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. 2021 Jun 11;16(6):e0253164. doi: 10.1371/journal.pone.0253164

Knowledge about mother to child transmission of HIV/AIDS, its prevention and associated factors among reproductive-age women in sub-Saharan Africa: Evidence from 33 countries recent Demographic and Health Surveys

Achamyeleh Birhanu Teshale 1,*, Zemenu Tadesse Tessema 1, Adugnaw Zeleke Alem 1, Yigizie Yeshaw 1,2, Alemneh Mekuriaw Liyew 1, Tesfa Sewunet Alamneh 1, Getayeneh Antehunegn Tesema 1, Misganaw Gebrie Worku 3
Editor: Pande Putu Januraga4
PMCID: PMC8195361  PMID: 34115798

Abstract

Background

In sub-Saharan Africa (SSA) 90 percent of babies acquired HIV/AIDS from infected mothers. Maternal knowledge about mother to child transmission (MTCT) of HIV/AIDS and its prevention is a cornerstone for elimination of MTCT of HIV/AIDS. Despite this, there is limited evidence about knowledge about MTCT of HIV/AIDS and its prevention and associated factors in SSA. Therefore, this study aimed to assess knowledge of MTCT of HIV/AIDS, its prevention (PMTCT) and, associated factors among reproductive-age women in sub-Saharan Africa.

Objective

To assess Knowledge about mother to child transmission of HIV/AIDS and its prevention and associated factors among reproductive-age women in Sub-Saharan Africa.

Methods

The recent SSA countries’ Demographic and Health Surveys (DHS), which were conducted from 2008/09 to 2018/19, was our data source. We appended 33 countries’ DHS data for our analysis. For our study, a total weighted sample of 350,888 reproductive-age women was used. Due to the hierarchical nature of the DHS data, we conducted a multilevel analysis. Finally, the adjusted odds ratio with its 95% confidence interval was reported, and variables with p-value≤0.05 were considered as significant predictors of knowledge of MTCT of HIV/AIDS and its prevention.

Results

In this study, 56.21% (95% CI: 56.05–56.38) of respondents had correct knowledge about MTCT of HIV/AIDS and its prevention among reproductive-age women in SSA. In the multilevel logistic regression analysis: being in the older age group, better education level, being from a rich household, having mass media exposure, having parity of one and above were associated with higher odds of knowledge about MTCT of HIV/AIDS and its prevention. However, being perceiving distance from the health facility as a big problem was associated with lower odds of knowledge about MTCT of HIV/AIDS and its prevention.

Conclusion

Knowledge about MTCT of HIV/AIDS and its prevention among reproductive-age women in SSA was low. Therefore, it is better to consider the high-risk groups during the intervention to increase awareness about this essential public health issue and to tackle its devastating outcome.

Background

Morbidity and mortality due to human immunodeficiency virus (HIV) infection have decreased worldwide over the past decade due to preventive programs such as increased coverage of antiretroviral therapy (ART) and prevention of mother-to-child transmission (MTCT) of HIV/AIDS [1]. Prevention of mother-to-child transmission (PMTCT) program has prevented approximately 1.4 million new childhood HIV infections and is a major contributor to the elimination of new HIV infections in low- and middle-income countries [2,3].

In the era of Option B+, initiation of antiretroviral therapy for all pregnant mothers to PMTCT of HIV/AIDS, a larger number of women living with HIV (WLHIV) are on ART and while more than 70% of WLHIV are on ART during pregnancy in most SSA countries. However, there are still gaps to improve uptake and adherence of ART [3]. Early intiation ART can suppress maternal viral load, and each additional week of ART during the antenatal period will reduce MTCT of HIV by 20% [4–6]. About 50% of the 180,000 new pediatric HIV infections in 2017 were infected during breastfeeding and it is estimated that in the absence of any intervention to prevent MTCT, the risk of transmission ranges from 15–45 percent (5–10 percent during pregnancy, 10–20 percent during childbirth, and 10–20 percent via mixed infant feeding) [7]. However, with successful measures, this rate can be decreased to less than 5% [7].

Nearly 90 percent of all children and adolescents living with HIV are in Sub-Saharan Africa (SSA) [8]. Yet, the effect of the epidemic among those populations varies widely throughout the region [8]. Despite substantial improvements in the accessibility of ART, around 7.9 percent of children died in SSA countries [9]. Even though 90 percent of babies who acquire the disease from infected mothers are found in SSA [10], maternal knowledge about MTCT of HIV/AIDS and its prevention is low ranging from 34.9 percent in Ethiopia to 78 percent in Nigeria [11–16].

