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HIV/AIDS awareness and risk behaviour among pregnant women in Semey, Kazakhstan, 2007

HIV/AIDS awareness and risk behaviour among pregnant women in Semey, Kazakhstan, 2007 Background: Central Asia has one of the most rapidly increasing HIV prevalence in the world. The aim of this study was to evaluate current knowledge, risk behaviour and attitudes to voluntary counselling and testing concerning HIV/AIDS among pregnant women in Semey, Kazakhstan. Methods: We collected 226 questionnaires in a consecutive sample from a population on 520 pregnant women. The results were related to ethnicity, age and education level. Results: Ninety-six percent had heard about HIV. Positive findings were that 89% and 86% of the women were aware of the two main routes of transmission: sexual intercourses without a condom and sharing needles while injecting drugs. The women had first heard about HIV/AIDS through the media with, 52%, and at school with 40%. Only 46% and 68% of the women pointed out breastfeeding and mother-to-child transmission during pregnancy or delivery as routes of transmission. Eighty-three percent were prepared not to breastfeed their baby if they were found to be HIV positive. Slightly more, 86%, accepted the need to take medicine, but fewer women, 68%, were positive to Caesarean section. Negative findings were that only 28% answered that there are ways to protect oneself against sexually transmitted HIV/AIDS and specified that this was condom use. Conclusion: The pregnant women in Semey have poor knowledge about specific mother-to-child HIV transmission and do not know about the means of reducing mother-to-child HIV infection. The information in the public health program needs to be improved. However, most of the women in Semey were positive to prevention strategies for mother-to-child transmission after hearing about it. Vertical transmission of HIV from mother-to-child Background Today about 33 million people are living with HIV. Of accounts for the vast majority of the infections among the them 15 million are women and 2.5 million children children. Mother-to-child HIV transmission occurs intrau- under the age of 15 [1]. terine, intra-partum and during breastfeeding. Without Page 1 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 antiretroviral treatment, the risk of an infected woman Methods transmitting the virus to her child is between 16 and 40%. The study was conducted between June 14 and July 25, Breastfeeding contributes at least a 10% risk of transmis- 2007 in Semey, Kazakhstan. We collected 226 question- sion [2]. Timely administration of antiretroviral drugs to naires from a consecutive sample of pregnant women the HIV infected pregnant woman and her newborn sig- attending four different antenatal clinics at different parts nificantly reduces the risk of mother-to-child transmis- of the city. During a year there are around 1000 pregnan- sion [3]. With antiretroviral treatment resulting in low cies in Semey followed at 23 antenatal clinics. At the viral load, no breastfeeding and elective Caesarean the included clinics 520 pregnant women were registered at HIV transmission rate to the child can be reduced to 0–2% the time of the study. [4]. Elective Caesareans are most important for women with high HIV viral loads at the time of delivery. A questionnaire was designed to obtain three areas of interest: sociodemographic characteristics, general aware- Pregnancy has not been proven to have any negative ness of HIV/AIDS and attitudes and risk behaviour. The effects on women with asymptomatic HIV infection [5]. It questionnaire starts out with the sociodemographic ques- seems that advanced HIV infection, however, can increase tions, like age, educational and employment level for the the risk for spontaneous abortion or premature birth [2]. woman and her husband, parity, socio-economic status, religion and ethnical group. In the next part, general In Kazakhstan, 16 500 people are estimated to live with awareness of HIV/AIDS follows questions about if the HIV/AIDS which means a prevalence of 0.1–0.2% [6]. The woman has heard about HIV/AIDS before, and in case of, HIV epidemic is strongly concentrated to vulnerable pop- how she first heard about it, knowledge of route of trans- ulations, like injecting drug users, sex workers and prison- mission, knowledge of HIV prevention and symptoms. ers. In addition to these groups, the epidemic is spreading The third part includes questions concerning if they among other vulnerable groups like youth, migrants and wanted to be tested and if they wanted more children or truck drivers. About three-quarters of the new HIV diag- would be prepared not to breastfeed their baby, to take noses is among unemployed people. Currently the two pills and deliver through Caesarean to prevent HIV trans- main routes of HIV transmission in Kazakhstan are inject- mission to their baby, given they were HIV positive. In ing drug use and sexual transmission. addition, the third part includes questions about whom they would inform if they were tested positive, from Because of the increased involvement of women and chil- whom they would get support and finally questions con- dren in drug use and trafficking, it's likely that the HIV cerning use of condoms, sexual contacts and intravenous prevalence in these groups will rise. There are about 20 drug use. 000–50 000 female sex workers, of whom 30% are intra- venous drug users [7]. According to WHO/UNAIDS report The questionnaire contained three questions about con- in March 2006, there were 1500 people in need of antiret- dom use. The first and second questions about use of con- roviral drugs in Kazakhstan at the end of 2005. Just 15%, dom in steady relationship respectively with casual of those in need, received treatment [8]. partners were designed to assess the women's actual prac- tice of condom. The third question concerning responsi- In recent years efforts has been made to cover all pregnant bility for condom use is a question about the women's women with full prevention services and the mother-to- attitude. child prevention is a big part of the Kazakhstan HIV pro- gramme [6]. In average the number of births in Kaza- The questionnaires were translated to Kazakh and Russian khstan are 237 000 per year. In 2005 the antenatal care and the women were given questionnaires in the language coverage were estimated to 91% and the number of they preferred. women counselled on prevention of mother-to-child transmission (PMTCT) services were 129 706. The The women were informed that their participation and number of HIV infected women was estimated to fewer the completion of the questionnaire were entirely volun- than 500 and of those 47 (9%) received antiretroviral tarily and that they were free not to answer the questions therapy for PMTCT [9]. they found too private. The information given would be stored confidentially and no names or identifying infor- The aim of the study was to evaluate current knowledge, mation would appear in publications. A verbal consent risk behaviour and attitudes to voluntary counselling and was obtained for each participant. In addition to the ques- testing concerning HIV/AIDS among pregnant women in tionnaires, we interviewed 21 of the study participants. In Semey, Kazakhstan. This is important, considering that all interviews an interpreter was necessary; because of this the gateway for prevention of mother-to-child transmis- a local student was always present to help us to ask ques- sion is voluntary counselling and testing for HIV. tions and to take notes. Page 2 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 Open-ended questions were used and the women were General knowledge encouraged to give as much information as they could. Ninety-six percent (215/225) of the women had heard of We were careful not to suggest answers or to ask leading HIV/AIDS. questions. The questions were clustered around the areas: knowledge of differences between HIV and AIDS, living The majority, 52.1% (111/213), of the whole group had with HIV/AIDS, attitudes to people living with HIV/AIDS first heard about it from the media, 40% (85/213) knew and in particular knowledge about mother-to-child trans- it from school, 2.8% (6/213) from their parents, 1.9% (4/ mission and attitudes to voluntary counselling and test- 213) from friends and 3.3% (7/213) from other sources. ing. Two women did not answer this question. The older women (> 30 years old) had significantly more often, Ethical considerations 80% (95% CI 68–91), heard about HIV/AIDS from the The participation