Journal Pone 0285962

PLOS ONE
RESEARCH ARTICLE
HIV burden and the global fast-track targets

progress among pregnant women in Tanzania
calls for intensified case finding: Analysis of
2020 antenatal clinics HIV sentinel site
surveillance
Erick Mboya ID1☯*, Mucho Mizinduko1☯, Belinda Balandya1, Jeremiah Mushi2,
a1111111111
Amon Sabasaba1, Davis Elias Amani ID1, Doreen Kamori1, George Ruhago1,
a1111111111 Prosper Faustine2, Werner Maokola2, Veryeh Sambu2, Mukome Nyamuhagata2,
a1111111111 Boniphace S. Jullu3†, Amir Juya4, Joan Rugemalila5, George Mgomella6, Sarah Asiimwe7,
a1111111111 Andrea B. Pembe ID1, Bruno Sunguya1
a1111111111
1 Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, 2 Ministry of Health,
Dodoma, Tanzania, 3 St. Francis University College of Health and Allied Sciences, Morogoro, Tanzania,
4 Tanzania Field Epidemiology and Laboratory Training Program, Dar es Salaam, Tanzania, 5 Muhimbili
National Hospital, Dar es Salaam, Tanzania, 6 Centre for Diseases Control, Country Office, Dar es Salaam,
Tanzania, 7 Global Fund, Tanzania Country Team, Tanzania
OPEN ACCESS
☯ These authors contributed equally to this work.
Citation: Mboya E, Mizinduko M, Balandya B,
† Deceased.
Mushi J, Sabasaba A, Amani DE, et al. (2023) HIV
* [email protected]
burden and the global fast-track targets progress
among pregnant women in Tanzania calls for
intensified case finding: Analysis of 2020 antenatal
clinics HIV sentinel site surveillance. PLoS ONE Abstract
18(10): e0285962. https://doi.org/10.1371/journal.
pone.0285962
Background
Editor: Hamufare Dumisani Dumisani Mugauri,
For successful HIV response, updated information on the burden and progress toward HIV
University of Zimbabwe Faculty of Medicine:
University of Zimbabwe College of Health Sciences, elimination targets are required to guide programmatic interventions. We used data from the
ZIMBABWE 2020 HIV sentinel surveillance to update on the burden and factors associated with HIV
Received: May 4, 2023 infection, HIV status awareness, and ART coverage among pregnant women in Tanzania
mainland.
Accepted: September 28, 2023
Published: October 12, 2023

Methodology
Copyright: This is an open access article, free of all
We conducted the surveillance in 159 antenatal clinics (ANC) from all 26 regions of Tanza-
copyright, and may be freely reproduced,
distributed, transmitted, modified, built upon, or nia’s mainland from September to December 2020. This cross-sectional study included all
otherwise used by anyone for any lawful purpose. pregnant women (�15 years) on their first ANC visit in the current pregnancy during the sur-
The work is made available under the Creative vey period. Routine HIV counselling and testing were done at the facility. A multivariable
Commons CC0 public domain dedication.
logistic regression model accounting for the survey design was used to examine factors
Data Availability Statement: The data for this associated with HIV infections.
study cannot be shared publicly because the
research team behind this manuscript designed
and carried out the surveillance at a request from Results
the Ministry of Health, Tanzania (MoH). For
38,783 pregnant women were enrolled (median age (IQR) = 25 (21–30) years). HIV preva-
researchers who meet the criteria for access to
confidential data, the data may be accessed lence was 5.9% (95%CI: 5.3% - 6.6%), ranging from 1.9% in the Manyara region to 16.4%
through a request to the MoH, who is the primary in the Njombe region. Older age, lower and no education, not being in a marital union, and
PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 1 / 17