According to various studies done elsewhere, knowledge about MTCT and PMTCT of HIV/AIDS is correlated with factors such as maternal age, maternal education, wealth status, occupation, marital status, media exposure, and residence [11,12,17–19]. Maternal knowledge about MTCT of HIV/AIDS and its prevention is a cornerstone for elimination of MTCT of HIV. Although the majority of the population in SSA are lived in rural areas with restricted availability and accessibility of health facilities, most of the studies on knowledge about MTCT of HIV/AIDS and its prevention were conducted among available women, such as those who came to the health facility for their antenatal care follow up [20–24]. In addition, up to our knowledge, there is no updated information on this regard using nationally representative data (using the recent DHS surveys) at the SSA scale. Therefore, this study aimed to assess knowledge of MTCT of HIV/AIDS, its prevention (PMTCT), and associated factors among reproductive-age women in 33 sub-Saharan Africa countries.

Methods

Data source and study population

The recent SSA countries Demographic and Health Surveys (DHS), which were conducted from 2008/09 to 2018/19, was our data source. There were 35 countries DHS conducted in the study period. However, we appended 33 countries’ DHS data for our analysis since the two countries (Senegal and Tanzania) DHS had no observation regarding our outcome variable. For our study, a total weighted sample of 350,888 reproductive-age women was used.

Study variables

Outcome variable

The outcome variable in this study was knowledge about MTCT of HIV/AIDS and its prevention (PMTCT). It was a composite score of four different questions: HIV can be transmitted from a mother to her baby during pregnancy (yes/no), HIV be transmitted from a mother to her baby during delivery (yes/no), HIV be transmitted from a mother to her baby by breastfeeding (yes/no), there are special medicines that a doctor or a nurse can give to a woman infected with HIV to reduce the risk of transmission to the baby (yes/no).

Then a woman had correct knowledge if she answers all the four questions correctly (if the woman said yes for all of the questions) and not knowledgeable if she did not give the correct answer for at least one of the questions.

Independent variables

Both individual level and community level independent variables were incorporated in assessing factors associated with knowledge about MTCT of HIV/AIDS and its prevention among reproductive-age women in SSA.

Individual-level variables: maternal age, maternal education, current marital status, household wealth status, religion, employment, mass media exposure (television, newspaper, and/or radio), parity, number of under-five children, and distance from the health facility were incorporated as individual-level factors.

Community-level variables: Residence, community illiteracy level, and community level of non-media exposure were the community-level variables. The two community-level variables (community illiteracy level and community level of non-media exposure) were created by aggregating the individual-level women education and media exposure, respectively, at the cluster level. These community-level variables were categorized as low and high based on the national median value.

Data management and statistical analysis

We extract, recode, and do the analysis using Stata version 14 software. Throughout the analysis, weighting was done to assure the representativeness and non-response rate as well as to get an appropriate statistical estimate (robust standard error) [25]. Due to the hierarchical nature of the DHS data, we conducted a multilevel analysis. In conducting the analysis, we fit four models. The first model (Null model) was fitted without any explanatory variables to assess the variability of the outcome between clusters or to assess the intra-class correlation coefficient (ICC). The second model (Model 2) was done by incorporating individual-level variables only. The third (Model 3) and the fourth (Model 4) models were fitted with community level only and both individual and community level variables respectively. For random effect analysis (to assess the community or cluster level variability of comprehensive knowledge about MTCT and its prevention, ICC and proportional change in variance (PCV) were used. Deviance was used to verify model fitness, and the best-fit model has been deemed a model with the lowest deviance.

To select eligible variables for the multivariable analysis we conducted a bivariable analysis. Those variables with a p-value less than or equal to 0.20 in the bivariable analysis were eligible for the multivariable analysis. Then, in the multivariable analysis, the adjusted odds ratio (AOR) with its 95% confidence interval (CI) was reported, and variables with p-value≤0.05 were considered as significant predictors of knowledge about MTCT of HIV/AIDS and its prevention.

Ethical consideration

Since we were using publicly accessible data, ethical approval was not needed. In addition, this research was considered exempt by the Institute of Public Health, College of Medicine and Health Sciences, University of Gondar Institutional Review Committee. However, by registering or online requesting we have accessed the data set from the DHS website (https:/dhsprogram.com).

Results

Sociodemographic characteristic of respondents

For the final analysis, we used a total weighted sample of 350,888 reproductive-age women. Most of the study participants (9.90%) were from Nigeria (S1 Table). The median age of participants was 28 years with IQR = 21–36 years. The majority (35.78%) of respondents had attended secondary education. Around two-thirds (63.36%) of respondents were currently married and 60.56% were employed. The majority (64.07%) of respondents did not perceive distance from the health facility as a big problem and around three-fourth (73.66%) of the participants had exposure to at least one media (television, newspaper, and/or radio). Regarding place of residence, most (58.37%) of respondents were from rural areas (Table 1).

Table 1. Sociodemographic characteristics of respondents.