in the study was voluntary with media than the younger women at age 20–30 on 47% informed consent. The questionnaire was anonymous (95% CI 39–55). In contrast the younger women (age < with no registration of names, medical data or other per- 20 and 20–30), had significantly more often heard about sonal information. In our manuscript it is not possible to the disease at school, 64% (95% CI 35–92) for women identify individual patients. We have a written decision age < 20 and 46% (95% CI 37–54) for women age 20–30, from the Head of the Ethical Committee at Semey, Kaza- as compared with women with age over 30, for whom the khstan that no further ethical review is required. With the corresponding figure was 16% (95% CI 6–27). Only one anonymous design and no registration of personal sensi- out of the 56 women who correctly answered yes to the tive data, the study does not need to be reviewed by the statement that there are differences between HIV and Swedish Ethical Committee according to their rules. No AIDS was able to specify those differences, but the 21 information was collected from the women who refused women we interviewed with open questions were better at to participate. specifying the differences between HIV and AIDS. Among those who specified, many answers were unclear and dif- ficult to interpret. However, we did obtain some more or Results Study population less correct answers like: "HIV is the causative agent of the A total of 226 pregnant women participated in our study. disease AIDS", "HIV means you are a carrier, while AIDS Their ages ranged from 18 to 47 years, with a mean age of means you are sick" and "with HIV you live longer than 26.8 and a median age of 25. Thirteen women did not with AIDS". answer the question about their age; therefore these Knowledge about transmission and symptoms women were excluded when we referred our results to age. Parity ranged from 0 to 4 children, with a mean of 0.68 To the open question regarding the main way HIV/AIDS and a median of 1 child. Eighteen women did not answer is spread from one person to another many women gave the question about parity. several answers, the most common being "sexual contact" given by 76% (122/160). The second most common Of the 226 women, 76.2% (170/223) were Kazakh, answer was blood transfusion, with 30% (48/160). Nine- 18.4% (41/223) Russian, 2.2% (5/223) Tatar, 1.8% (4/ teen percent (30/160) wrote intravenous drug use/needle 223) German and 1.3% (3/223) others. The three women sharing and 3% (5/160) wrote they didn't know. who did not answer the question about their ethnicity were excluded when we referred our results to ethnicity. To discover misconceptions about transmission about Religion is closely linked with ethnicity. Of the Kazakh HIV/AIDS the women were asked to include/exclude ways women who answered the question about religion, 100% that HIV/AIDS can or not can be transmitted. These were Muslim. Among the Russian women who answered answers, with reference to the women's level of education the question about religion, 93% were Christian Ortho- [see Additional file 2] dox. Of the whole group 79.7% (173/217) were Muslim, 18.9% (41/217) Christian Orthodox and 1.4% (3/217) In general women, with higher levels of education were other. No significant association was found between occu- better than women with low education at correctly exclud- pation and ethnic origin. When it comes to education ing and including transmission routes of HIV/AIDS. The among the women we refer to additional file 1. differences were significant for "shaking hands/hugging/ living in the same house", "changing clothes with some- Russian women significantly more often attended Special one who has HIV/AIDS", "sexual intercourses with con- College (66%; 95% CI 51–80%) compared to 35% (95% dom", and "sharing needles while injecting drugs". For CI 28–41%) for Kazakh women. Kazakh women had a details, see Additional file 2. tendency to more often attend University/Institute/Acad- emy. As many as 76% (157/206) answered correctly, with no, to the statement you can not tell, by looking at a person, Page 3 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 whether he/she is infected with HIV/AIDS. Younger friends and healthcare personnel. Note that the women women (age < 20) significantly more often, 100%, could tick several alternatives. answered no to the statement that by looking at a person you can see if he/she is infected with HIV/AIDS, as com- Attitudes to PMTCT, prevention of mother-to-child pared with women aged 20–30 years, 76% (95% CI 69– transmission 83) and women aged over 30 years, 70% (95% CI 57–84). Seven women said they would want to have more chil- dren even if they were found to be HIV positive. Among The open question "Do you know any symptoms of HIV/ the women who said no to have more children 82% (176/ AIDS" was left blank by 111 women. Of the responders, 216), the main reason given was the risk of infecting the 66% (69/104) answered no. Among the women who baby. Significantly more highly educated women said no, could mention any symptoms the most common answers 87% (95% CI 81–92), to having more children as com- were fever/sub febrile 37% (13/35), loss of immunity pared with the less educated women, 66% (95% CI 53– 34% (12/35), weakness 29% (10/35) and cahexia/weight 79). Of the responders 83%, were prepared not to breast- loss 17% (6/35). When the women's ability to mention feed their baby if they were found to be HIV positive. symptoms of HIV/AIDS were refered to educational level, Somewhat more, 86%, were prepared to take medicine, the women with low education levels significantly more but fewer women, 68%, were prepared to accept Caesar- often, 95% (95% CI 85–100), answered that did not ean section to prevent mother-to-child transmission. know any symptoms, as compared with women with Risk behaviour and protection higher levels of education, 60% (95% CI 50–70). Ninety-six percent (179/186) had had one sexual partner Knowledge about treatment during the last sixth months. The three questions about A total of 14% (28/201) believed that there is a medicine condom use were as follow: "Use of condom in steady to cure HIV/AIDS, and nearly the same number, 15% (30/ relationship?", "Use of condom with casual partners?" 202) stated that there are other ways to cure HIV/AIDS. and "Who has the responsibility for condom use?" Of the Many more, almost one out of three, stated that there are women who answered the first question 21% (42/201) possible ways to slow the progression of the disease. answered always, 40% (80/201) never and 39% (79/201) sometimes. Of the responders to the second question, as Having HIV/AIDS few as 57% (78/137) answered always, 34% (47/137) Of the whole group 41% (88/215) of the women wanted never and 9% (12/137) answered sometimes. to be tested for HIV/AIDS. Fifty-nine percent (124/211) of the women said they would tell the healthcare personnel About two thirds, 68% (141/206), of the women stated if they were found to be HIV positive, 35% (74/211) that that men and women have equal responsibility to make they would tell their mothers and 32% (68/211) their sure a condom is used during sexual intercourses. Of our partners. Fifteen women left the question blank. Statisti- responders 65% (134/206) answered that there are ways cally significantly more Russian women, 51% (95% CI to protect oneself against sexually transmitted HIV/AIDS. 36–66) said they would tell their partner as compared Of the women who answered yes to this question, 55% with the Kazakh women, 26% (95% CI 19–33), but on (74/134) specified ways to protect oneself. Note that the the other hand there was a tendency among the Kazakh women were allowed to give more than one way of pro- women to say more often that they would tell their friends tection. than among the Russian women. There was also a ten- dency for the Russian women to say more often that they The far most common answer was to use condoms, 82% would tell their mothers, but the difference was within the (61/74). Other answers were "avoiding casual sexual con- margins of error. tacts" and "use of clean syringes". When the women were asked if they had sufficient information to protect them- Regarding from whom the women thought they would selves against HIV/AIDS, 42% (89/211) answered no and get support if they were found to be HIV positive, the far nearly the same number, 42% (88/211) answered yes. most common answer was mother, with 51%. Only 45% Russian women answered to a significantly higher degree thought that they would get support from healthcare per- 63% (95% CI 