Compliance with maternal HIV retesting for pregnant women attending care in selected health facilities in Namutumba district, Uganda

Abstract

Background

Retesting for HIV during pregnancy, labor, and postpartum is crucial for identifying new infections and ensuring timely interventions to prevent mother-to-child transmission (PMTCT). Uganda's national guidelines recommend that pregnant women be retested in the 3rd trimester or during labor/delivery. However, limited information exists regarding adherence to these guidelines, which may affect the effectiveness of PMTCT efforts.

Aim

To assess compliance with maternal HIV retesting and the factors influencing retesting among pregnant women attending care in selected health facilities in Namutumba district.

Methods

This cross-sectional study was conducted from January to June 2024 in six government health facilities in Namutumba district. Quantitative data were collected from randomly selected mothers who delivered during the study period using a structured questionnaire in an open data kit. For the qualitative component, data were collected through key informant interviews with healthcare workers to explore barriers and facilitators to HIV retesting. Quantitative data were analyzed using STATA version 17, while qualitative data underwent manual thematic analysis.

Results

The study showed that most respondents were young women, with an average age of 25.7 years, most of whom lived in rural areas (89.3%) and were married (88%). HIV retesting prevalence was 85%. Key factors associated with retesting included secondary education [APR 1.55, 95% CI (1.03-2.34)], tertiary education [APR 1.72, 95% CI (1.10-2.61)], attending at least five ANC visits [APR 1.11, 95% CI (1.01-1.21)], and spousal accompaniment for ANC or delivery [APR 1.18 (1.05-1.34)]. Facilitators included community outreach, education, and incentives while barriers involved testing kit shortages, poor documentation, stigma, and human resource constraints.

Conclusions

HIV retesting in Namutumba district's high-volume health facilities was below the recommended 100% needed to eliminate mother-to-child transmission.

Recommendations

Prioritize interventions to increase retesting uptake, focus on health education, promote spousal involvement, and address human resource gaps in HIV testing services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-12249-z.

Background

More than four decades since the start of the HIV epidemic, the virus remains a significant global public health challenge. By the end of 2022, an estimated 39 million people were living with HIV [1]. Young people are particularly affected, with approximately 130,000 children infected with HIV in 2022, many through mother-to-child transmission [2]). Early detection and treatment of maternal HIV are critical to reducing mother-to-child transmission (MTCT), with testing playing a key role in prevention efforts [1]. Integrating HIV testing into antenatal care (ANC) and providing universal antiretroviral therapy (ART) to pregnant women with HIV has been a successful approach to reducing MTCT. However, there remains a risk of HIV infection acquired during the third trimester or labor that may go undetected without retesting [3]. The World Health Organization (WHO) recommends routine HIV testing in the first trimester and retesting in the third trimester or during labor in high-prevalence settings to minimize MTCT risks.

Sub-Saharan Africa bears the brunt of the HIV epidemic, accounting for most new infections and AIDS-related deaths worldwide. The region is home to approximately two-thirds of all people living with HIV [1]. Women are disproportionately affected, making up 63% of new infections in 2022 [1]. To address this, strategies such as retesting during pregnancy and postpartum have been recommended [4]. Despite these efforts, many women in sub-Saharan Africa face challenges in accessing healthcare services or miss HIV testing due to inadequate counseling [5]. Retesting has proven effective in detecting maternal infections and reducing MTCT, as seen in a Kenyan study [6]. However, studies in the region show varying rates of HIV retesting during pregnancy, ranging from 25% to 62% [7–9], with few focusing on adherence to national guidelines for retesting in the third trimester or during labor.

Uganda remains a high-burden country, with an adult HIV prevalence of 5.8% in 2021, higher among women at 7.2% [10]. This highlights the need for effective measures to ensure HIV testing during pregnancy and labor to prevent MTCT. In 2021, 5,300 new childhood HIV infections occurred in Uganda due to MTCT [11], potentially linked to poor adherence to national HIV testing guidelines. Uganda’s Ministry of Health (MOH) recommends retesting HIV-negative pregnant women in the third trimester or during labor, yet many women are not retested, increasing the risk of transmission to their children [12]. Data from the District Health Information System (DHIS2) for Namutumba district between April and June 2023 showed that 15% of pregnant women were retested for HIV during the third trimester, while 4% of women in labor were tested. The lack of compliance with these guidelines, coupled with inadequate data on eligible women for retesting, complicates efforts to measure maternal HIV retesting rates. Previous studies have explored HIV testing among pregnant women [13–15], but none have specifically addressed compliance with retesting, leaving a critical gap for the prevention of MTCT. This study aims to determine compliance with maternal HIV retesting in Namutumba district and the associated factors.