Variables Number of respondents (N = 350888) Percentage (%)
Maternal age
    15–19 68959 19.65
    20–24 66145 18.85
    25–29 63156 18.00
    30–34 52412 14.94
    35–39 43311 12.34
    40–44 31518 8.98
    45–49 25387 7.23
Maternal education
    No formal education 92418 26.34
    Primary education 111717 31.84
    Secondary education 125535 35.78
    Tertiary and higher education 21218 6.05
Current marital status
    Married 222308 63.36
    Not married 128580 36.64
Employment
    Employed 212486 60.56
    Not employed 138402 39.44
Wealth index
    Poorest 56010 15.96
    Poorer 62152 17.71
    Middle 66853 19.05
    Richer 76165 21.71
    Richest 89708 25.57
Mass media exposure
    Had exposure 258456 73.66
    Not had exposure 92432 26.34
Distance from the health facility
    A big problem 126076 35.93
    Not a big problem 224812 64.07
Parity
    Nulliparous 91023 25.94
    Primiparous 52144 14.86
    Multiparous 123281 35.13
    Grand multiparous 84440 24.06
Number of under-five children
    None 106337 30.31
    1–2 199719 56.92
    3–6 44832 12.78
Residence
    Urban 146083 41.63
    Rural 204805 58.37
Community illiteracy level
    Low 178650 50.91
    High 172238 49.09
Community-level of media non-exposure
    Low 154130 43.93
    High 196758 56.07
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Knowledge about MTCT of HIV/AIDS and its prevention among reproductive-age women in SSA

Among 350,888 participants, all of them ever heard about HIV/AIDS. About 81.56%, 86.82%, 89.66%, and 78.52% of participants know that HIV can be transmitted during pregnancy, delivery, breastfeeding, and know that there are certain medications to prevent MTCT of HIV/AIDS respectively. However, 56.21% (95% CI: 56.05–56.38) of respondents had correct knowledge about MTCT of HIV/AIDS with great variation between countries ranging from 13.56% in Comoros to 76.02% in Zambia (Tables 2 and S2).

Table 2. Knowledge about MTCT of HIV/AIDS and its prevention among reproductive-age women in SSA.

Knowledge of MTCT and PMTCT Number of respondents (N = 12763) Percentage (%)
1. HIV transmitted during pregnancy
    No 64697 18.44
    Yes 286191 81.56
2. HIV transmitted during delivery
    No 46261 13.18
    Yes 304627 86.82
3. HIV transmitted during breastfeeding
    No 36284 10.34
    Yes 314604 89.66
4. There are drugs to avoid HIV transmission to the child during pregnancy (PMTCT)
    No 75372 21.48
    Yes 275516 78.52
5. Comprehensive knowledge of MTCT and PMTCT
    Knowledgeable 197240 56.21
    Not knowledgeable 153648 43.79
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Factors associated with knowledge about MTCT of HIV/AIDS and its prevention in SSA

Random effect analysis

Table 3 revealed the random effect model and model comparison. In the null model, the ICC was 23%, which showed that 23% of the variation on knowledge about MTCT of HIV/AIDS and its prevention in SSA was attributed due to differences between clusters or communities. In addition, the proportional change in variance (PCV) in the final model revealed that about 38.78% of the variation of knowledge about MTCT of HIV/AIDS and its prevention in SSA was explained by both individual and community-level factors. Regarding model comparison, the fourth model (Model 3) was the best-fitted model since it had the lowest deviance (468,878) (Table 3).

Table 3. Random effect analysis and model comparison in the assessment of factors associated with knowledge about MTCT of HIV/AIDS and its prevention in SSA.
Parameter Null model Model 1 Model 2 Model 3
Community-level variance 0.980 0.930 0.882 0.600
ICC (%) 23.00 22.04 21.15 15.42
PCV (%) Reference 5.10 10.00 38.78
Deviance 474854.22 468901.96 474001.14 468878
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Fixed effect analysis

In the bivariable analysis, all factors were eligible (had p≤0.20) for the multivariable analysis. In the multivariable multilevel analysis, individual-level factors: maternal age, maternal education, household wealth status, mass media exposure, distance from the health facility, and parity were found to be significant factors associated with knowledge about MTCT of HIV/AIDS and its prevention among reproductive-age women in SSA. The odds of having knowledge about MTCT of HIV/AIDS and its prevention was higher among older women as compared to women aged from 15–19 years. The odds of having knowledge about MTCT of HIV/AIDS and its prevention was 1.22 (AOR = 1.22; 95%CI: 1.20–1.25), 1.35 (AOR = 1.35; 95%CI: 1.33–1.38), and 1.41 (AOR = 1.41; 95%CI: 1.36–1.46) times higher among mothers who had primary education, secondary education, and tertiary and higher education respectively as compared to those who did not attend formal education. Mothers from poor, middle, richer, and richest households had 1.07 (AOR = 1.07; 95%CI: 1.05–1.10), 1.15 (AOR = 1.15; 95%CI: 1.12–1.17), 1.22 (AOR = 1.22; 95%CI: 1.19–1.25), and 1.25 (AOR = 1.25; 95%CI: 1.22–1.29) times higher odds of knowledge about MTCT of HIV/AIDS and its prevention as compared to those who were from the poorest household. Mothers who had mass media exposure had 1.10 (AOR = 1.10; 95%CI: 1.09–1.12) times higher odds of knowledge about MTCT of HIV/AIDS and its prevention as compared to their counterparts. Mothers who perceive distance from the health facility as a big problem had 4% (AOR = 0.96; 95%CI: 0.95–0.97) lower odds of knowledge about MTCT of HIV/AIDS and its prevention as compared to their counterparts. The odds of knowledge about MTCT of HIV/AIDS and its prevention was 1.37 (AOR = 1.37; 95%CI: 1.34–1.41), 1.40 (AOR = 1.40; 95%CI: 1.37–1.44), and 1.23 (AOR = 1.23; 95%CI: 1.19–1.28) times higher among Primiparous, multiparous, and grand multiparous mothers respectively as compared to nulliparous mothers (Table 4).