49–78) that they had sufficient information sonnel, and even fewer, 21%, said they would get support compared to Kazakh women 36% (95% CI 28–43). from their fathers, partners 33% or friends 23%. Sixteen HIV epidemic women (7%) did not answer the question. A comparison between Kazakh and Russian women showed that more Of our responders 47% (93/198) answered that certain Russian women expected to get support from mothers and groups of people are more often infected with HIV than partners, while Kazakh women more often mentioned others. The far most common group was drug addicts/ Page 4 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 intravenous drug users, mentioned by 88% (49/56) of the behaviour "sexual intercourse without condom", 89% responders. Other groups, given by less than 10% each, (95% CI 85–93), as compared with 73% (95% CI 67–78) were people with many sexual partners, prostitutes, in Aksu and "sharing needles while injecting drugs", 86% homeless people, homosexual people, medical people, (95% CI 81–90) compared to 55% (95% CI 49–61) in people with low social status, and people without knowl- Aksu as routes of transmission. This is positive because edge about the disease and blood donors/recipients. One these two routes are the most important routes for the misconception was that 11% (6/56) of the responders general population to be aware of. answered that people with poor immune defence sys- tems/organisms are more often infected. The finding that pregnant women in general are aware of the two main routes: sexual intercourse without a condom Discussion and sharing needles while injecting drugs, of HIV trans- The HIV epidemic in Central Asia is continuing to spread mission is in agreement with previous studies [11-13], and has reached Kazakhstan. The number of reported HIV and might not be so surprising since media focus on these cases is still relatively low and mainly concentrated to vul- two main routes in their information to the public. There nerable populations such as intravenous drug users and were more difficulties in excluding incorrect routes of sexual workers. To prevent future spread of the HIV epi- transmission. Almost one fifth though that kissing could demic and to prevent stigmatization in Kazakhstan and be a route of HIV transmission and only 44% answered other countries in Central Asia it is important to evaluate correctly that HIV can not be spread by mosquitoes. This HIV knowledge and to educate the population with cor- is slightly lower than in the Hong Kong study where 57% rect information. answered to mosquitoes as vectors of HIV [14]. The mis- conception about mosquitoes as a transmission route has Knowledge also been seen in other similar studies [10-12] and might It is reassuring to see that only ten women out of 226 did not be very surprising, since HIV is a blood-borne disease. not know there was a disease called HIV or AIDS. This cor- The pregnant women in our study, like the women in a responds to the findings in several other studies concern- similar study conducted in the province Yunnan, China ing awareness about HIV/AIDS among pregnant women [11] excluded, to a higher, but not satisfactory extent daily from India [10], China [11], Papua New Guinea [12] and domestic contacts such as eating from the same plates and Ghana [13]. Compared with the women in Aksu, north- cups, shaking hands, hugging, living in the same house west China, the women in Semey had more often heard of and changing clothes with someone who has HIV/AIDS as about HIV/AIDS. 95% (95% CI 92–98) compared to 85% possible routes of transmission. The fact that a high pro- (95% CI 80–89) in Aksu. It is positive that the media are portion of the women responded "don't know" in addi- a major source of information, exactly as in the Aksu study tion to the women with incorrect answers further and the Papua New Guinea study [12]. That a majority of illustrates their limited knowledge. the women are aware of a disease called HIV/AIDS and that media are a major source of information shows that Our conclusion is, as in the study conducted in Aksu, that the HIV epidemic is discussed in public and that the most of the women know that HIV is a sexually transmit- media are an efficient way of spreading information. In ted disease, but there are still people who have poor addition illiteracy is rare in Kazakhstan, which facilitate knowledge of HIV/AIDS and people with misconceptions for the women to take share of the given information. about how it is spread. These misconceptions may influ- ence the dissemination patterns of HIV and increase the However, it is also important that the information is cor- stigmatization of the HIV positive, as well as giving rise to rect, otherwise misconceptions may lead to further stig- misguided fears. It is essential to continue to raise the level matization. Because the women had difficulties of knowledge of HIV/AIDS through campaigns in the distinguish HIV from AIDS and only 16% could mention media and at schools. One thing that needs to be commu- symptoms of HIV/AIDS, we conclude that the women's nicated is that there is no medicine to cure a HIV infec- knowledge in general was superficial with little under- tion, only 40% (95% CI 33–47) of the women answered standing of the details and the nature of the disease. We correctly that this was the case. This may reflect that the were pleased to find that as many as 76% answered that information about HIV/AIDS in the media focus on risk you can not tell by looking at a person if she/he is infected behaviour and not on possible treatment. In addition the with HIV/AIDS. The younger women, as compared with prevalence of HIV is low in Kazakhstan and few of the the older women, significantly more often answered no to women participating in our study had met or knew any- this question. This may be explained by the fact that now- one with the infection i.e. they have never come across adays students got a lot more information at school. persons under treatment for HIV/AIDS. This is signifi- cantly lower than the corresponding figure for the women The women in Semey were, as compared with the women in the Hong Kong study, where 79% (95% CI 73–84) in Aksu, significantly better at pointing out the high risk answered no to the statement that there are medicines Page 5 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 available to cure HIV/AIDS. The pregnant women in pregnancy 97% (95% CI 94–99) and delivery 91% (95% Ghana also significantly more often, 90% (95% CI 86– CI 86–94) as possible routes of mother-to-child transmis- 93), answered no to the statement that there are medi- sion, but when it came to breastfeeding around the same cines/treatment available to cure HIV/AIDS. That signifi- percentage of women in both our study and the Hong cantly more women in Ghana know that there are no Kong study identified this as a route of HIV transmission. available treatment to cure HIV/AIDS can be explained by The uncertainty about mother-to-child transmission as a that the prevalence is higher (3.1% in 2003, according to route of HIV transmission has also been identified in CIA homepage) in Ghana and therefore more women other studies [11,13,15,16]. In contrast to the studies have come across friends or relatives under treatment. mentioned above, two similar studies conducted in India [10] and Papua New Guinea [12] reports a higher percent- Having HIV/AIDS age, 80% and 69% respectively, of women who knew There were fewer women in our study, who would take a about breastfeeding as a route of transmission of HIV HIV test if it was provided, 41% (CI 95% 34–47) as com- from mother to child. When it comes to knowledge about pared with 77% (95% CI 71–83) in the Hong Kong study. pregnancy and delivery as routes of transmission, around Greater willingness among pregnant women to take an the same proportion of pregnant women in India and HIV test is also reported from several other studies [10- Papua New Guinea, as in the Hong Kong study [14], knew 13,15,16]. The low prevalence of pregnant women willing about these routes. to take an HIV test in Kazakhstan is not positive and can be explained of that Kazakhstan has a high coverage, 91% Even if the women in Semey seem to have poor knowl- in 2005 of antenatal care [9]. Therefore, many of the edge about routes of mother-to-child HIV transmission, it women participating in our study already had been tested is positive to see that only seven out of 226 women said for HIV/AIDS in the beginning of their current pregnancy. they would want to give birth to more children if they Considering this