Methods

Study site

The study was conducted in Namutumba district, located in the eastern region of Uganda. The district has a projected population of 334,400 by 2024 [16], predominantly residing in rural areas. The district was selected because the available data from the DHIS2 revealed that it is one of the districts with most women not retested during ANC and maternity which puts the children born to these women at risk of being infected with HIV. Six government health facilities in the district were purposively selected and included in the study to realize the required sample size.

Study population

Pregnant women who delivered from the study facilities during the period of data collection were included in the study.

Study design

This was a descriptive cross-sectional study employing both quantitative and qualitative methods of data collection. The quantitative component focused on assessing compliance with maternal HIV retesting and identifying associated factors, while the qualitative component explored barriers and facilitators to HIV retesting through key informant interviews.

Sample size determination

Sample size for the quantitative component

The sample size was computed using the Kish Leslie formula where the outcome of interest is a proportion [17].

$$n=Z^2\frac{P\left(1,-,P\right)}{{\delta }^2}$$

Where:

n= Sample Size

Z= 1.96 (z-statistic at 95% Confidence interval for a 2-tailed test)

P= is the assumed proportion of the outcome of interest (HIV retesting among pregnant women), estimated at 50% due to lack of evidence=0.5.

d = Maximum error (5%)

$$n=\frac{1.{96}^2*0.5\left(1,-,.,0.5\right)}{0.{05}^2}$$

n=384 respondents

Adjusting for none-response response rate of 10%, the samples size (n)=427

Given the finite population , the sample size was adjusted as follows:

$$\text{Adjusted sample size}=\frac{n}{1+(\text{n}/\text{Pop})}$$

Where Pop= 542 total number of average bimonthly deliveries conducted in the period May 2023 -December 2023 for the six selected health facilities according to DHIS2 and n= calculated sample size (427).

n=the calculated sample size

Adjusted sample size= 427/ (1+(427/542))

n=238

This sample size was distributed across the study sites using proportionate-to-size sampling as presented in Table 1.

Table 1.

Distribution of the study participants

Health facility	Number of deliveries conducted (Oct 2023-Dec 2023)	Proportion of deliveries clients (%)	Expected sample size
Bulange HC III	139	10	24
Ivukula HC III	124	9	21
Magada HC III	200	14	33
Nabisoigi HC III	187	13	31
Namutumba HC III	324	23	55
Nsinze HC IV	437	31	74
Total	1411	100	238

Sample size for qualitative component

For the qualitative component, a total of 12 key informant interviews were conducted with health workers (midwives, counselors, or mentor mothers) to explore compliance with maternal HIV retesting. Interviews were conducted until data saturation was reached. Trained research assistants with expertise in qualitative data collection conducted the interviews using key informant interview (KII) guides.

Sampling procedure

For the quantitative interviews

Six government health facilities in Namutumba district (one Health Centre IV and five Health Centre IIIs) were purposively selected for their maternity services, which facilitated tracking maternal HIV retesting. The selection included both higher-level and mid-level facilities, ensuring diversity representative of rural Uganda's healthcare settings. Data on mothers who had given birth were retrieved from maternity registers and cross-checked with antenatal registers to confirm attendance and a negative first ANC HIV test result. Eligible women were identified through this triangulation process and selected using convenience sampling. Consenting participants were approached during maternity care, and questionnaires were administered, with responses on HIV retesting verified against register data for accuracy.

For the qualitative interviews

The participants for the qualitative part of the study were selected purposively based on their expertise and direct involvement in maternal retesting to provide barriers and facilitators to maternal HIV retesting for pregnant women. These included HIV counselors or mentor mothers and midwives who oversee HIV testing at the facility.

Study variables and measurements

The dependent variable was HIV retesting, defined as whether a pregnant woman underwent HIV retesting in the 3rd trimester or during labor/delivery. This was measured as a binary variable (1 = retested, 0 = not retested) based on self-reported information and verified by health facility records.