Table 4. Multilevel analysis of factors associated with knowledge about MTCT of HIV/AIDS and its prevention among reproductive-age women in SSA.
Variables Models fitted
Null model Model 1 Model 2 Model 3
AOR(95%CI) AOR(95%CI) AOR(95%CI)
Maternal age
    15–19 1.00 1.00
    20–24 1.22(1.19–1.25) 1.22(1.19–1.25)
    25–29 1.31(1.27–1.35) 1.31(1.27–1.34)
    30–34 1.36(1.32–1.41) 1.36(1.32–1.41)
    35–39 1.40(1.36–1.45) 1.40(1.35–1.45)
    40–44 1.35(1.30–1.40) 1.35(1.30–1.40)
    45–49 1.27(1.22–1.32) 1.27(1.22–1.32)
Maternal education
    No formal education 1.00 1.00
    Primary 1.22(1.20–1.24) 1.22(1.20–1.25)
    Secondary 1.35(1.33–1.38) 1.35(1.33–1.38)
    Tertiary and higher 1.41(1.36–1.46) 1.41(1.36–1.46)
Current marital status
    Married 0.92(0.91–0.94) 0.96(0.92–1.01)
    Not married 1.00 1.00
Employment
    Employed 1.02(1.01–1.03) 1.01(0.98–1.03)
    Not employed 1.00 1.00
Wealth index
    Poorest 1.00 1.00
    Poorer 1.07(1.05–1.10) 1.07(1.05–1.10)
    Middle 1.15(1.12–1.18) 1.15(1.12–1.17)
    Richer 1.23(1.20–1.26) 1.22(1.19–1.25)
    Richest 1.27(1.24–1.30) 1.25(1.22–1.29)
Mass media exposure
    Had exposure 1.10(1.09–1.12) 1.10(1.09–1.12)
    Not had exposure 1.00 1.00
Distance from the health facility
    A big problem 0.96(0.94–0.97) 0.96(0.95–0.97)
    Not a big problem 1.00 1.00
Parity
    Nulliparous 1.00 1.00
    Primiparous 1.37(1.34–1.41) 1.37(1.34–1.41)
    Multiparous 1.41(1.37–1.45) 1.40(1.37–1.44)
    Grand multiparous 1.23(1.19–1.28) 1.23(1.19–1.28)
Number of under-five children
    None 1.00 1.00
    1–2 0.99(0.98–1.01) 0.99(0.98–1.01)
    3–6 0.92(0.90–0.95) 0.96(0.90–1.01)
Residence
    Urban 1.00 1.00
    Rural 0.81(0.80–0.82) 0.98(0.96–1.01)
Community illiteracy level
    Low 1.00 1.00
    High 0.98(0.89–1.08) 0.99(0.90–1.10)
Community-level of mass media non-exposure
    Low 1.00 1.00
    High 1.03(0.94–1.13) 1.09(0.99–1.21)
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Discussion

This study aimed to assess Knowledge about maternal to child transmission of HIV/AIDS and its prevention and associated factors among reproductive-age women in SSA. In this study, 56.21% of respondents had correct knowledge about MTCT of HIV/AIDS and its prevention. This finding is lower than a study done in Zimbabwe, Tanzania, Nigeria, and the United States of America [12–14,16]. However, the finding of our study is higher than studies done in Ethiopia and Uganda [11,15,17]. This discrepancy may be because this study was based on the pooled analysis, which incorporates SSA countries. In addition, the difference in the study period and the study population might be the other reason.

In the multilevel analysis, individual-level variables such as maternal age, maternal education, wealth index, media exposure, distance from the health facility, and parity were significantly associated with knowledge about MTCT of HIV/AIDS and its prevention. Being an older age group was associated with higher odds of knowledge about MTCT of HIV/AIDS and its prevention compared to younger aged women (women aged 15–19 years). This is in line with a study done in Zimbabwe [12]. This may be attributed to the proximity of older women during their consecutive pregnancy to various maternal health services. Besides, this might indicate strategies to support younger women (adolescents) to increase awareness of HIV transmission and reduce MTCT and support ART adherence and viral suppression are not adequate [7].

Educated mothers had higher odds of knowledge about MTCT of HIV/AIDS and its prevention compared to those who had no formal education. This is in concordance with previous studies done elsewhere [11,17,26]. This may be because educated women have more access to different health-related information and can easily understand HIV/AIDS and its MTCT.

