since its beginning due to the continued worldwide spread of infections

with alarming and increasing speed (UNAIDS, 2018) Since the beginning of

the epidemic, more than 70 million people have been infected with the HIV

virus and about 3.5 million people have died of HIV Globally, at the end of

2017, there were 36.9 million people living with HIV An estimated 1.8 million

individuals worldwide became newly infected with HIV in 2016, with about

5,000 new infections per day This included 2.1 million children under the age

of 15 years In 2015, more than 1.4 million pregnant women were living with

HIV, who needed intervention to prevent their children from getting the disease

from them Sub-Saharan Africa alone contributed to 90% of this burden (UNAIDS, 2018)

The most significant sources of HIV infection in children and infants

is the transmission of HIV from infected mother to child during pregnancy,

childbirth, and breastfeeding Without intervention, the risk of transmission ranges from 5% to 10% during pregnancy, 10% to 15% during labor and delivery, and 5% to 20% through breastfeeding (WHO, 2018a, 2018c)

Approximately 70% of people living with HIV globally were aware of their

HIV status in 2016 The remaining 30% (over 11 million people) still need access to HIV counseling and testing services Knowledge, attitudes and practices (KAP) regarding HIV/AIDS prevention among pregnant women

attending antenatal care is an essential gateway for support services to HIV

prevention, treatment and care (WHO, 2017)

HIV is a leading cause of death and disease, especially in sub-Saharan Africa The introduction of anti-retroviral therapy (ART) in 1996 greatly reduced HIV-related mortality in the region The creation of the Joint United Nations Programmed on HIV/AIDS (UNAIDS) in 1996, the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002, and the US President's Emergency Plan for AIDS Relief (PEPFAR) in 2003 galvanized the mobilization of resources to combat the HIV epidemic As a result, HIV mortality has declined overall in low-income and middle-income countries since 2004 The global HIV incidence peaked in 1997, at 3.3 million new infections, and it decreased to 4.8% per year in 2005 From 2005 to 2015, the global incidence remained relatively stable, at about 2.5 to 2.6 million cases per year People living with HIV increased rapidly, from 2.4 million in 1985 to 28

million in 2000 From 2000 to 2015, the number of people living with HIV increased by 0.8% per year, reaching 38.8 million in 2015 (WHO, 2018c)

1.3 Situation of HIV infection in the Lao PDR

In the Lao PDR, HIV remains an important cause of morbidity, particularly in big urban areas The prevalence among the general population aged 15-49 years in Laos was 0.29% in 2013, with the number of people living with HIV estimated at 11,628 in 2014 By 2015 the population living with HIV was 0.3%; the estimated number of the most at risk population in 2015 was 187,857, based on Asian Epidemic Modeling and Spectrum data The number

of PLHIV children was estimated at 6,268 The HIV incidence in Laos is estimated to be between 800 and 1000 cases per year This figure is relatively low compared with countries in the Greater Mekong Sub-region (GMS) The HIV epidemic in Laos is classified as low prevalence, but showing an increasing trend from 0.16% (2003) to 0.29% (2014) in people aged 15 to 49 years Sex workers (SW), men who have sex with men (MSM), transgender people (TG) and people who inject drugs (PWID) form the key portions of the affected population (Asian-Development-Bank-Laos, 2016)

In recent years, Laos has become a “land-linked” country, opening its corridors to its neighboring countries, namely Cambodia, China, Myanmar, Thailand, and Viet Nam, which have relatively higher HIV prevalence rates These transit routes provide job opportunities, trade and increased mobility for people in and out of the country The increased mobility across borders provides a venue for HIV vulnerability and the emergence of groups at high risk, thus continuously making Laos vulnerable to new HIV threats Valuable data was generated in 2014 with the new estimates taken from the updated Spectrum and ASEAN epidemic model projections and new rounds of the Integrated Biological and Behavioral Survey (IBBS) for MSM and female sex workers The HIV prevalence among the general population aged 15-49 years remains low at 0.29% Nevertheless it showed an increasing trend from 0.16%