The independent variables included:

• Age: Measured in completed years and categorized into age groups (<20,20–24,25–29,30–34,35–39,40+).

• Residence: Categorized as rural or urban based on self-reported location.

• Marital Status: Categorized as married, single, widowed, or separated.

• Education level: Classified as no formal education, primary, secondary, or tertiary.

• Parity: Categorized as Nulliparous, 1–3 children or ≥ 4 children.

• Religion: Grouped as Catholic, Protestant, Muslim, or other.

• Occupation: Classified as none, self-employed or employed.

• Timing of first ANC attendance: Categorised as 1^st trimester, 2^nd trimester or 3^rd trimester.

• Number of ANC Visits: Categorized as 1–2 contacts, 3–4 contacts, 5–7 Contacts, 8+ Contact

Qualitative variables

Barriers and facilitators to HIV retesting were assessed through key informant interviews. Thematic analysis was used to identify recurring themes such as system-related barriers (e.g., kit shortages) and facilitators (e.g., spousal support).

Data collection procedure

Quantitative data

The interviews with mothers were conducted in person, and quantitative data were collected using a structured questionnaire uploaded into the Open Data Kit (ODK) platform. Each structured interview lasted approximately 30 minutes.

Qualitative data

For the qualitative component, data were collected through Key Informant Interviews (KIIs) guided by a structured interview guide. The interviews were audio-recorded to ensure accurate data capture, with the recordings securely stored on a password-protected computer to maintain confidentiality. Each KII lasted between 40 minutes and 1 hour and was conducted in either English or Lusoga. When necessary, translation was performed during the transcription process, and the transcriptions were summarized for analysis.

The interviews were conducted privately to uphold confidentiality, and the interviewers, who were unfamiliar to the respondents, clearly explained their roles before starting. It is worth noting that the KII responses were generally concise, and no follow-up questions were asked, as these interviews were not designed to be in-depth but aimed to gather specific information relevant to the study objectives. Additionally, not all respondents answered every question, which may have been influenced by factors such as the structured nature of the interviews or the respondents' comfort levels with certain topics. This was considered during the analysis and interpretation of the data.

Data collection tools

The questionnaire and key informant interview guide used in this study were developed specifically for this research. An English version of these tools is available as a supplementary file (see Supplementary file).

Data management and statistical analysis

Data collected using ODK was processed in Microsoft Excel, cleaned, and analyzed in STATA version 17. Descriptive statistics (mean, median, proportions) described participants' background characteristics, while modified Poisson regression identified factors associated with maternal HIV retesting in the third trimester or labor. Bivariable analysis factors with a p-value <0.2 were included in the multivariable model, built through stepwise elimination. Crude and adjusted prevalence ratios with 95% confidence intervals and p-values were presented in a table. Qualitative data from key informant interviews were analyzed using the Framework Method [18], a predefined thematic analysis framework. Transcripts were independently double coded by SM. and EB...Discrepancies in coding were resolved through discussion and consensus, involving a senior researcher for final agreement. A master sheet was created to summarize the themes, subthemes, frequencies, and key issues, incorporating descriptive statistics and contrasting individual perspectives for a comprehensive understanding.

Quality control and assurance

Research assistants who possessed a minimum of a bachelor’s degree were hired and they were trained for two days so that they understood the objectives of the study as well as become familiar with the study tools. After training the research assistants, a pre-test was conducted in one of the health facilities that were not part of the study to guide in further refining of the tools. The study tool was designed in ODK with checks to ensure data quality. The principal investigator reviewed the completeness and accuracy of the data collected each day. A debrief meeting was held at the end of each field day to encourage the research assistants to share experiences while in the field so that any challenges arising from the field were addressed. The qualitative interview tools were updated at the end of every interview and coding of the transcripts was done by two independent people to reduce bias in theme formation.

Results

A total of 358 participants were initially screened for eligibility, of which 264 met the inclusion criteria. Among those eligible, 40 declined to participate, leaving 224 participants enrolled and included in the final analysis. The mean age of the respondents was 25.7± (5.6) years, and at least 64% (143/224) were aged between 20 and 29 years. The majority (89.3%) resided in rural areas and were married (88.0%). Sixty-four percent (143/224) of the respondents had primary education. Slightly over half of the participants (120/224) were protestants by religion. Seventy-one percent of the participants (160/224) were self-employed and at least two-thirds (154/224) had at least 4 children. Most of the participants (74.1%) had attended ANC up to 7 with only 4.9% attending 8 and above visits as recommended by MoH. Two-thirds (148/224) of the participants made their first ANC contact in the second trimester. Pregnancy was not planned in 51.3% of the participants as shown in Table 2. The qualitative findings, obtained through key informant interviews with healthcare workers, highlight significant barriers and facilitators to maternal HIV retesting. These include issues such as health system constraints, stigma, lack of resources, and patient-related factors like spousal involvement.