The study at hand also revealed that being from households with good socioeconomic status had higher odds of knowledge about MTCT of HIV/AIDS and its prevention as compared to their counterparts. This is in line with studies conducted in Ethiopia and Tanzania [11,27]. The greater level of awareness among women from households with good socioeconomic status could be due to their easy access to maternal health services such as PMTCT programs.

In this study, being having exposure to mass media was associated with higher odds of knowledge about MTCT of HIV/AIDS and its prevention as compared to their counterparts. This is congruent with a study done in Ethiopia [11]. This means, to eliminate MTCT of HIV, it is necessary to give special attention to illiterate and poor women in PMTCT services and touch them with targeted MTCT and PMTCT messages through various forms of mass media.

Mothers who perceived distance from the health facility as a big problem had higher odds of knowledge about MTCT of HIV/AIDS and its prevention. This may be due to women from remote areas did not have adequate access to health facilities [28], which in turn results in lower utilization of maternal health services and other infrastructures such as schooling. This results in mothers to have lower awareness about MTCT of HIV/AIDS and its prevention.

Parity was associated with knowledge about MTCT of HIV/AIDS and its prevention. Consistent with other studies [27,29], in this study, multiparous women had higher odds of knowledge about MTCT of HIV/AIDS and its prevention. This may be because multiparous women may have a greater likelihood of exposure to maternal health services, including HIV testing and counseling services, during their consecutive pregnancy.

This study was based on nationally representative data with appropriate statistical analysis (multilevel analysis). Due to this, it can help policymakers and governmental and non-governmental organizations for taking appropriate interventions. However, the study was not without limitations. First, since it was based on the information available in the survey data some factors that may be associated with the outcome variable such as quality and availability of health services and knowledge about HIV/AIDS were not assessed. Second, since it was based on the survey data we are unable to show the temporal relationship between the outcome variable and the incorporated independent variables. Furthermore, we used DHS conducted during the previous ten years, and there could be changes in awareness of MTCT and ART regimens, as well as ART uptake prior to and during pregnancy (Option B+) over time. Therefore, caution is required during the interpretation of the study results.

Conclusion

Knowledge about MTCT of HIV/AIDS and its prevention among reproductive-age women in SSA was low. In the multilevel analysis, older age, being attending primary and above education, from rich households, having mass media exposure, perceiving distance from the health facility as not a big problem, and parous women were associated with higher odds of knowledge about MTCT of HIV/AIDS and its prevention. Therefore, it is better to consider the high-risk groups during the intervention to increase awareness about this essential public health issue and to tackle its devastating outcomes.

Supporting information

S1 Table. Percentage distribution of study participants by country.

(DOCX)

Click here for additional data file. (12.9KB, docx)
S2 Table. Prevalence of knowledge about mother to child transmission of HIV/AIDS and its prevention among reproductive age women in Sub-Saharan Africa.

(DOCX)

Click here for additional data file. (13.1KB, docx)

Acknowledgments

Our sincere gratitude and appreciation go to the MEASURE DHS PROGRAM for enabling us to use the data sets.

Abbreviations

AIDS

Acquired Immune Deficiency Syndrome

AOR

Adjusted Odds Ratio

CI

Confidence Interval

DHS

Demographic and Health Surveys

HIV

Human Immune Deficiency Virus

ICC

Intra-class Correlation Coefficient

MTCT

Mother to child Transmission

PMTCT

Prevention of Mother to Child Transmission

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Pande Putu Januraga

21 Apr 2021

PONE-D-20-37111

Knowledge about mother to child transmission of HIV/AIDS, its prevention and associated factors among reproductive-age women in sub-Saharan Africa: Evidence from 33 countries recent Demographic and Health Surveys

PLOS ONE

Dear Dr. Teshale,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 05 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Pande Putu Januraga, M.D., DrPH

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to provide an input to this manuscript. This is a really interesting study which could fill the gap regarding PMTCT knowledge and its prevention among reproductive age women in SSA.

Minor changes to manuscript is recommended as follow:

Abstract:

Line 31: “conducted from 2008/19 to 2018/19” : is it the correct period?

Line 33: “a multilevel analysis”. Please elaborate more on this. Please also include the information regarding potential associated factors included in the analysis.

Background:

Line 59 “50 percent of the 180,000 new 60 pediatric HIV infections were infected in 2017”. What does this supposed to mean?

Line 60 : ‘it is estimated that in the absence of any 61 intervention to prevent MTCT, the risk of transmission ranges from 15-45 percent (5-10 percent 62 during pregnancy, 10-20 percent during childbirth, and 10-20 percent via mixed infant feeding).”.Can you provide a reference for this statement?

Line 64 : “Nearly 90 percent of all children and adolescents living with HIV are in Sub-Saharan Africa (SSA).”any reference for this?

Line 74: “Although the majority of the population in SSA are lived in rural areas with restricted 75 availability and accessibility of health facilities, most of the studies on knowledge about MTCT of 76 HIV/AIDS and its prevention were conducted among available women, such as those who came 77 to the health facility for their antenatal care follow up”. Can you provide a reference for this?