the high rate of women answering no to were found to be HIV positive. However, in comparison have an HIV test may not indicate unwillingness, instead to the women in the Aksu study this result is not satisfac- it may indicate the fact that they already have been tested. tory. The women in the Aksu study stated significantly When it comes to informing those close to themselves a more often, 97% (95% CI 95–99), that they would not majority of the women said they would inform the health- have more children, as compared with 82% (95% CI 77– care personnel if they were found to be HIV positive. This 87) of the Semey women. This may be a result of that a indicates that many of the women have put their confi- family is central for the women in Kazakhstan and the dence in the health care system, which increases the sys- women may have difficulties to accept not to have any tem's chance to stop further spread of HIV and to give the more children, in contrast the women in China are not infected women treatment. Only one out of three women allowed to give birth to more than one child according to felt confident enough to inform and get support from their law. It is also positive that the vast majority of the their husband, which is a problem, since informing one's women were prepared not to breastfeed (the same was partner is an important issue in the prevention of further seen in the Aksu study) and to take medication to prevent spread. The study conducted in Aksu showed similar mother-to-child transmission. It is therefore of great results. importance that HIV positive mothers get help both financially and with information so that they actually can Knowledge and attitudes toward PMTCT, prevention of take the necessary medication and not breastfeed. mother-to-child transmission The women in Semey had limited knowledge about The majority of the women were prepared to accept Cae- mother-to-child HIV transmission, considering that pre- sarean section if being HIV positive and being recom- vention of mother-to-child transmission of HIV is a large mended this operation to reduced mother to child part of the Kazakhstan HIV program. Both the question- transmission. One out of four women answered "don't naires and the interviews confirmed this lack of aware- know" to this question. A possible explanation for why ness. Although 68% (95% CI 62–75) knew that HIV could just 68% of the women answered they were prepared to be transmitted to the foetus by an infected mother during have Caesarean section could be that the women don't pregnancy and delivery, only 46% knew that breastfeed- know what the term "Caesarean section" means. Another ing can be a route of transmission. An explanation can be explanation may be that some women consider it too that transmission from mother to child not is a main expensive. route in Kazakhstan and therefore the women have not been reached on prevention strategies and information HIV epidemic about this transmission way. A comparison with the The women in Semey are not a group with generally high women in the Hong Kong study shows that the Hong risk behaviour. Many women are aware that intravenous Kong women were significantly better at pointing out drug use is a problem in Kazakhstan, but few of our Page 6 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 responders had been in contact with drug use personally. Authors' contributions Slightly less than half our responders wrote that certain All the authors have together participated in the design of groups are more often infected with HIV/AIDS than oth- the study. ES and SS have made the interview, distributed ers. Of those who specified their answers, 11% answered the questionnaires and registered the data with the super- that people with poor immune defence systems/organ- vision by MU. ES, SS have made the analysis of the data isms were more often infected, a misconception probably together with RA and the statistician Salmir Nasić. RA, attributable to confusion with the information that HIV MU, ES, SS have participated in interpretation of data and causes poor immune defence system. The high level of preparation of the manuscript. All the authors have read condom use in steady relations may be reflecting that the and approved the final manuscript. majority of the participating women were well educated and living in a city. An average family in the cities has Additional material lower number of children than an average family in rural villages. Additional file 1 Education among the pregnant women in Semey related to ethnic group. Conclusion The data provided present the level of education among the ethnic groups Almost all the women in our study had heard of a disease with 95% confidence intervals. called HIV/AIDS. The women's knowledge, however, was Click here for file [http://www.biomedcentral.com/content/supplementary/1471- somewhat superficial and many could not specify their 2458-8-295-S1.pdf] answers. Still, most of the women managed to identify sexual contacts and intravenous drug/needle sharing as Additional file 2 main routs of transmission. The knowledge among preg- Knowledge of HIV transmission routes according to educational level and nant women in Semey was similar to the knowledge total. The data provided present the level of HIV knowledge related to level among pregnant women in Aksu, northwest China. of education and ethnic group. The results are presented in a table with 95% confidence intervals. The media were a main source of information, showing Click here for file [http://www.biomedcentral.com/content/supplementary/1471- that the HIV epidemic is discussed in public and that the 2458-8-295-S2.pdf] media are an efficient way of disseminating information. However, it is important that the information is correct, including that social contacts are not a risk, otherwise mis- conceptions may lead to further stigmatization. Acknowledgements We thank all the women who took part in the study. One conclusion is that pregnant women in Semey have poorer knowledge than the pregnant women in Hong We also thank statistician Salmir Nasić for help with the calculations and Kong about specific mother-to-child HIV transmission Secretary Lisbeth Jinnestål Fernow for help with the manuscript. and do not know about the means of reducing mother-to- The study has been supported by a grant from the Sahlgrenska Academy at child HIV infection. However, most of the women in Gothenburg University Semey were positive to prevention strategies for mother- to-child transmission. It is therefore important that testing References and counselling for both men and women are available 1. WHO/UNAIDS 2007 AIDS Epidemic update [http:// free of charge. Individuals who test positive need to be data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf] supported to prevent further risk behaviour, and HIV pos- 2. 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Cochrane Database Syst Rev 2007:CD003510. the use of condoms cannot be underestimated, since con- 5. Hocke C, Morlat P, Chene G, Dequael L, Dabis F, the Group d"Epi- dom use is one of the most important means of prevent- demiologie Clinique de SIDA an Aquitane: Prospective cohort ing extension of the HIV epidemic. study of the effect of pregnancy on the progression of human immunodeficiency virus infection. Obstet Gynecol 1995, 86:886-891. Competing interests 6. WHO Summary country profile for HIV/AIDS in Kazakhstan The authors declare that they have no competing interests. [http://www.who.int/hiv/HIVCP_KAZ.pdf]. 20070606 7. WHO/UNAIDS Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections [http://www.who.int/Glo Page 7 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 balAtlas/predefinedReports/EFS2006/EFS_PDFs/EFS2006_KZ.pdf]. 8. WHO/UNAIDS Progress on global access to HIV antiretro- viral therapy, a report on "3 by 5" and beyond, March 2006 [http://www.who.int/hiv/fullreport_en_highres.pdf] 9. WHO/UNAIDS/Unicef Children and AIDS; A stocktaking report, Actions and progress during the first year of Unite for Children, Unite against AIDS, New York 2007 [http:// www.unicef.org/china/ Children_and_AIDS_stocktaking_report_Jan_2007_ENG.pdf] 10. Rogers A, Meundi A, Amma A, Rao A, Shetty P, Antony J, Sebastian D, Shetty AK: HIV-related knowledge, attitudes, perceived benefits, and risks of HIV testing among pregnant women in rural southern India. AIDS PATIENT CARE and STDs 2006, 20:803-811. 11. Hesketh T, Duo L, H Li, Tomkins AM: Attitudes to HIV and HIV testing in high prevalence areas of China: informing the introduction of voluntary counselling and testing pro- grammes. Sex Transm Infections 2005, 81:108-112. 12. Andersson M, Sandström C, Mola G, Amoa AB, Andersson r, Yauieb A: Awareness of and attitudes towards HIV among pregnant women at the Antenatal Clinic, Port Moresby General Hos- pital. P N G Med J 2003, 46(3–4):152-165. 13. Addo VN: Pregnant women's knowledge of and attitudes to HIV testing at Komfo Anokye Teaching Hospital, Kumasi. GHANA MEDICAL JOURNAL 2005, 39:50-54. 14. Ho CF, Loke AY: HIV/AIDS knowledge and risk behaviour in Hong Kong Chinese pregnant women. Journal of Advanced Nurs- ing 2003, 43(3):38-245. 15. Okonkwo KC, Reich K, Alabi AI, Umeike N, Nachman SA: An eval- uation of awareness: attitudes and beliefs of pregnant Nige- rian women toward voluntary counselling and testing for HIV. AIDS PATIENT CARE and STDs 2007, 21:252-260. 16. Mahmoud MM, Nasr AM, Dar Elgalal A, Gassmelseed DE, Abdalelhafiz MA: Knowledge and attitude toward HIV voluntary counsel- ling and testing services among pregnant women attending an antenatal clinic in Sudan. Journal of Medical Virology 2007, 79:469-473. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/8/295/pre pub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Public Health Springer Journals