Table 2.

Characteristics of mothers who delivered in the selected healthcare facilities in Namutumba district

Independent variable	Frequency n, (N=224)	Percentage (%)
Respondents’ age (years)	Mean (SD)=25.7± (5.6) years
<20	28	12.5
20–29	143	63.8
30–39	28	21.4
40+	5	2.2
Place of residence
Rural	200	89.3
Urban	24	10.7
Marital status
Married/Cohabiting	197	88.0
Divorced/separated	9	4.0
Single/never married	18	8.0
Level of education
No formal education	14	6.3
Primary education	143	63.8
Secondary education	48	21.4
Tertiary education	19	8.5
Religion
Muslim	54	24.1
Protestant	120	53.6
Catholics	38	17.0
Others	12	5.4
Occupation
None	54	24.1
Self-employed	160	71.4
Employed	10	4.5
Parity
Nulliparous	23	10.3
1–3 children	154	67.9
≥ 4 children	49	21.9
Number of ANC contacts made
0–7 contacts	213	95.1
≥8 contacts	11	4.9
Timing of 1st ANC contact
1st trimester	64	28.6
2nd trimester	148	66.1
3rd trimester	12	5.3
Planned pregnancy
No	115	51.3
Yes	109	48.7
Awareness of the importance of HIV retesting
No, I'm not aware of the importance	13	5.8
Somewhat, I need more information	44	19.6
Yes, I understand its importance	167	74.6
Accompanied by spouse during ANC or delivery
No	199	88.8
Yes	25	11.2

Socio-demographic and pregnancy-related characteristics of study participants

Proportion of pregnant women who get retested for HIV according to the national guidelines attending care in the selected health facilities of Namutumba district

Most of the mothers (85%) had retested for HIV according to the standard national guidelines as shown in Fig. 1. Regarding facilities, HIV retesting was highest at Nabisoigi HCIII (96.7%, (29/30) and lowest at Bulange HCIII (59.1%, 13/22) as shown in Fig. 2.

Fig. 1.

The proportion of pregnant women retesting for HIV attending care in health facilities of Namutumba district

Fig. 2.

Variation of HIV retesting among pregnant women attending care in selected health facilities of Namutumba district

Individual factors associated with maternal HIV retesting for pregnant women attending care in the selected health facilities in Namutumba district

Bivariate and multivariate analysis of individual factors associated with maternal HIV retesting was done using modified Poisson regression and corresponding prevalence ratios (Crude and Adjusted), 95% confidence intervals, and p-values are presented in Table 3.

Table 3.

Individual factors associated with maternal HIV retesting among 191 pregnant women in selected health facilities of Namutumba district