in 2003 to 0.29% in 2014 The highest prevalence of HIV can be found in key affected populations, primarily among MSM at 1.6%, followed by PWID at 1.5% and SW at 1.4% Factors that may have contributed to this trend include the rise in cross border migration, especially with the higher HIV prevalence in neighboring countries in the GMS Furthermore, the improved economy elevating Laos from a low to a lower-middle income economy (LMIC), the establishment of the ASEAN Economic Community (AEC), improved transport and communication systems, and more employment opportunities facilitate the ease of migration In 2014, for the newly reported HIV cases, there were 53%

of males and 47% females for a male to female ratio of 1.1 but female PLHIV were younger than males with 54.2% of female cases being less than 30 years

of age and only 35.4% of males less than 30 (JICASurvey, 2016) The majority

of HIV cumulative cases were identified in border provinces along the Mekong River and constituted 85.9% of all HIV reported cases during 1990-2014 Sexual activity is the primary mode of transmission Heterosexual contact accounted for the majority of HIV transmission at 88% during 1990-2014 The second most common route of transmission is from mother to child (4.9%) (GARP, 2015)

In Laos, among the children living with HIV, many children are only identified as HIV positive when they begin to get sick or fail to thrive The number of deaths may be due to the increasing number of PLHIV coming late for a diagnosis (53.2%) In PMTCT activities linking HIV and Maternal and Child Health (MCH), 50% of pregnant women attending ANC received provider-initiated counseling (using 2014 as the baseline) (Elizabeth, 2016) The estimated percentage of child HIV infections from HIV positive women delivering in the past 12 months was 34.4% This was derived by dividing the estimated number of children newly infected with HIV due to mother to child transmission among children born in the previous 12 months (114 cases representing the numerator) by the number of HIV positive women who

delivered in the previous 12 months (331 cases representing the denominator) (Elizabeth, 2016)

To increase the uptake of HIV/AIDS prevention among pregnant women, an early referral to care and M&E system improvement were conducted Counseling at the ANC at hospitals by health providers helped to prevent HIV/AIDS among pregnant women and its transmission to their children The introduction of voluntary testing and counseling (VTC) to pregnant women is one of the important campaigns the government has started Pregnant women do not have immediate access to ANC and VTC in most areas and this leads to a patient loss in the follow-up among HIV/AIDS positive women who have given birth There is a need to orient and train health staff on PMTCT and protocols on positive prevention Based on the ongoing pilot project, providing KAP counseling services on HIV/AIDS prevention to all pregnant women registering or reporting for antenatal care is the most important step The aim in the coming planning period is to describe the level of knowledge, attitudes and practices towards HIV/AIDS prevention among pregnant women attending antenatal care at the Setthathirath Hospital, information which the authorities can use in the future for improving their policies

1.4 HIV infection among pregnant women

Since the start of the global HIV epidemic, women have been

disproportionately affected by HIV in many regions To date, women account for more than half of all people living with HIV AIDS-related illnesses remain the leading cause of death for reproductive women (aged 15-44 years) Female adolescents and youths (10-24 years) account for a disproportionate number of new HIV infections (UNAIDS, 2019b) In 2016, new infections among young women aged 15-24 years were 44% higher than men of the same age In eastern and southern Africa, young women made up 26% of new HIV infections despite only accounting for 10% of the population It is estimated that there are

7,500 young women across the world acquiring HIV every week Women and girls are particularly at risk of HIV infection because of a lack of access to health care services (denial of access to services that only women require experience discrimination from service providers, and poor service quality)

A lack of access to comprehensive HIV/AIDS and sexual reproductive health services means that women are less able to look after their sexual and reproductive health and rights, and reduce their risk of HIV/AIDS infection Studies have shown that increasing educational achievement among women and girls is linked to better sexual and reproductive health outcomes Hence a lack

of access to education makes women and girls vulnerable to HIV/AIDS infection Other factors including poverty, gender-based violence, intimate partner violence, and child marriage put women and girls at risk to HIV/AIDS infection (UNAIDS, 2019b)