HIV/AIDS awareness and risk behaviour among pregnant women in Semey, Kazakhstan, 2007

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Springer Journals
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Copyright © 2008 by Sandgren et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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1471-2458
DOI
10.1186/1471-2458-8-295
pmid
18721467
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Abstract

Background: Central Asia has one of the most rapidly increasing HIV prevalence in the world. The aim of this study was to evaluate current knowledge, risk behaviour and attitudes to voluntary counselling and testing concerning HIV/AIDS among pregnant women in Semey, Kazakhstan. Methods: We collected 226 questionnaires in a consecutive sample from a population on 520 pregnant women. The results were related to ethnicity, age and education level. Results: Ninety-six percent had heard about HIV. Positive findings were that 89% and 86% of the women were aware of the two main routes of transmission: sexual intercourses without a condom and sharing needles while injecting drugs. The women had first heard about HIV/AIDS through the media with, 52%, and at school with 40%. Only 46% and 68% of the women pointed out breastfeeding and mother-to-child transmission during pregnancy or delivery as routes of transmission. Eighty-three percent were prepared not to breastfeed their baby if they were found to be HIV positive. Slightly more, 86%, accepted the need to take medicine, but fewer women, 68%, were positive to Caesarean section. Negative findings were that only 28% answered that there are ways to protect oneself against sexually transmitted HIV/AIDS and specified that this was condom use. Conclusion: The pregnant women in Semey have poor knowledge about specific mother-to-child HIV transmission and do not know about the means of reducing mother-to-child HIV infection. The information in the public health program needs to be improved. However, most of the women in Semey were positive to prevention strategies for mother-to-child transmission after hearing about it. Vertical transmission of HIV from mother-to-child Background Today about 33 million people are living with HIV. Of accounts for the vast majority of the infections among the them 15 million are women and 2.5 million children children. Mother-to-child HIV transmission occurs intrau- under the age of 15 [1]. terine, intra-partum and during breastfeeding. Without Page 1 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 antiretroviral treatment, the risk of an infected woman Methods transmitting the virus to her child is between 16 and 40%. The study was conducted between June 14 and July 25, Breastfeeding contributes at least a 10% risk of transmis- 2007 in Semey, Kazakhstan. We collected 226 question- sion [2]. Timely administration of antiretroviral drugs to naires from a consecutive sample of pregnant women the HIV infected pregnant woman and her newborn sig- attending four different antenatal clinics at different parts nificantly reduces the risk of mother-to-child transmis- of the city. During a year there are around 1000 pregnan- sion [3]. With antiretroviral treatment resulting in low cies in Semey followed at 23 antenatal clinics. At the viral load, no breastfeeding and elective Caesarean the included clinics 520 pregnant women were registered at HIV transmission rate to the child can be reduced to 0–2% the time of the study. [4]. Elective Caesareans are most important for women with high HIV viral loads at the time of delivery. A questionnaire was designed to obtain three areas of interest: sociodemographic characteristics, general aware- Pregnancy has not been proven to have any negative ness of HIV/AIDS and attitudes and risk behaviour. The effects on women with asymptomatic HIV infection [5]. It questionnaire starts out with the sociodemographic ques- seems that advanced HIV infection, however, can increase tions, like age, educational and employment level for the the risk for spontaneous abortion or premature birth [2]. woman and her husband, parity, socio-economic status, religion and ethnical group. In the next part, general In Kazakhstan, 16 500 people are estimated to live with awareness of HIV/AIDS follows questions about if the HIV/AIDS which means a prevalence of 0.1–0.2% [6]. The woman has heard about HIV/AIDS before, and in case of, HIV epidemic is strongly concentrated to vulnerable pop- how she first heard about it, knowledge of route of trans- ulations, like injecting drug users, sex workers and prison- mission, knowledge of HIV prevention and symptoms. ers. In addition to these groups, the epidemic is spreading The third part includes questions concerning if they among other vulnerable groups like youth, migrants and wanted to be tested and if they wanted more children or truck drivers. About three-quarters of the new HIV diag- would be prepared not to breastfeed their baby, to take noses is among unemployed people. Currently the two pills and deliver through Caesarean to prevent HIV trans- main routes of HIV transmission in Kazakhstan are inject- mission to their baby, given they were HIV positive. In ing drug use and sexual transmission. addition, the third part includes questions about whom they would inform if they were tested positive, from Because of the increased involvement of women and chil- whom they would get support and finally questions con- dren in drug use and trafficking, it's likely that the HIV cerning use of condoms, sexual contacts and intravenous prevalence in these groups will rise. There are about 20 drug use. 000–50 000 female sex workers, of whom 30% are intra- venous drug users [7]. According to WHO/UNAIDS report The questionnaire contained three questions about con- in March 2006, there were 1500 people in need of antiret- dom use. The first and second questions about use of con- roviral drugs in Kazakhstan at the end of 2005. Just 15%, dom in steady relationship respectively with casual of those in need, received treatment [8]. partners were designed to assess the women's actual prac- tice of condom. The third question concerning responsi- In recent years efforts has been made to cover all pregnant bility for condom use is a question about the women's women with full prevention services and the mother-to- attitude. child prevention is a big part of the Kazakhstan HIV pro- gramme [6]. In average the number of births in Kaza- The questionnaires were translated to Kazakh and Russian khstan are 237 000 per year. In 2005 the antenatal care and the women were given questionnaires in the language coverage were estimated to 91% and the number of they preferred. women counselled on prevention of mother-to-child transmission (PMTCT) services were 129 706. The The women were informed that their participation and number of HIV infected women was estimated to fewer the completion of the questionnaire were entirely volun- than 500 and of those 47 (9%) received antiretroviral tarily and that they were free not to answer the questions therapy for PMTCT [9]. they found too private. The information given would be stored confidentially and no names or identifying infor- The aim of the study was to evaluate current knowledge, mation would appear in publications. A verbal consent risk behaviour and attitudes to voluntary counselling and was obtained for each participant. In addition to