Also , how your study is different compare to references that you have provided on line 200 -202.

Methods

Line 84: “Demographic and Health Surveys (DHS), which were conducted from 85 2008/19 to 2018/19, was our data source”. I this the correct period?

Line 116: “weighting was done to assure the representativeness and non-response rate as well as to get an 117 appropriate statistical estimate (robust standard error)”. Can the authors elaborate more on this?

Line 120 : ‘to assess the variability of 120 the outcome between clusters”. What are the clusters?

Line 123 : “Deviance was used to verify model fitness, and the best-fit model has been 124 deemed a model with the lowest deviance”. Please mention the results of this analysis in the result section.

Results:

Line 161: “the random effect model and model fitness/comparison”. The authors did not mention the use of random effect analysis in the method section. If the authors used random effect analysis, what was the cluster being used?

Discussion:

The discussion section has been really interesting but would have been better if the author also relates the results with the current policy and programs implemented in SSA.

What are the overall results telling us about what should be done in general, to address the issues?

Reviewer #2: This manuscript evaluates knowledge of PMTCT among more than 350,000 women of reproductive age in 33 countries in SSA using DHS data. The results evaluate “comprehensive knowledge of PMTCT” based on correct responses to all four questions included in the DHS data. Overall, the majority (≥80%) of women responding to the individual questions were correct, yet combined, this was 56% on all 4 questions.

While the authors set out to use “recent DHS surveys”, some of the DHS data are fairly old (2008/09) and both knowledge of MTCT and ART regimens and uptake of ART prior to and during pregnancy (Option B+) has significantly changed compared to DHS data since 2014/15 or more recently. I would recommend the authors consider including only those countries with DHS data in the past 5-6 years to better represent recent knowledge and prevention of MTCT. This may reduce the number of countries included in the analysis, but will better reflect current knowledge, which is important.

• Lines 57-63 state that “most pregnant women are unwilling to participate in the program,...” and focuses on transmission risk during breastfeeding among women not on ART. I would restate this to reflect that in the era of Option B+ a larger number of women living with HIV (WLHIV) are on ART and while more than 70% of WLHIV are on ART in pregnancy in most SSA countries, there are still gaps to improve uptake and adherence of ART. Also important to include the importance of viral suppression and timing of ART initiation in the perinatal period as it relates to MTCT risk. Lastly, make it clear that the transmission risk during breastfeeding is among women not on ART.

• In the discussion, it would be helpful to incorporate results from studies that have tried the strategies to reduce MTCT and raise awareness to add to the statements of what should be done. For instance, adding to lines 211-213, in many countries in SSA there are targeted strategies to support younger women (adolescents) to increase awareness of HIV transmission and reduce MTCT and support ART adherence and viral suppression. Moreover, lines 225-227 regarding mass media, what have studies using mass media shown in terms of increasing awareness of HIV in the community? These data would strengthen the discussion in alignment with your results.

**********

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Reviewer #1: No

Reviewer #2: No

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Jun 11;16(6):e0253164. doi: 10.1371/journal.pone.0253164.r002

Author response to Decision Letter 0

29 Apr 2021

Date: April 29, 2021

Response to editor and reviewer comment

Title: Knowledge about mother to child transmission of HIV/AIDS, its prevention and associated factors among reproductive-age women in sub-Saharan Africa: Evidence from 33 countries recent Demographic and Health Surveys

Manuscript number: PONE-D-20-37111

Dear editor and reviewer, thank you for your comment and suggestions. We have considered all your comments and suggestions in the revised manuscript. Here, below, is the point-by-point response for the issues raised by the editor and reviewers.

Thank you

Response to editor comment

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Authors’ response: Thank you. We have confirmed that the revised manuscript meets PLOS ONE's style requirements, including those for file naming

Response to reviewers comment

Response to Reviewer #1:

1. Abstract:

Line 31: “conducted from 2008/19 to 2018/19” : is it the correct period?

Authors’ response: Thank you very much. It was to mean 2008/09 to 2018/19 and we have corrected it in the revised manuscript.

Line 33: “a multilevel analysis”. Please elaborate more on this. Please also include the information regarding potential associated factors included in the analysis.

Authors’ response: Dear reviewer. Thank you very much for your comment. However, the detailed methodology regarding the multilevel analysis and the potential associated factors included in the analysis are found in the methods section. If we put what you have recommend in the abstract, the word of the abstract will be above 350 and this is not possible according to the PLoS ONE Journal.

2. Background:

Line 59 “50 percent of the 180,000 new 60 pediatric HIV infections were infected in 2017”. What does this supposed to mean?

Authors’ response: Thank you. We have rewritten it to read, “About 50% of the 180,000 new pediatric HIV infections in 2017 were infected during breastfeeding”.

Line 60 : ‘it is estimated that in the absence of any intervention to prevent MTCT, the risk of transmission ranges from 15-45 percent (5-10 percent 62 during pregnancy, 10-20 percent during childbirth, and 10-20 percent via mixed infant feeding).” Can you provide a reference for this statement?