Variable	Maternal HIV retesting n (%)	CPR	95%CI		p-value	APR	95%CI		p-value
Respondents’ age (years)
<20	22 (11.5)	ref
20–29	125 (65.5)	1.11	[0.91	1.36]	0.305
30–39	40 (20.9)	1.06	[0.84	1.34]	0.619
40 years and above	4 (2.1)	1.01	[0.63	1.65]	0.941
Place of residence
Rural	170 (89.0)	ref
Urban	21 (11.0)	1.02	[0.88	1.21]	0.726
Marital status
Married/Cohabiting	172 (90.0)	ref
Divorced/separated	7 (3.7)	0.89	[0.63	1.27]	0.522
Single/never married	12 (6.3)	0.76	[0.55	1.34]	0.211
Level of education
No formal education	7 (3.7)	ref
Primary education	120 (62.8)	1.68	[0.99	2.85]	0.055	1.41	[0.94	2.11]	0.101
Secondary education	45 (23.6)	1.88	[1.10	3.18]	0.020	1.55	[1.03	2.34]	0.035*
Tertiary education	19 (10.0)	2.00	[1.18	3.38]	0.010	1.72	[1.10	2.61]	0.010**
Religion
Muslim	47 (24.6)	ref
Protestant	100 52.4)	0.95	[0.84	1.09]	0.514
Catholics	35 (18.3)	1.06	[0.92	1.22]	0.425
Others	9 (4.7)	0.86	[0.61	1.21]	0.395
Occupation
None	44 (23.0)	ref
Self-employed	138 (72.3)	1.06	[0.92	1.22]	0.432
Employed	9 (4.7)	1.10	[0.87	1.41]	0.423
Parity
Nulliparous	20 (10.5)	ref
1–3 children	130 (68.0)	0.98	[0.83	1.17]	0.850
At least 4 children	41 (25.5	0.96	[0.79	1.17]	0.708
Number of ANC contacts made
0–4 contacts	137 (71.7)
At least 5 contacts	54 (28.3)	1.15	[1.05	1.26]	0.003	1.11	[1.01	1.21]	0.034**
Timing of 1st ANC contact
1st trimester	57 (29.8)
2nd trimester	131 (68.6)	0.99	[0.90	1.10]	0.907	1.08	[0.97	1.21]	0.152
3rd trimester	3 (1.6)	0.28	[0.10	0.74]	0.012	0.38	[0.16	0.92]	0.033**
Planned pregnancy
No	94 (49.2)	ref
Yes	97 (50.8)	1.08	[0.98	1.21]	0.126	1.01	[0.92	1.10]	0.856
Awareness of the importance of retesting
No.	5 (2.6)	ref
Somewhat, I need more information	29 (15.2)	1.71	[0.83	3.53]	0.143	1.14	[0.59	2.23]	0.658
Yes, I understand its importance	157 (82.2)	2.44	[1.23	4.87]	0.011	1.58	[0.83	2.99]	0.159
Accompanied by Spouse to ANC
No	167 (87.4)	ref
Yes	24 (12.6)	1.14	[1.03	1.26]	0.009	1.18	[1.05	1.28]	0.007**

^*p value<0.05

^**p value<0.01

At the bivariate level, mothers with secondary education were significantly associated with an increased prevalence of HIV retesting based on national guidelines [CPR 1.88, 95% CI 1.10–3.18, p = 0.02]. Similarly, mothers with tertiary education had a two-fold higher prevalence of retesting [CPR 2.00, 95% CI 1.18–3.38, p = 0.01] compared to those with no formal education. Attending at least 5 ANC visits was positively associated with HIV retesting [CPR 1.15, 95% CI 1.03–1.26, p = 0.003], while initiating the first ANC visit in the third trimester showed a decreased prevalence [CPR 0.28, 95% CI 0.10–0.74, p = 0.03]. Additionally, awareness of the importance of retesting was associated with a higher prevalence [CPR 2.44, 95% CI 1.23–4.87, p = 0.01] compared to those unaware while women accompanied by their spouse had a higher prevalence of retesting [CPR 1.14, 95% CI 1.03–1.26, p = 0.009].

At the multivariate level, secondary education was associated with a higher prevalence of retesting [APR 1.55, 95% CI 1.03–2.34, p = 0.04], while tertiary education further increased this likelihood [APR 1.72, 95% CI 1.10–2.61, p = 0.01]. Attending at least 5 ANC visits remained positively associated [APR 1.11, 95% CI 1.01–1.21, p = 0.03] while being accompanied by a spouse was significantly associated with increased retesting [APR 1.18, 95% CI 1.05–1.28, p = 0.007]. Conversely, starting ANC in the third trimester was linked to a reduced prevalence of retesting [APR 0.38, 95% CI 0.16–0.92, p = 0.03]. These findings are summarized in Table 3.

Facilitators and Barriers to maternal HIV retesting for pregnant women attending care in selected health facilities in the Namutumba district

Maternal HIV retesting during pregnancy is vital for timely HIV detection and management, reducing mother-to-child transmission, and improving health outcomes. While barriers hinder retesting, facilitators enhance willingness and ability, offering insights to inform strategies for improving retesting rates.

Eight key themes emerged from the qualitative data, highlighting barriers and facilitators of maternal HIV retesting. Barriers included stockouts of testing kits, stigma, gender-based violence, human resource constraints, and documentation challenges. Facilitators included health education and counseling, incentives, and community sensitization and outreach programs. These themes provide a comprehensive understanding of the factors influencing maternal HIV retesting in the study context.