the ques- testing concerning HIV/AIDS among pregnant women in tionnaires, we interviewed 21 of the study participants. In Semey, Kazakhstan. This is important, considering that all interviews an interpreter was necessary; because of this the gateway for prevention of mother-to-child transmis- a local student was always present to help us to ask ques- sion is voluntary counselling and testing for HIV. tions and to take notes. Page 2 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 Open-ended questions were used and the women were General knowledge encouraged to give as much information as they could. Ninety-six percent (215/225) of the women had heard of We were careful not to suggest answers or to ask leading HIV/AIDS. questions. The questions were clustered around the areas: knowledge of differences between HIV and AIDS, living The majority, 52.1% (111/213), of the whole group had with HIV/AIDS, attitudes to people living with HIV/AIDS first heard about it from the media, 40% (85/213) knew and in particular knowledge about mother-to-child trans- it from school, 2.8% (6/213) from their parents, 1.9% (4/ mission and attitudes to voluntary counselling and test- 213) from friends and 3.3% (7/213) from other sources. ing. Two women did not answer this question. The older women (> 30 years old) had significantly more often, Ethical considerations 80% (95% CI 68–91), heard about HIV/AIDS from the The participation in the study was voluntary with media than the younger women at age 20–30 on 47% informed consent. The questionnaire was anonymous (95% CI 39–55). In contrast the younger women (age < with no registration of names, medical data or other per- 20 and 20–30), had significantly more often heard about sonal information. In our manuscript it is not possible to the disease at school, 64% (95% CI 35–92) for women identify individual patients. We have a written decision age < 20 and 46% (95% CI 37–54) for women age 20–30, from the Head of the Ethical Committee at Semey, Kaza- as compared with women with age over 30, for whom the khstan that no further ethical review is required. With the corresponding figure was 16% (95% CI 6–27). Only one anonymous design and no registration of personal sensi- out of the 56 women who correctly answered yes to the tive data, the study does not need to be reviewed by the statement that there are differences between HIV and Swedish Ethical Committee according to their rules. No AIDS was able to specify those differences, but the 21 information was collected from the women who refused women we interviewed with open questions were better at to participate. specifying the differences between HIV and AIDS. Among those who specified, many answers were unclear and dif- ficult to interpret. However, we did obtain some more or Results Study population less correct answers like: "HIV is the causative agent of the A total of 226 pregnant women participated in our study. disease AIDS", "HIV means you are a carrier, while AIDS Their ages ranged from 18 to 47 years, with a mean age of means you are sick" and "with HIV you live longer than 26.8 and a median age of 25. Thirteen women did not with AIDS". answer the question about their age; therefore these Knowledge about transmission and symptoms women were excluded when we referred our results to age. Parity ranged from 0 to 4 children, with a mean of 0.68 To the open question regarding the main way HIV/AIDS and a median of 1 child. Eighteen women did not answer is spread from one person to another many women gave the question about parity. several answers, the most common being "sexual contact" given by 76% (122/160). The second most common Of the 226 women, 76.2% (170/223) were Kazakh, answer was blood transfusion, with 30% (48/160). Nine- 18.4% (41/223) Russian, 2.2% (5/223) Tatar, 1.8% (4/ teen percent (30/160) wrote intravenous drug use/needle 223) German and 1.3% (3/223) others. The three women sharing and 3% (5/160) wrote they didn't know. who did not answer the question about their ethnicity were excluded when we referred our results to ethnicity. To discover misconceptions about transmission about Religion is closely linked with ethnicity. Of the Kazakh HIV/AIDS the women were asked to include/exclude ways women who answered the question about religion, 100% that HIV/AIDS can or not can be transmitted. These were Muslim. Among the Russian women who answered answers, with reference to the women's level of education the question about religion, 93% were Christian Ortho- [see Additional file 2] dox. Of the whole group 79.7% (173/217) were Muslim, 18.9% (41/217) Christian Orthodox and 1.4% (3/217) In general women, with higher levels of education were other. No significant association was found between occu- better than women with low education at correctly exclud- pation and ethnic origin. When it comes to education ing and including transmission routes of HIV/AIDS. The among the women we refer to additional file 1. differences were significant for "shaking hands/hugging/ living in the same house", "changing clothes with some- Russian women significantly more often attended Special one who has HIV/AIDS", "sexual intercourses with con- College (66%; 95% CI 51–80%) compared to 35% (95% dom", and "sharing needles while injecting drugs". For CI 28–41%) for Kazakh women. Kazakh women had a details, see Additional file 2. tendency to more often attend University/Institute/Acad- emy. As many as 76% (157/206) answered correctly, with no, to the statement you can not tell, by looking at a person, Page 3 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 whether he/she is infected with HIV/AIDS. Younger friends and healthcare personnel. Note that the women women (age < 20) significantly more often, 100%, could tick several alternatives. answered no to the statement that by looking at a person you can see if he/she is infected with HIV/AIDS, as com- Attitudes to PMTCT, prevention of mother-to-child pared with women aged 20–30 years, 76% (95% CI 69– transmission 83) and women aged over 30 years, 70% (95% CI 57–84). Seven women said they would want to have more chil- dren even if they were found to be HIV positive. Among The open question "Do you know any symptoms of HIV/ the women who said no to have more children 82% (176/ AIDS" was left blank by 111 women. Of the responders, 216), the main reason given was the risk of infecting the 66% (69/104) answered no. Among the women who baby. Significantly more highly educated women said no, could mention any symptoms the most common answers 87% (95% CI 81–92), to having more children as com- were fever/sub febrile 37% (13/35), loss of immunity pared with the less educated women, 66% (95% CI 53– 34% (12/35), weakness 29% (10/35) and cahexia/weight 79). Of the responders 83%, were prepared not to breast- loss 17% (6/35). When the women's ability to mention feed their baby if they were found to be HIV positive. symptoms of HIV/AIDS were refered to educational level, Somewhat more, 86%, were prepared to take medicine, the women with low education levels significantly more but fewer women, 68%, were prepared to accept Caesar- often, 95% (95% CI 85–100), answered that did not ean section to prevent mother-to-child transmission. know any symptoms, as compared with women with Risk behaviour and protection higher levels of education, 60% (95% CI 50–70). Ninety-six percent (179/186) had had one sexual partner Knowledge about treatment during the last sixth months. The three questions about A total of 14% (28/201) believed that there is a medicine condom use were as follow: "Use of condom in steady to cure HIV/AIDS, and nearly the same number, 15% (30/ relationship?", "Use of condom with casual partners?" 