1.5 Transmission of HIV from mother to infant

The transmission rate from infected mother to the infant is estimated about 50% to 70% This is probably occurring in late pregnancy or during childbirth Breastfeeding increases the risk of HIV/AIDS transmission by about 14% HIV/AIDS positive women should be educated and counseled so they can make an informed decision about how to best feed their infants (US, 2018) Every year nearly 400,000 children are infected with HIV through MTCT, which is responsible for more than 90% of HIV infections in children (Lorainne Tudor Car., 2011) In high-income countries, the MTCT rate is less than 1% through the provision of perinatal prevention in mother-to-child HIV transmission (PMTCT) interventions In low-and middle-income countries, PMTCT programmed coverage remains low and consequently transmission rates remain high The World Health Organization recommends the integration

of PMTCT programmers with other healthcare services to increase access and improve uptake of these interventions It is necessary to assess the effect of integration of perinatal PMTCT measures with other healthcare services with

regard to coverage and service uptake compared to stand-alone PMTCT programmers and healthcare services or partially integrated PMTCT interventions (Lorainne Tudor Car., 2011)

1.6 Prevention of Mother to Child Transmission (PMTCT)

The Prevention of Mother to Child Transmission is a commonly used term for describing the reduction of the transmission of the HIV virus from pregnant mothers to their infants This concept has been at the forefront of global HIV/AIDS prevention activities since 1998, following the success of the short-course Zidovudine and single-dose Nevirapine clinical trials It refers to the set of programmers/interventions designed to identify the pregnant mothers with HIV and provide them with effective interventions to prevent mother to child transmission (MTCT) It is an intervention to ensure that no child is born with HIV This approach envisions the advance towards an AIDS-free generation MTCT is a burning issue for HIV and AIDS treatment since 90% of new cases of HIV in infants and children are due to MTCT The PMTCT approach mainly uses Anti-Retroviral Therapy (ART) along with other preventive methods and interventions in cases of breastfeeding and child delivery in order to prevent the transmission of the virus to the infants Mother

to child transmission of HIV virus may occur during three different periods, i.e during pregnancy; during labor and delivery; and during breastfeeding Although mother to child transmission of the HIV virus is always dangerous and risky, it does not necessarily affect 100% of cases even if no ART or other PMTCT approaches are taken The chance of MTCT occurrence is around 25-40% (UNGASS, 2017)

A 2010 study of knowledge, attitudes and practices about the prevention of mother to child transmission of HIV (PMTCT) was made among pregnant women in Togo with the purpose of evaluating knowledge, attitudes and practices related to PMTCT by using a qualitative cross-sectional approach which was conducted in 22 antenatal clinics Data collection through an

interview was conducted with all the pregnant women visiting the clinics during January-February 2010 The women identified sexual relations (93.8%), objects soiled with blood (80.5%) and the transmission from mother to child (27.1%) as the main routes of HIV transmission A large majority (77.1%) agreed that unprotected sexual relations raised the risk of HIV transmission to the child More than a quarter (29.5%) considered that HIV-positive women should not have children The results indicated that pregnant women in Togo had a fairly good knowledge about HIV/AIDS Attitudes towards PMTCT were generally positive, but some behaviors such as condom use needed improvement (WHO, 2014).

A study on knowledge and practices of women regarding the prevention of mother to child transmission of HIV (PMTCT) in rural southwest Uganda showed that most women of childbearing age in Mwizi sub-county of Uganda lacked adequate knowledge to prevent MTCT despite a high awareness

of MTCT and the need for PMTCT for PMTCT knowledge to trickle down to rural women Messaging from village health workers, the major source of information, needs to be reinforced More training on techniques to reinforce PMTCT messages is needed Other forms of messaging, i.e radio and cell phone messages, village meeting discussions, and social gatherings might reinforce the prevention awareness (Atwiine et al., 2013)

1.7 Knowledge regarding HIV/AIDS prevention of pregnant women

In the Lao PDR, mothers during pregnancy, delivery, and breastfeeding face a number of challenges For pregnant women HIV/AIDS prevention is largely dependent on them having the relevant knowledge and skills to avoid the risk of infection In addition, it is critical to provide counseling services, obstetrics advice, and physical and psychological care services to clients Clients refers to the people living with HIV, most-at-risk populations and those affected which includes spouses, partners and family members (Guy, 2010)