Facilitators of maternal HIV retesting

Theme 1: health education and counseling

Health education talks delivered to antenatal care (ANC) attendees were highlighted as crucial for raising awareness about the importance of HIV testing and retesting during pregnancy. These talks empowered women to make informed decisions and alleviated fears and misconceptions about HIV testing and treatment. Comprehensive counselling services, particularly those conducted in a friendly and approachable manner, helped women understand the critical role of retesting in preventing mother-to-child HIV transmission. Strengthening education efforts at both the facility and community levels was seen as a key strategy to promote maternal HIV retesting.

"Health talks for mothers about the importance of HIV testing and retesting during pregnancy and coming with a spouse provides an advantage since you are attended to first and receive the HIV testing services as a couple." (KII2, HIV Counsellor HCIII )

Theme 2: community sensitization and outreach

Community sensitization programs and outreach activities were identified as effective ways to address barriers to maternal HIV retesting. These initiatives raised awareness among women, families, and communities about the health benefits of retesting, thereby increasing its demand and acceptance. Participants emphasized the importance of engaging community leaders and influencers to reduce stigma and foster a supportive environment for HIV testing.

"Carrying out community outreaches as VHTs go into the community to sensitize and mobilize them on the type of service being offered helps. We go into the community for HTS [HIV Testing Services] activities when they are already aware of our arrival and what services will be provided." (KII4, Mentor Mother HCIV)

Theme 3: incentives and motivation

Providing material incentives, such as food packages, baby supplies, mosquito nets, or hygiene kits, served as a strong motivator for women to undergo HIV retesting. Emotional support from peer groups also encouraged participation, as sharing experiences with other women reduced fear and anxiety associated with retesting.

"The provision of mosquito nets to mothers during their first ANC visit motivates them to return, hoping to receive another net when retested." (KII7, Midwife HCIII)

Barriers to maternal HIV retesting

Theme 4: stockouts of HIV testing kits

Participants frequently cited the unavailability of HIV testing kits as a significant barrier. Stockouts resulted in missed opportunities to identify new infections and prevent mother-to-child transmission. Health workers often prioritized first-time ANC attendees, leaving those requiring retesting underserved.

"Sometimes we run out of HIV testing kits. A mother is supposed to be retested, but the kits are either not enough or unavailable." (KII5, Midwife HCIII)

Theme 5: stigma

Stigma emerged as a major barrier, with women fearing judgment or discrimination from their partners, families, and communities if they tested positive. Concerns about social consequences, such as relationship strain or changes in social dynamics, deterred many from retesting. Misconceptions about testing accuracy and fear of the procedure further compounded these challenges.

"Some mothers fear the outcome of the results, especially if they already had an initial test. Others come only once for ANC and deliver at home." (KII8, HIV Counselor HCIII)

Theme 6: gender-based violence (GBV)

Gender dynamics and instances of GBV hindered maternal HIV retesting. Male partners sometimes refused to allow their wives to be tested, asserting control over health decisions and creating a hostile environment for testing.

"Some women refuse to be tested because they don’t have their partner's consent. If we test the wife without his approval, he might divorce her. This is a challenge for us as health workers." (KII4, Mentor Mother HCIII)

Theme 7: human resource constraints

Inadequate staffing at healthcare facilities resulted in long wait times and reduced access to maternal HIV retesting services. Overworked health workers faced burnout, which affected the quality of care provided.

"The human resource versus patient ratio is limited. We get many patients, but we are very few. One person is expected to support a cesarean section in the theater while also attending to pregnant women for retesting." (KII5, Midwife HCIV)

Theme 8: documentation challenges

Incomplete or inaccurate documentation emerged as a significant barrier to tracking retesting. Poor record-keeping practices, including loss of files and errors in data entry, led to missed follow-ups and reduced opportunities for timely interventions.

"The challenge is poor recording. Even though some mothers are retested, some midwives fail to code well in the antenatal register. Others have a negative attitude toward retesting because it involves a lot of documentation." (KII10, Midwife HCIII)

Discussion

The study assessed the proportion of maternal HIV retesting during pregnancy or labor in line with Uganda’s Ministry of Health (MOH) guidelines (2022). The guidelines recommend that every HIV-negative pregnant woman should retest in the third trimester, during labor, or shortly after delivery. This study found that approximately 8 out of 10 mothers in Namutumba district adhered to HIV retesting, reflecting high compliance. However, health system challenges, including frequent stockouts of testing kits, poor documentation, and human resource constraints, hindered achieving full compliance.