202) stated that there are other ways to cure HIV/AIDS. and "Who has the responsibility for condom use?" Of the Many more, almost one out of three, stated that there are women who answered the first question 21% (42/201) possible ways to slow the progression of the disease. answered always, 40% (80/201) never and 39% (79/201) sometimes. Of the responders to the second question, as Having HIV/AIDS few as 57% (78/137) answered always, 34% (47/137) Of the whole group 41% (88/215) of the women wanted never and 9% (12/137) answered sometimes. to be tested for HIV/AIDS. Fifty-nine percent (124/211) of the women said they would tell the healthcare personnel About two thirds, 68% (141/206), of the women stated if they were found to be HIV positive, 35% (74/211) that that men and women have equal responsibility to make they would tell their mothers and 32% (68/211) their sure a condom is used during sexual intercourses. Of our partners. Fifteen women left the question blank. Statisti- responders 65% (134/206) answered that there are ways cally significantly more Russian women, 51% (95% CI to protect oneself against sexually transmitted HIV/AIDS. 36–66) said they would tell their partner as compared Of the women who answered yes to this question, 55% with the Kazakh women, 26% (95% CI 19–33), but on (74/134) specified ways to protect oneself. Note that the the other hand there was a tendency among the Kazakh women were allowed to give more than one way of pro- women to say more often that they would tell their friends tection. than among the Russian women. There was also a ten- dency for the Russian women to say more often that they The far most common answer was to use condoms, 82% would tell their mothers, but the difference was within the (61/74). Other answers were "avoiding casual sexual con- margins of error. tacts" and "use of clean syringes". When the women were asked if they had sufficient information to protect them- Regarding from whom the women thought they would selves against HIV/AIDS, 42% (89/211) answered no and get support if they were found to be HIV positive, the far nearly the same number, 42% (88/211) answered yes. most common answer was mother, with 51%. Only 45% Russian women answered to a significantly higher degree thought that they would get support from healthcare per- 63% (95% CI 49–78) that they had sufficient information sonnel, and even fewer, 21%, said they would get support compared to Kazakh women 36% (95% CI 28–43). from their fathers, partners 33% or friends 23%. Sixteen HIV epidemic women (7%) did not answer the question. A comparison between Kazakh and Russian women showed that more Of our responders 47% (93/198) answered that certain Russian women expected to get support from mothers and groups of people are more often infected with HIV than partners, while Kazakh women more often mentioned others. The far most common group was drug addicts/ Page 4 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 intravenous drug users, mentioned by 88% (49/56) of the behaviour "sexual intercourse without condom", 89% responders. Other groups, given by less than 10% each, (95% CI 85–93), as compared with 73% (95% CI 67–78) were people with many sexual partners, prostitutes, in Aksu and "sharing needles while injecting drugs", 86% homeless people, homosexual people, medical people, (95% CI 81–90) compared to 55% (95% CI 49–61) in people with low social status, and people without knowl- Aksu as routes of transmission. This is positive because edge about the disease and blood donors/recipients. One these two routes are the most important routes for the misconception was that 11% (6/56) of the responders general population to be aware of. answered that people with poor immune defence sys- tems/organisms are more often infected. The finding that pregnant women in general are aware of the two main routes: sexual intercourse without a condom Discussion and sharing needles while injecting drugs, of HIV trans- The HIV epidemic in Central Asia is continuing to spread mission is in agreement with previous studies [11-13], and has reached Kazakhstan. The number of reported HIV and might not be so surprising since media focus on these cases is still relatively low and mainly concentrated to vul- two main routes in their information to the public. There nerable populations such as intravenous drug users and were more difficulties in excluding incorrect routes of sexual workers. To prevent future spread of the HIV epi- transmission. Almost one fifth though that kissing could demic and to prevent stigmatization in Kazakhstan and be a route of HIV transmission and only 44% answered other countries in Central Asia it is important to evaluate correctly that HIV can not be spread by mosquitoes. This HIV knowledge and to educate the population with cor- is slightly lower than in the Hong Kong study where 57% rect information. answered to mosquitoes as vectors of HIV [14]. The mis- conception about mosquitoes as a transmission route has Knowledge also been seen in other similar studies [10-12] and might It is reassuring to see that only ten women out of 226 did not be very surprising, since HIV is a blood-borne disease. not know there was a disease called HIV or AIDS. This cor- The pregnant women in our study, like the women in a responds to the findings in several other studies concern- similar study conducted in the province Yunnan, China ing awareness about HIV/AIDS among pregnant women [11] excluded, to a higher, but not satisfactory extent daily from India [10], China [11], Papua New Guinea [12] and domestic contacts such as eating from the same plates and Ghana [13]. Compared with the women in Aksu, north- cups, shaking hands, hugging, living in the same house west China, the women in Semey had more often heard of and changing clothes with someone who has HIV/AIDS as about HIV/AIDS. 95% (95% CI 92–98) compared to 85% possible routes of transmission. The fact that a high pro- (95% CI 80–89) in Aksu. It is positive that the media are portion of the women responded "don't know" in addi- a major source of information, exactly as in the Aksu study tion to the women with incorrect answers further and the Papua New Guinea study [12]. That a majority of illustrates their limited knowledge. the women are aware of a disease called HIV/AIDS and that media are a major source of information shows that Our conclusion is, as in the study conducted in Aksu, that the HIV epidemic is discussed in public and that the most of the women know that HIV is a sexually transmit- media are an efficient way of spreading information. In ted disease, but there are still people who have poor addition illiteracy is rare in Kazakhstan, which facilitate knowledge of HIV/AIDS and people with misconceptions for the women to take share of the given information. about how it is spread. These misconceptions may influ- ence the dissemination patterns of HIV and increase the However, it is also important that the information is cor- stigmatization of the HIV positive, as well as giving rise to rect, otherwise misconceptions may lead to further stig- misguided fears. It is essential to continue to raise the level matization. Because the women had difficulties of knowledge of HIV/AIDS through campaigns in the distinguish HIV from AIDS and only 16% could mention media and at schools. One thing that needs to be commu- symptoms of HIV/AIDS, we conclude that the women's nicated is that there is no medicine to cure a HIV infec- knowledge in general was superficial with little under- tion, only 40% (95% CI 33–47) of the women answered standing of the details and the nature of the disease. We correctly that this was the case. This may reflect that the were pleased to find that as many as 76% answered that information about HIV/AIDS in the media focus on risk you can not tell by looking at a person if she/he is infected behaviour and not on possible treatment. In addition the with HIV/AIDS. The younger women, as compared with prevalence of HIV is low in Kazakhstan and few of the the older women, significantly more often answered no to women participating in our study had met or knew any- this question. This may be explained by the fact that now- one with the infection i.e. they have never come across adays students got a lot more information at school. persons under treatment for HIV/AIDS. This is signifi- cantly lower than the corresponding figure for the women The women in Semey were, as compared with the women in the Hong Kong study, where 79% (95% CI 73–84) in Aksu, significantly better at pointing out the high risk answered no to the statement that there are medicines Page 5 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 available to cure HIV/AIDS. The pregnant women in pregnancy 97% (95% CI 94–99) and delivery 91% (95% Ghana also significantly more often, 90% (95% CI 86– CI 86–94) as possible routes of mother-to-child transmis- 93), answered no to the statement that there are medi- sion, but when it came to breastfeeding around the same cines/treatment available to cure HIV/AIDS. That signifi- percentage of women in both our study and the Hong cantly more women in Ghana know that there are no Kong study identified this as a route of HIV transmission. available treatment to cure HIV/AIDS can be explained by The uncertainty about mother-to-child transmission as a that the prevalence is higher (3.1% in 2003, according to route of HIV transmission has also been identified in CIA homepage) in Ghana and therefore more women other