Despite advances in our scientific understanding of HIV/AIDS prevention and treatment as well as years of significant effort by global health providers in big urban areas, leading government and civil society organizations consider there are too many pregnant women who still lack KAP for HIV/AIDS prevention Some of those at risk from HIV still do not know and lack access to PMTCT care and treatment, and there is still no cure, thus the continued need for HIV/AIDS prevention among pregnant women (UNAIDS, 2010) It was reported that the incidence of perinatal transmission varies from 13% and 48 % globally, 13% to 32% for the developed countries and 25% to 48 % for developing countries Transmission can take place antepartum, during delivery and postpartum by breastfeeding Transmission during the first trimester may take place, but current data suggests that a substantial proportion of perinatal HIV-1 transmissions take place rather late in pregnancy or during delivery The apparent absence of viral genome from fetal tissue, the presence of a normal immune system at birth, the absence of neonatal morbidity and reports of differential viral transmission in twins are arguments in favor of late transmission One of the greatest concerns for both women and their health care providers is the possibility that pregnancy may accelerate the onset of AIDS in mothers Pregnancy itself can be immunosuppressive and some investigators have hypothesized that the cumulative immunosuppressive effect of HIV-1 infection and pregnancy may accelerate the course of HIV-1 infection in pregnant women

One of the most important issues in reducing the rate of HIV infection was having a correct knowledge of how HIV was transmitted and strategies for preventing the transmission Having access to reliable information was the first step towards raising awareness and giving people the tools to protect them from infection The Lao Social Indicator Survey‟s 2011-2012 data points to the low level of knowledge about HIV/AIDS prevention and transmission among the poor and those with lower levels of educations Overall, a knowledge of HIV

transmission and prevention was very low in Lao households making them vulnerable to HIV infection (UNICEF, 2012)

A study assessed the pregnant women's knowledge related to HIV, MTCT of HIV/AIDS prevention and respondents' attitudes towards it with the objective to ascertain the knowledge and attitudes of pregnant women in Northwest Nigeria to HIV and MTCT despite the low literacy level in the target rural community Of the 450 respondents, the majority (96.2%) were aware of HIV Most of them (78%) had an adequate knowledge of MTCT of HIV (Ashimi AO, Omole-Ohonsi A, Amole TG, & Ugwa EA, 2014) About half of the respondents knew that MTCT of HIV could be prevented by not breastfeeding, more than a quarter (28%) agreed with the taking of anti-retroviral treatment during pregnancy and one fifth (20.2%) gave newborns anti-retroviral treatment as ways of preventing MTCT The respondents in this study had a high level of awareness of HIV/AIDS, and a good general knowledge of MTCT and attitude towards PMTCT, but a below average knowledge of specific interventions on the prevention of MTCT of HIV (Ashimi, Omole-Ohonsi, Amole, & Ugwa, 2014)

A study conducted among pregnant mothers attending ANC found that age, marital status, religion and educational status had no significant association with knowledge of MTCT and PMTCT of HIV However, government employees and those women whose husbands were government employees had a significant association with a knowledge of MTCT/ PMTCT

of HIV than those housewives who did not, (AOR = 2.84, 95% CI (1.042, 7.741) and (AOR = 4.32, 95% CI: 1.25, 12.11) respectively Urban women had more knowledge than their rural counterparts (AOR=2.34, 95% CI:.995, 5.52) (Dessie & Tigabu, 2018)

Among the reproductive characteristics of women such as the number

of live children and parity there was not a significant association with a knowledge on PMTCT However, antenatal care follow up during the last

pregnancy was significantly associated with knowledge on MTCT and PMTCT

of HIV/AIDS after performing a multivariate analysis The odds of knowledge

on the prevention of MTCT was about seven times higher among women who had undergone the last ANC follow up (AOR = 7.61, 95% CI ((3.46, 16.72)) than those who had not (Dessie & Tigabu, 2018)

1.8 Attitudes regarding HIV/AIDS prevention of pregnant women

A study in southern Laos gave attention to attitudes of pregnant women towards 'Focus Antenatal Care' (FANC) which was utilized with antenatal care (ANC) This is an umbrella term used to describe the treatment and monitoring of expectant mothers and their unborn children The FANC approach was applied to every pregnant woman at risk of complications and gave special attention to their diet This was done to help prevent the transmission of HIV/AIDS from mother to child (Etuk, 2017)