Despite limited literature on maternal HIV retesting during pregnancy or postpartum in Uganda, the study's findings align with regional trends. For instance, in Mozambique, 84.8% of HIV-negative women retested during follow-up ANC visits [19]. Although this is below the e-MTCT goal of 95%, the retesting rate in Namutumba district (85%) was significantly higher than the rates reported in Tanzania (30%) and Zambia (25%) [7];[8]. The relatively high compliance in this study can be attributed to Uganda’s robust implementation of integrated HIV testing services (HTS) in antenatal care (ANC) settings. Nonetheless, efforts should focus on scaling up maternal HIV retesting to meet the e-MTCT target of 100%, particularly addressing disparities among healthcare facilities.

Maternal HIV retesting plays a critical role in preventing mother-to-child transmission (MTCT) of HIV by enabling early detection and continuous monitoring of HIV status, thereby reducing transmission risks to newborns [12]. The study revealed significant associations between maternal characteristics and HIV retesting. Mothers with at least secondary education were more likely to retest than those without formal education, likely due to better understanding and internalization of HIV counseling messages. This finding aligns with research showing that higher education levels correlate with improved health service utilization [20]. Similarly, mothers with more than four ANC visits were more likely to retest, as frequent visits allow adequate time for follow-up testing and reinforce health messages. Conversely, late ANC booking in the third trimester reduced retesting prevalence by 62%, highlighting the need for early ANC initiation to enhance testing opportunities [9, 21].

Spousal accompaniment to ANC or delivery increased retesting prevalence by 18%. Studies from Uganda, Ethiopia, Kenya, and Tanzania support the role of partner involvement in improving reproductive health service uptake, including HIV testing [22, 23]. However, only 11% of mothers in this study were escorted by their spouses, underscoring the need to explore barriers to male partner involvement in future research.

Facilitators of Maternal HIV Retesting

Health education and counseling emerged as critical facilitators, helping women understand the importance of repeat testing and reducing stigma. Community-based initiatives, such as sensitization campaigns and outreach, further increased awareness and access to testing services. These findings align with studies highlighting the role of community mobilization in promoting maternal retesting [5, 24].

Incentives and motivational strategies also played a significant role. Financial incentives, for instance, led to increased retesting rates in Uganda and Ecuador [25, 26]. However, these strategies should complement community-based approaches and positive provider-client interactions to maximize their impact [27].

Barriers to Maternal HIV Retesting

Stockouts of HIV testing kits emerged as a critical barrier. Providers often prioritized initial tests for pregnant women over retests during shortages, leading to missed opportunities for early HIV detection. These findings are consistent with research emphasizing the importance of maintaining reliable supply chains for testing kits [6]. Strategies such as HIV self-testing could mitigate the impact of stockouts by ensuring consistent access for both mothers and their partners.

Stigma was another significant barrier. Women reported fear of unintended HIV status disclosure, partner rejection, and discrimination, consistent with findings from Tanzania and other settings [28, 29]. These fears undermine access to PMTCT services and emphasize the need for stigma-reduction interventions and enhanced confidentiality in service delivery.

Gender-based violence (GBV) further limited access to HIV retesting, with some male partners denying consent for testing. This aligns with evidence linking GBV to poor reproductive health outcomes and underscores the importance of integrating GBV screening and support services into ANC settings [30, 31]. However, barriers such as inadequate training and resources for addressing GBV in healthcare settings must be addressed [32].

Human resource constraints, including staff shortages and high patient volumes, hindered consistent maternal retesting. Similar challenges have been reported in Kenya, where only 77% of women were retested during pregnancy or postpartum [6]. Addressing these constraints requires optimizing staff allocation and integrating task-shifting approaches.

Documentation challenges also limited the ability to track retesting adherence accurately. In Mozambique, for example, the absence of unique health identifiers complicated tracking women across facilities, leading to gaps in retesting data [19]. Improving documentation systems and leveraging digital health solutions could enhance data accuracy and program monitoring.