Authors’ response: Thank you. We have provided the reference.

Line 64 : “Nearly 90 percent of all children and adolescents living with HIV are in Sub-Saharan Africa (SSA).”any reference for this?

Authors’ response: Thank you. We have provided the reference in the revised manuscript.

Line 74: “Although the majority of the population in SSA are lived in rural areas with restricted 75 availability and accessibility of health facilities, most of the studies on knowledge about MTCT of HIV/AIDS and its prevention were conducted among available women, such as those who came to the health facility for their antenatal care follow up”. Can you provide a reference for this? Also , how your study is different compare to references that you have provided on line 200 -202.

Authors’ response: Thank you. We have cited the above statement in the revised manuscript. Our study is different from other studies, especially those indicated/cited on line 200-202 since this study is based on pooled data from SSA countries. The other studies were conducted in individual countries (they represent a single country) and they may not represent the whole SSA for policymakers and for governmental and non-governmental organizations to take appropriate intervention.

3. Methods

Line 84: “Demographic and Health Surveys (DHS), which were conducted from 85 2008/19 to 2018/19, was our data source”. Is this the correct period?

Authors’ response: Thank you. It was typing error and in the revised manuscript, we have amended to read, 2008/09 to 2018/19.

Line 116: “weighting was done to assure the representativeness and non-response rate as well as to get an appropriate statistical estimate (robust standard error)”. Can the authors elaborate more on this?

Authors’ response: Thank you. Sampling weights are adjustment factors applied to each case in tabulations to adjust for differences in probability of selection and interview between cases in a sample. However when standard errors, confidence intervals or significance testing is required, then it is important to take into account the complex sample design of the DHS data. For the complex sample design, it is necessary to know three pieces of information – the primary sampling unit or cluster variable, the stratification variable, and the weight variable. To apply the complex sample design parameters in estimating indicators, each of the statistical software use a different set of commands and for this study we used Stata svyset and svy commands. Therefore, we have applied weighting using v005 (weight=v005/1000000) to assure representativeness and we have accounted complex sample design (using the above stata command) to get appropriate statistical estimate. Dear reviewer, we have incorporated only important advantages with reference and if we incorporate all the issues regarding weighting in the main manuscript, it may distort our method section. Therefore, in the revised manuscript, we have cited this issue in the method section for readers who need further explanation.

Line 120 : ‘to assess the variability of the outcome between clusters”. What are the clusters?

Authors’ response: Thank you. All the DHS data have cluster number represented by v001. Cluster means Enumeration areas. For example, there are 645 (202 in urban areas and 443 in rural areas) clusters/EAs for the 2016 EDHS data and overall in sub-Saharan Africa there are 1612 clusters/EAs.

Line 123 : “Deviance was used to verify model fitness, and the best-fit model has been deemed a model with the lowest deviance”. Please mention the results of this analysis in the result section.

Authors’ response: Thank you. We have included it in the random effect analysis section with bracket. Besides, we have incorporated this in table 3.

4. Results:

Line 161: “the random effect model and model fitness/comparison”. The authors did not mention the use of random effect analysis in the method section. If the authors used random effect analysis, what was the cluster being used?

Authors’ response: Thank you. We have mentioned the use of random effect analysis. we have added such information in data management and analysis section “For random effect analysis (to assess the community or cluster level variability of comprehensive knowledge towards MTCT and its prevention), ICC and proportional change in variance (PCV) was used”. Besides, the cluster being used for each country was represented by v001 and 1612 clusters were used at SSA level.

5. Discussion:

The discussion section has been really interesting but would have been better if the author also relates the results with the current policy and programs implemented in SSA.

Authors’ response: Than you. It is difficult to relate/discuss each finding with the policy and programs what exist before (there may not be program before). However, we have tried to relate our findings with current policy and programs in the revised manuscript. Moreover, when concluding our results, we have concluded to the standard of policymakers and responsible bodies in the area.

What are the overall results telling us about what should be done in general, to address the issues?

Authors’ response: Thank you. The overall result tells that ONLY 56.21% of mothers in SSA had comprehensive knowledge AND to increase maternal knowledge towards MTCT and PMTCT; interventions should be targeted to factors at individual level such as those with no formal education, those from remote areas, low socioeconomic status, nulliparous mothers, and those mothers with no access to media.

Response to Reviewer #2:

1. While the authors set out to use “recent DHS surveys”, some of the DHS data are fairly old (2008/09) and both knowledge of MTCT and ART regimens and uptake of ART prior to and during pregnancy (Option B+) has significantly changed compared to DHS data since 2014/15 or more recently. I would recommend the authors consider including only those countries with DHS data in the past 5-6 years to better represent recent knowledge and prevention of MTCT. This may reduce the number of countries included in the analysis, but will better reflect current knowledge, which is important.