The experience of HIV/AIDS prevention directed at and focusing on the attitudes of pregnant women attending antenatal care (ANC) achieved high and favorable responses There were some weaknesses related to patient expectations when giving ANC to pregnant women These hospital visits provided essential assistance such as counseling It was during these consultations that a pregnant woman could change her attitude to have a positive outlook on HIV/AIDS prevention, and the detection and management

of infections and related complications (Ojong., 2015)

The mean attitude of the respondents stood at 2.44±0.593 With 45.2% stating that advice regarding proper health during pregnancy can be sourced outside the hospital About 38.8% of the pregnant mothers said they preferred postponing the advice till the postnatal period Meanwhile 39.2% determined how long to breastfeed their child themselves, with 38% choosing

to read online advice because the cost of transportation to the nearest antenatal care center was prohibitive As a consequence only 49.2% of the respondents

had a positive attitude toward attending antenatal care clinics (Ogunba BO., 2017)

The study showed that age, religion, marital status, the occupation of the respondent, the distance of home from a health institution and spouse‟s occupation had no significant association with the attitude of the pregnant mother towards PMTCT However, it was found that urban women had a more favorable attitude towards PMTCT than rural women with an AOR=1.14, 95%

CI (1.111, 4.388) (Dessie & Tigabu, 2018) Concerning the reproductive characteristics of women, such as their attendance at the last ANC and the place

of their last delivery, a significant association was found with attitudes of pregnant mothers (AOR=1.99, 95% CI: 1.9, 4.39) and (AOR=2.24, 95% CI: 1.04, 4.85) respectively However, parity, the number of live children, the number of current ANC follow ups and gravidity did not show any significant association with attitudes towards the prevention of HIV/AIDS transmission from mother to child (Dessie & Tigabu, 2018)

1.9 Practices regarding HIV/AIDS prevention of pregnant women

Cultural, sexual, religious, and legal influences often make it difficult

to freely discuss sexual practices, preferences, sexual desires, the number and type of sexual partners, and the use of birth control In addition, there is often a

“cloak of silence” related to sexual practices Such subjects are often taboo and associated with embarrassment, shame, guilt, and rejection as they practice certain risk behaviors in their own personal lives (Rogers et al., 2005)

In some societies, the use of condoms is not sanctioned by the religious leaders, and the cultural norms of silence regarding sexual practices, preferences, and desires can be problematic These sexual practices might include men having sex with men, sexual abuse, child abuse, and heterosexual intercourse Thus, many dimensions of culture challenge HIV/AIDS prevention and care Moreover issues like a fear of contracting HIV and becoming sick and

dying from the disease make people reluctant to inquire about reproductive health

Antenatal care (ANC) is the care a woman receives throughout her pregnancy in order to maintain good health for her and her fetus Various factors discourage ANC attendance and birth giving at clinics knowledge about rural Laotian birthing practices and preferences in order, although these cultural practices around rural birthing in Lao PDR, to prevent these, pregnant women have to take care of themselves and not work hard (Sychareun et al., 2016)

The study was conducted among pregnant mother attending ANC This study showed that prevention of mother-to-child transmission (PMTCT) and factors affecting its practice among women were analyzed using different explanatory variables All of the respondents 223 (96.1%) have been tested for HIV Among these 52 (23.3%) tested three month ago, 13 (5.8%) tested six month ago, 41 (18.4%) tested one year ago and 117 (52.5%) tested on the regent pregnancy Majority of them, 207 (89.2%) and 205 (88.4%) had pre- and post-counseling services respectively Among the respondents, 194 (83.6%) shared the result of HIV test with their husband/partner whereas, the remaining

17 (7.3%) did not share the result to their husband/partner at the time of testing and 9 (3.9%) had no husband/partner at the time of testing The rest (4.9%) did not test for fear of stigma and discrimination and lack of confidentiality (Abajobir & Zeleke, 2013)

Among the respondents, 122 (52.6%) of the partner/ husband tested for HIV/AIDS during their ANC follow up More than four-fifth, 148 (84.5%), had no any participation in community-conversation on HIV/ AIDS Among the respondents, 153 (67.7%) discussed about HIV/ AIDS and 132 (56.9%) discussed about the issues of HIV testing in current pregnancy with their husband Regarding the perception of their husband on HIV screening, 148 (63.8%) wanted to have couple testing, 34 (14.7%) wanted only the woman to

be tested, 10 (4.3%) did not want to be tested either and the other 34 (14.7%) did not want to respond (Abajobir & Zeleke, 2013)