Study strengths and limitations

Strength

The triangulation of data sources and methods was a strength of our study. Indeed, our data was obtained using two methods (KIIs, and quantitative) and from a diverse range of participants at various levels. This provided a comprehensive range of varied insights and perspectives on the barriers and facilitators to maternal HIV retesting.

Limitations

The study was conducted in public health facilities, excluding pregnant women who attended antenatal care or delivered in private health facilities within Namutumba, limiting generalizability as HIV testing and retesting patterns may differ between public and private settings. Additionally, as a cross-sectional study, it does not establish causal relationships between the factors and compliance with maternal HIV retesting. The study primarily used the Health Belief Model, which focused on individual perceptions of compliance, but did not fully address systemic factors such as staffing shortages, documentation issues, and supply chain problems, which also influenced compliance. Future research could integrate additional frameworks to capture these contextual factors more comprehensively. Furthermore, the study did not include perspectives from doctors, nurses, or patients, focusing instead on health workers like midwives, counselors, and mentor mothers. While these health workers were directly involved in the retesting process, incorporating a broader range of perspectives could provide a more holistic understanding of the challenges and opportunities related to maternal HIV retesting. Despite these limitations, the study offers valuable insights into maternal HIV retesting in lower-tier health facilities in Namutumba district.

Conclusions and Implications

At least 8 in 10 expectant mothers were retested for HIV during the third trimester, labor, or shortly after delivery, aligning with HIV testing policy guidelines. However, this falls short of the 100% retesting rate recommended by the WHO. Higher education levels and attending at least five antenatal care (ANC) visits were associated with higher retesting rates, while starting ANC in the third trimester was linked to lower retesting rates. Barriers to maternal HIV retesting included stockouts of testing kits, stigma, human resource constraints, and documentation challenges. Health education, counseling, incentives, community sensitization, and outreach were identified as facilitators for improving retesting rates.

To address these gaps, public health facilities in Namutumba should be empowered to scale up maternal HIV retesting to meet the Ministry of Health and WHO's target of 95% for the elimination of mother-to-child transmission (MTCT) of HIV. Authorities should prioritize interventions aimed at increasing retesting uptake among women with lower education levels and promote early ANC attendance to ensure more opportunities for retesting.

The Ministry of Health should also address barriers such as test kit shortages and the lack of trained staff in clinics, ensuring the continuous supply of testing kits, especially in remote and underserved areas. Strengthening supply chains and improving human resources at health facilities are critical to overcoming these challenges and improving maternal HIV retesting compliance.

Authors' contributions

S.M., conceived the idea. E.B., and E.B., conceptualized the study design. S.M., led the process of acquiring the datasets, refining, and guiding the data analysis plan. S.M., led the analysis, S.M., led the interpretation of the results and development of the draft manuscript. E.B., E.B., reviewed the manuscript and provided critical feedback on the study design and the refining of the final version of the manuscript. S.M., E.B., and E.B., refined the final manuscript and responded to journal and review comments. All authors reviewed and approved the final manuscript.

Funding

The United States Agency for International Development (USAID)) supports the Local Partner for Health Services in East Central Uganda under the prime Makerere University Joint AIDS program. However, no funding was received for this work. The content of the article is the responsibility of the authors alone and does not necessarily reflect the views of USAID, the United States government, Makerere University Joint AIDS program.

Data availability

The data that support these findings are available from the corresponding author upon reasonable request.Interested parties should contact the corresponding author at malshafnvc@gmail.com

Declarations

Ethics approval and consent to participate

Ethical approval for this study was sought from the Makerere University School of Public Health Research and Ethics Committee. All participants provided informed consent before taking part in the study. The consent process adhered to ethical guidelines and was approved by the Makerere University School of Public Health Research and Ethics Committee, ensuring that participants were thoroughly informed about the study's purpose, procedures, and any potential risks.

Administrative clearance to access the study participants was obtained from the district health office of Namutumba district and the administration of respective health facilities. All collected data were handled with confidentiality. All interviews were conducted with consideration of the participant’s privacy. Participants were reassured of confidentiality and anonymity. This was enhanced by identifying a quiet and convenient place within each of the study health facilities for interviews. There were no major risks associated with this study and all participants were informed about any potential risks that would arise. There were no direct benefits attached to this study and all participants were informed prior to consenting to participate in this study.

Consent for publication

Not applicable

Competing interests

The authors declare no competing interests.