Authors’ response: Thank you very much. It is difficult to conclude the findings from four or five countries in SSA to the whole SSA countries. Therefore, we prefer to conduct this study using DHS conducted in the past 10 years, despite its limitations. Dear reviewer, we have acknowledged your issue as limitation of this study in the last paragraph of the discussion section.

2. Lines 57-63 state that “most pregnant women are unwilling to participate in the program,...” and focuses on transmission risk during breastfeeding among women not on ART. I would restate this to reflect that in the era of Option B+ a larger number of women living with HIV (WLHIV) are on ART and while more than 70% of WLHIV are on ART in pregnancy in most SSA countries, there are still gaps to improve uptake and adherence of ART. Also important to include the importance of viral suppression and timing of ART initiation in the perinatal period as it relates to MTCT risk. Lastly, make it clear that the transmission risk during breastfeeding is among women not on ART.

Authors’ response: Thank you. We have accepted your suggestions and comments and we have incorporated them in the revised manuscript.

3. In the discussion, it would be helpful to incorporate results from studies that have tried the strategies to reduce MTCT and raise awareness to add to the statements of what should be done. For instance, adding to lines 211-213, in many countries in SSA there are targeted strategies to support younger women (adolescents) to increase awareness of HIV transmission and reduce MTCT and support ART adherence and viral suppression. Moreover, lines 225-227 regarding mass media, what have studies using mass media shown in terms of increasing awareness of HIV in the community? These data would strengthen the discussion in alignment with your results.

Authors’ response: Thank you. We have considered your comments accordingly.

Attachment

Submitted filename: Response letter.docx

Click here for additional data file. (19.5KB, docx)

Decision Letter 1

Pande Putu Januraga

27 May 2021

PONE-D-20-37111R1

Knowledge about mother to child transmission of HIV/AIDS, its prevention and associated factors among reproductive-age women in sub-Saharan Africa: Evidence from 33 countries recent Demographic and Health Surveys

PLOS ONE

Dear Dr. Teshale,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 11 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Pande Putu Januraga, M.D., DrPH

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Dear Authors,

Thank you for submitting the revised version of the manuscript with responses to the reviewers.

I believe that the authors have responded to the reviewers' comments appropriately. However, I still have minor comments that need to be responded to before a final decision.

Editor comments:

Line 57, for some readers, particularly in non-generalized epidemics context, the option B+ may be difficult to understand; please provide an explanation for the term.

Line 72-74 is only a one-sentence paragraph; please integrate the line into the next paragraph.

All the best,

Pande

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Jun 11;16(6):e0253164. doi: 10.1371/journal.pone.0253164.r004

Author response to Decision Letter 1

29 May 2021

Date: May 28, 2021

Rebuttal letter

Title: Knowledge about mother to child transmission of HIV/AIDS, its prevention and associated factors among reproductive-age women in sub-Saharan Africa: Evidence from 33 countries recent Demographic and Health Surveys

Manuscript number: PONE-D-20-37111R1

Dear editors and reviewers, thank you for your constructive comments and suggestions. Here, below, is the authors’ point-by-point response for the comments raised.

Response to questions regarding Journal Requirements

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Authors’ Response: Thank you for the comment. The author have confirmed that there is no retracted article in the reference list and we have checked and rewritten reference 1 and 2 accordingly (see the revised manuscript).

Response for Additional Editor Comments

Line 57, for some readers, particularly in non-generalized epidemics context, the option B+ may be difficult to understand; please provide an explanation for the term.

Authors’ Response: Option B+ is offering immediate antiretroviral therapy for mothers living with HIV to prevent the vertical transmission HIV/AIDS regardless of their CD4 count. That is, option B+ is initiation of antiretroviral therapy for all pregnant mothers, regardless of their CD4 count, to PMTCT of HIV/AIDS. In the revised manuscript, we have consider such points.

Line 72-74 is only a one-sentence paragraph; please integrate the line into the next paragraph.

Authors’ Response: Thank you. We have considered your comment (we have added the lines into the next paragraph) in the revised manuscript.

Attachment

Submitted filename: Rebuttal letter.docx

Click here for additional data file. (13.4KB, docx)

Decision Letter 2

Pande Putu Januraga

1 Jun 2021

Knowledge about mother to child transmission of HIV/AIDS, its prevention and associated factors among reproductive-age women in sub-Saharan Africa: Evidence from 33 countries recent Demographic and Health Surveys

PONE-D-20-37111R2

Dear Dr. Teshale,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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Kind regards,

Pande Putu Januraga, M.D., DrPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Pande Putu Januraga

3 Jun 2021

PONE-D-20-37111R2

Knowledge about mother to child transmission of HIV/AIDS,  its prevention and associated factors among reproductive-age women in sub-Saharan Africa: Evidence from 33 countries recent Demographic and Health Surveys

Dear Dr. Teshale:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Pande Putu Januraga

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Percentage distribution of study participants by country.

    (DOCX)

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    S2 Table. Prevalence of knowledge about mother to child transmission of HIV/AIDS and its prevention among reproductive age women in Sub-Saharan Africa.

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