A multivariate analysis showed that age, religion, residence, marital status, spouse‟s occupation and occupation of the respondents did not result in any significant association when discussing the issue of HIV with spouses/partners during the pregnancy period In regard to the reproductive characteristics of women related to their PMTCT practice, a logistic regression analysis was done (Dessie & Tigabu, 2018)

Among the reproductive characteristics, it was found that women whose spouse/partner had tested for HIV during ANC follow up and had delivered their last child at an medical institution had a significant association with (AOR=7.54 95% CI (3.30,1719)) and (AOR=2.77 95% CI (1.399, 5.509)) respectively However, parity, gravidity and the number of live children were found to have no significant association with the practice of prevention of mother to child transmission of HIV (Dessie & Tigabu, 2018)

1.10 Conceptual framework

Figure 1: The Conceptual Framework for the study of “Knowledge, attitudes and

practices regarding HIV/AIDS prevention among pregnant women attending antenatal care at the Setthathirath Hospital in Vientiane Capital, Lao People‟s Democratic Republic”

The conceptual framework has been drawn up to show the relationship

between the independent and dependent variables

Knowledge about HIV prevention among pregnant women

Attitude towards HIV prevention among pregnant women

Practices forHIV prevention among pregnant women

Chapter 2: Subject and Methods 2.1 Subject

This research project studied views among pregnant women relating to antenatal care services at the Setthathirath Hospital in Vientiane Capital

2.1.1 Inclusion criteria:

- Pregnant women aged 15-49 years who attended ANC at the Antenatal Ward

at the Setthathirath Hospital during the period of study (15 January, 2019 to 15 February, 2019)

- Pregnant women who could speak the Lao language with a satisfactory proficiency

2.1.2 Exclusion criteria:

- Pregnant women who refused to sign the consent form and did not agree to join the study

- All pregnant women who could give written informed consent

- Pregnant women with mental health disorders

2.2 Setting and duration

2.2.1 Setting: This research was conducted among pregnant women who

attended antenatal care services at the Setthathirath Hospital

2.2.2 Duration: 16 July, 2018 to 31 May, 2019

2.3 Study design

We applied a cross-sectional design with a quantitative survey which incorporated a self-administered questionnaire Data on socio-demographic characteristics, knowledge, attitudes, and practices towards HIV/AIDS prevention among pregnant women who attended ANC at the Setthathirath Hospital was collected

( )

Wherein:

 n is the sample size

 Z = 1.96 (95% confidence interval for the standard normal distribution)

 P is the proportion of pregnant women who had good practices for HIV/AIDS prevention in a previous study Since there were no current estimates in the Lao PDR, we chose p=0.5 to get the maximum sample size

 d is the precision level, in this study we chose d = 0.07

After running these calculations we gained a sample size of 196 We estimated 10% for the respondents who would refuse to participate in the interview The final samples size were 215

2.5 Sampling method

All pregnant women aged 15-49 years who attended ANC at the Antenatal Ward of the Setthathirath Hospital during the period of study met the criteria for selection in the study sampling Data collectors were used and the sampling technique to select employed simple random sampling In this study, we estimated our sample size to be 215 pregnant women According to the number of pregnancy examinations, there were about 50 pregnant women attending ANC per day at the Setthathirath Hospital Hence we randomly selected ten pregnant women per day to enroll into our study

The respondents were chosen as follows using the sampling technique:

- They selected random numbers in the range from 1 to 5 daily Then the first pregnant women to draw the random numbers were the first group of candidates asked to participate in our interview

- Subsequently more pregnant women were chosen in intervals of five

2.6 Data collection

The researcher sent an introductory letter to the director of the Setthathirath Hospital asking for permission to collect data Then the researcher sent a letter to the heads of each department in the hospital asking for permission to conduct research