studies [11,13,15,16]. In contrast to the studies have come across friends or relatives under treatment. mentioned above, two similar studies conducted in India [10] and Papua New Guinea [12] reports a higher percent- Having HIV/AIDS age, 80% and 69% respectively, of women who knew There were fewer women in our study, who would take a about breastfeeding as a route of transmission of HIV HIV test if it was provided, 41% (CI 95% 34–47) as com- from mother to child. When it comes to knowledge about pared with 77% (95% CI 71–83) in the Hong Kong study. pregnancy and delivery as routes of transmission, around Greater willingness among pregnant women to take an the same proportion of pregnant women in India and HIV test is also reported from several other studies [10- Papua New Guinea, as in the Hong Kong study [14], knew 13,15,16]. The low prevalence of pregnant women willing about these routes. to take an HIV test in Kazakhstan is not positive and can be explained of that Kazakhstan has a high coverage, 91% Even if the women in Semey seem to have poor knowl- in 2005 of antenatal care [9]. Therefore, many of the edge about routes of mother-to-child HIV transmission, it women participating in our study already had been tested is positive to see that only seven out of 226 women said for HIV/AIDS in the beginning of their current pregnancy. they would want to give birth to more children if they Considering this the high rate of women answering no to were found to be HIV positive. However, in comparison have an HIV test may not indicate unwillingness, instead to the women in the Aksu study this result is not satisfac- it may indicate the fact that they already have been tested. tory. The women in the Aksu study stated significantly When it comes to informing those close to themselves a more often, 97% (95% CI 95–99), that they would not majority of the women said they would inform the health- have more children, as compared with 82% (95% CI 77– care personnel if they were found to be HIV positive. This 87) of the Semey women. This may be a result of that a indicates that many of the women have put their confi- family is central for the women in Kazakhstan and the dence in the health care system, which increases the sys- women may have difficulties to accept not to have any tem's chance to stop further spread of HIV and to give the more children, in contrast the women in China are not infected women treatment. Only one out of three women allowed to give birth to more than one child according to felt confident enough to inform and get support from their law. It is also positive that the vast majority of the their husband, which is a problem, since informing one's women were prepared not to breastfeed (the same was partner is an important issue in the prevention of further seen in the Aksu study) and to take medication to prevent spread. The study conducted in Aksu showed similar mother-to-child transmission. It is therefore of great results. importance that HIV positive mothers get help both financially and with information so that they actually can Knowledge and attitudes toward PMTCT, prevention of take the necessary medication and not breastfeed. mother-to-child transmission The women in Semey had limited knowledge about The majority of the women were prepared to accept Cae- mother-to-child HIV transmission, considering that pre- sarean section if being HIV positive and being recom- vention of mother-to-child transmission of HIV is a large mended this operation to reduced mother to child part of the Kazakhstan HIV program. Both the question- transmission. One out of four women answered "don't naires and the interviews confirmed this lack of aware- know" to this question. A possible explanation for why ness. Although 68% (95% CI 62–75) knew that HIV could just 68% of the women answered they were prepared to be transmitted to the foetus by an infected mother during have Caesarean section could be that the women don't pregnancy and delivery, only 46% knew that breastfeed- know what the term "Caesarean section" means. Another ing can be a route of transmission. An explanation can be explanation may be that some women consider it too that transmission from mother to child not is a main expensive. route in Kazakhstan and therefore the women have not been reached on prevention strategies and information HIV epidemic about this transmission way. A comparison with the The women in Semey are not a group with generally high women in the Hong Kong study shows that the Hong risk behaviour. Many women are aware that intravenous Kong women were significantly better at pointing out drug use is a problem in Kazakhstan, but few of our Page 6 of 8 (page number not for citation purposes) BMC Public Health 2008, 8:295 http://www.biomedcentral.com/1471-2458/8/295 responders had been in contact with drug use personally. Authors' contributions Slightly less than half our responders wrote that certain All the authors have together participated in the design of groups are more often infected with HIV/AIDS than oth- the study. ES and SS have made the interview, distributed ers. Of those who specified their answers, 11% answered the questionnaires and registered the data with the super- that people with poor immune defence systems/organ- vision by MU. ES, SS have made the analysis of the data isms were more often infected, a misconception probably together with RA and the statistician Salmir Nasić. RA, attributable to confusion with the information that HIV MU, ES, SS have participated in interpretation of data and causes poor immune defence system. The high level of preparation of the manuscript. All the authors have read condom use in steady relations may be reflecting that the and approved the final manuscript. majority of the participating women were well educated and living in a city. An average family in the cities has Additional material lower number of children than an average family in rural villages. Additional file 1 Education among the pregnant women in Semey related to ethnic group. Conclusion The data provided present the level of education among the ethnic groups Almost all the women in our study had heard of a disease with 95% confidence intervals. called HIV/AIDS. The women's knowledge, however, was Click here for file [http://www.biomedcentral.com/content/supplementary/1471- somewhat superficial and many could not specify their 2458-8-295-S1.pdf] answers. Still, most of the women managed to identify sexual contacts and intravenous drug/needle sharing as Additional file 2 main routs of transmission. The knowledge among preg- Knowledge of HIV transmission routes according to educational level and nant women in Semey was similar to the knowledge total. The data provided present the level of HIV knowledge related to level among pregnant women in Aksu, northwest China. of education and ethnic group. The results are presented in a table with 95% confidence intervals. The media were a main source of information, showing Click here for file [http://www.biomedcentral.com/content/supplementary/1471- that the HIV epidemic is discussed in public and that the 2458-8-295-S2.pdf] media are an efficient way of disseminating information. However, it is important that the information is correct, including that social contacts are not a risk, otherwise mis- conceptions may lead to further stigmatization. Acknowledgements We thank all the women who took part in the study. One conclusion is that pregnant women in Semey have poorer knowledge than the pregnant women in Hong We also thank statistician Salmir Nasić for help with the calculations and Kong about specific mother-to-child HIV transmission Secretary Lisbeth Jinnestål Fernow for help with the manuscript. and do not know about the means of reducing mother-to- The study has been supported by a grant from the Sahlgrenska Academy at child HIV infection. However, most of the women in Gothenburg University Semey were positive to prevention strategies for mother- to-child transmission. It is therefore important that testing References and counselling for both men and women are available 1. WHO/UNAIDS 2007 AIDS Epidemic update [http:// free of charge. Individuals who test positive need to be data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf] supported to prevent further risk behaviour, and HIV pos- 2. 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Journal of Medical Virology 2007, 79:469-473. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/8/295/pre pub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes)

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