The data was collected by the principal researcher and the research assistants during four weeks from 15 January, 2018 to 15 February, 2019 A self-administered questionnaire was used The interviews were started only after the written consent

of the eligible pregnant women had been obtained and when the purposes and benefits of the study had been explained After completion, the questionnaires were collected by the data collectors Following this questionnaires were verified for accuracy and completeness

 Attitudes

 Practices

2.8 Definitions/ Concepts, measures and assessment

2.8.1 Definitions/ Concepts

2.8.1.1 Demographic characteristics: These were collected in the verbal

response of the mothers to items related to information regarding HIV/AIDS prevention and its transmission from mother to child such as birth order, age, current marital status, religion, and educational status, current occupation, spouse‟s current occupation and number of pregnancies

2.8.1.2 Knowledge: These were collected in the verbal response of the

mothers to items related to information regarding HIV/AIDS prevention and its transmission from mother to child Individuals who scored above the mean for knowledge questions were considered as having a good knowledge, whereas those who scored below the mean were considered as having a poor knowledge of HIV/AIDS prevention

2.8.1.3 Attitudes: Individuals who scored above the mean for attitude

questions were considered as having a good attitude, whereas those who scored below the mean were considered as having a poor attitude for HIV/AIDS prevention

2.8.1.4 Practices: This refers to pregnant women who knew and applied

HIV/AIDS prevention

2.8.1.5 Maternity: This refers to women belonging to the 15 to 45 year age

group who attended antenatal care at the Setthathirath Hospital Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period While motherhood is often a positive and fulfilling experience, for too many women it is associated with suffering, ill-health and even death (WHO, 2019)

2.8.1.6 Pregnant women: Pregnancy is the term used to describe the period

in which a fetus develops inside a woman's womb or uterus Pregnancy usually lasts about 40 weeks, or just over 9 months, as measured from the last menstrual period to delivery Health care providers refer to three segments of pregnancy, called trimesters (NICHD, 2017) In this study, a pregnant woman refers to one of the pregnant women who are attending to antenatal care at the Setthathirath Hospital

2.8.2 Measures and assessments:

The data was collected using a self-administrated questionnaire First

of all, the questionnaire was prepared in English by the researcher and translated into the Lao language Most of the questions were multiple-choice questions, but a few questions on snacking habits and daily allowances were opened-ended questions The questionnaire consisted of six parts with 51 questions To measure the dependent variables, e.g., knowledge, attitudes and practices towards HIV/AIDS prevention and independent variables, e.g., socio-demographic factors, psychological factors and the respondent‟s history of reproductive health, the following approach was applied:

2.8.2.1 Knowledge regarding HIV/AIDS prevention among pregnant women

We used 18 questions to measure the knowledge of study respondents towards HIV/AIDS prevention These questions gathered information on HIV/AIDS prevention, responsible pathogen, mode of transmission, and risk of infection In each question, the correct answer obtained 1 score and a wrong answer received 0 score Therefore, the total score for knowledge were 18 score and the lowest was 0 The evaluation of the knowledge score was based on the mean score which was calculated from totaled scores Study respondents who

scored less than the mean were classified as having a “poor knowledge” and

those who scored equal or greater than the mean were classified as having a

“good knowledge” (Aweke et al 2017)

2.8.2.2 Attitudes regarding HIV/AIDS prevention among pregnant women

The attitude were measured from ten questions, which used five Likert Scales (Ray, 1982) to construct the attitude levels, we considered the study respondents who had exclusively answered three categories, e.g neutral,

disagree and strongly disagree were classified as “negative attitudes” and those respondents who answered agree or strongly agree were classified as “positive

attitudes” (Aweke et al., 2017)

2.8.2.3 Practices regarding HIV/AIDS prevention among pregnant women

The practices were derived from seven questions, which were related to the action for the prevention of HIV among study respondents Each question was coded with 1 for correct practice and 0 for wrong practice The level of

practice was considered having a “good practice” if the study respondent correctly answered at least five out of seven questions and having a “poor

practice” if they provided less than five correct answers (Nkwabong,

Meboulou, Kamgaing, & Keddi Jippe, 2018)

2.8.2.4 Socio-demographic characteristics among pregnant women

This part contained nine questions encompassing birth order, age,

marital status, religion, educational status, occupation, and spouse‟s occupation, present income and present residence (address)

2.8.2.5 Psychological factors among pregnant women

This part included two questions The questions covered the fear of stigmatization associated with HIV and the respondent‟s trust in the KAP

providers at the ANC unit

2.8.2.6 Reproductive history among pregnant women

This part consisted of five questions, which dealt with information on the number of ANC visits during the last pregnancy, the number of ANC visits during the current pregnancy, the place of last delivery, the number of

live children and the number of pregnancies

2.9 Data quality and analysis

Filled questionnaire forms were analyzed using Epidata software

and consistency with the hard copies The entered data was later transferred

to STATA version 13 (www.stata.com)

 Descriptive analysis: A descriptive analysis was used to describe the

independent variables such as socio-demographic factors, psychological factors, and a history of reproductive health including the knowledge, attitudes and practices of the respondents

 Bivariate analysis: Bivariate analyses were used to associate the dependent

variables,(knowledge, attitudes and practices towards HIV/AIDS prevention) and independent variables (e.g., socio-demographic factors, psychological factors and history of reproductive health) (Mahendru & De, 2013) Variables with a significance level of less than 20% (p-value < 0.2) were eligible for consideration in the initial model of multivariate analysis

 Multivariate logistic regression: A multivariate logistic regression was

performed on variables that had a p-value of less than 0.2 from the bivariate models After checking the collinearity statistic, only variables with a low collinearity statistic were kept The variables were removed according to high p-values and model fit Only variables with a p-value less than 0.05 were considered in the final model fit and these were considered as predictive factors

2.10 Ethical issues

This study collected the data from a pretested questionnaire for which there was little need for concern with respect to ethical issues We used the informed consent form to ask for permission from each study subject and only those who accepted were included in the study

2.11 Limitations and bias and how to minimize these biases

Our study focused only on knowledge, attitudes, and practices regarding HIV/AIDS prevention among pregnant women in a big hospital in Laos Women with a low income and education could not be covered Furthermore, many women with a high risk of HIV/AIDS infection feared being stigmatized In Laos, women positive with HIV were unwilling to disclose their status to friends and relatives

Chapter 3: Results

During our study period, a total of 240 pregnant women aged 15-45 years

who visited the ANC consultation unit at the Setthathirath Hospital were invited to participate in our study Among them, 215 persons completed all the questionnaire

forms and were included in the final analysis From sub-section 3.1 to 3.6, we

describe the findings from our study including the association with underlying factors

3.1 Socio-demographic factors

Table 3.1: Socio-demographic characteristics of study respondents (n = 215)

0.4

Educational status

No education

Primary (grade 1 to 5)

Lower secondary (grade 1 to 3)

Upper secondary (grade 4 to 7)

Non-rural private employment

1.8

Husband’s occupation

Farmer

Government staff

Non-commercial private employment

Small shop trader

Table 3.1 summarizes the socio-demographic characteristics of study participants From 215 study participants, about half of them (59.5%) were aged 25-34 years old, 31.6% was aged 15-24 years and 8.8% were 35 years and above Most of the study participants (93.4%) were currently married The vast majority (96.1%) of the respondents were Buddhist Less than one-third (26.9%) of the study participants had a tertiary education level or higher About 39.5% of them were housewives, while the common occupation (34.4%) of their spouses was private

employment About two thirds (67.4%) of the study participants had a monthly

family income level of more than 1,000,000 kip (approximately 116 USD) and 70.2% of the study participants were from urban areas

3.2 Psychological factors

Table 3.2: Psychological perceptions among study respondents of HIV

Infection (n=215)

Fear of stigmatization due to HIV

19.5

Table 3.2 displays the psychological perceptions of study participants with respect to HIV infection From 215 pregnant women enrolled in the study, 40.9% reported that they rarely or never feared stigmatization linked to HIV infection and 79.1% said that they trusted in the KAP providers at the ANC clinic

3.3 Reproductive health history

Table 3.3: Reproductive health history of study respondents (n=215)

Remember last menstrual period

Number of living children

8.3

Table 3.3 summarizes the reproductive health history of the study participants Among 215 pregnant women, only half of them remembered their last menstrual period Most of the study participants (72.1%) visited the ANC clinic before delivery The majority of study participants (95.8%) gave birth at a hospital