PLOS ONE HIV burden and the global fast-track targets progress among pregnant women in Tanzania
owner of the data.To access data, a third party is living in urban or semi-urban areas were associated with higher odds of HIV infection. HIV
also required to sign the Data Transfer Agreement status awareness among women who tested positive was 70.9% (95% CI: 67.5%- 74.0%).
through the National Health Research and Ethics
Committee which is the research regulatory body
ART coverage among those aware of their status was 91.6% (86.5%- 94.9%). Overall,
in the country. Data requests can be directed to 66.6% (95% CI: 62.4%- 70.6%) of all pregnant women who tested positive for HIV knew
[email protected]. their HIV status and were on ART.
Funding: The 2020 National ANC HSS was funded
by Ministry of Health through the financial support
Conclusion
of the Global Fund for AIDS TB and Malaria.
Muhimbili University of Health and Allied Sciences HIV is increasingly prevalent among pregnant women in Tanzania mainland especially
was commissioned to prepare, lead, and manage among older, those with lower or no formal education, those outside marital union, and preg-
the survey. The preparation of this manuscript was
nant women living in urban and semi-urban areas. Behind the global fast-target to end HIV/
not funded. The HSS funders had no role or
influence on the process of writing and conduct of AIDS, about a third of pregnant women living with HIV initiating ANC were not on ART. Inter-
the survey. ventions to increase HIV testing and linkage to care among women of reproductive age
Competing interests: The authors have declared should be intensified.
that no competing interests exist.
Introduction
About 19.7 million women above 15 years were living with HIV in 2021, and about 1.3 million
women become pregnant each year [1, 2]. The risk of transmission of HIV from mother to
child ranges from 15% to 45% during pregnancy, labor, delivery, and breastfeeding if proper
preventive measures are not taken [3, 4]. In 2020 alone, about 160,000 children had newly
acquired HIV principally through vertical transmission, and about 1.8 million children were
living with HIV worldwide [1]. The African region is the most affected region with 25.6 mil-
lion people living with HIV (PLHIV) and about 60% of the global new HIV infections [2].
Despite the overall burden of HIV infection, women of reproductive age experience a higher
burden as compared to men. In Africa, the prevalence of HIV among women of reproductive
age ranges from <0.1% to 23.5% [5].
Tanzania is ranked among the 22 priority countries constituting 90% of all pregnant
women living with HIV worldwide [6]. The country is ranked third among countries with the
highest annual incidences of HIV globally. It recorded 72,000 new cases in the year 2018. Ado-
lescents and young women contributed a disproportionately higher burden compared to other
sub-populations [7]. About 36,700 women aged 15–49 were newly infected with HIV in 2020
and an estimated 28,000 in 2021 [5, 8]. Although the country has observed a significant reduc-
tion in mother-to-child transmission (MTCT) of HIV from 23% in 2011 to 11% in 2020, it is
still behind the global targets and is one of the six countries with a slow pace or no decline in
MTCT of HIV [6, 9].
Tanzania also focuses on ending HIV/AIDS as a public health threat by 2030. Reaching the
fast-track targets calls for a better understanding of the local epidemic. The 95-95-95 fast-track
targets aimed to ensure that 95% of PLHIV should know their HIV-positive status, 95% of peo-
ple who know their status should be on treatment, and 95% of those on ART should attain and
maintain viral suppression by 2030 [10]. Among adults living with HIV in 2016 in Tanzania,
only 51.8% were aware that they were HIV-infected and 47.1% were aware and on ART [11].
Although women living with HIV were more likely to know their HIV-positive status and be
on ART compared with the general population, the level of HIV status awareness and ART
coverage was still very low. Only 55.4% of them were aware of their HIV-positive status and
slightly over half (51.5%) of those infected were on ART [11]. This hampers efforts to eliminate
HIV/AIDS by 2030 [12, 13].

For over two decades, the HIV sentinel surveillance (HSS) among pregnant women attend-
ing ANC has provided estimates of the burden and trend of HIV infections in Tanzania [14–
17]. Six rounds of HSS have been done since 2000 and results indicate a decline in the preva-
lence of HIV infections among pregnant women in Tanzania from 9.6% in 2001 to 5.6% in
2011 [16]. However, results from the last HSS, in 2017 (unpublished), showed an increase in
prevalence to 6.1%. The HSS also plays a vital role in informing the need for HIV testing, and
other HIV and STIs-related needs at the national and sub-national levels to prevent mother-
to-child transmission (PMTCT) of HIV [14, 18]. The HSS has also been expanding to include
all regions, representing facilities from urban, semi-urban, and rural areas. In line with the
ambitious global targets, recent surveys also collected information on HIV status awareness
and ART coverage among pregnant women which help to inform on the progress towards the
goals and effectiveness of the interventions.
In line with the need to close the gap in HIV control, essential to the national and global
response to HIV, we analyzed data from the seventh HSS round conducted in 2020 to update
national data on the burden and factors associated with HIV infection, awareness of HIV sta-
tus, and coverage of ART among pregnant women in Tanzania mainland.
Materials and methods

Surveillance duration and site selection
The seventh HSS was conducted from September to December 2020 in 26 regions of Tanzania’s
mainland from 159 antenatal clinics (ANCs) providing PMTCT services. As for the previous HSS
rounds, two urban, two semi-urban, and two rural sites were conveniently selected from each
region, except for the Dar es Salaam region, where all six sites are classified as urban. ANCs in the
seventh HSS round included 148 ANCs that participated in the sixth HSS (conducted in 2017).
Ten ANCs were purposively selected to replace 10 ANCs that participated in 2017 and were no
longer providing ANC services during the current survey period. One urban ANC was newly
added to the Geita region which had only one urban ANC site in the previous round of HSS.
ANC coverage of at least one visit is more than 98% and PMTCT services are integrated
into ANCs [9]. In 2019, 2.2 million pregnant women accepted HIV testing, and 98.3% of all
pregnant women attended PMTCT services [9]. Pregnant women with HIV-positive test
results initiate ART irrespective of their CD4 cell count, in line with the national guidelines
[19]. Women who opt out at their first ANC visit are informed that they can access HIV testing
at any future visit if they change their minds [19].
Survey population
All pregnant women aged 15 years and above attending ANC on their first visit in the current
pregnancy during the survey period were eligible for inclusion in the ANC HSS. However,
only those who provided written consent and were willing to give a blood sample for routine
PMTCT HIV testing were included in the surveillance. To achieve the targeted sample size, all
sites carried out data collection continuously for three consecutive months. Assuming an
alpha level of 0.05, with 159 ANCs sampled, and 38,755 women included in the analysis with
an intracluster correlation of 0.16, this survey had the power of �80% to detect at least a 2.5%
change in the prevalence of HIV as that of 6.3% reported in 2017.
Data collection
This surveillance was integrated into routine ANC activities where all women attending the
ANC on a particular day were informed of the ongoing surveillance. The provider explained

the surveillance procedures and obtained written informed consent from the participant for
each component of the survey (the interview and routine rapid testing for HIV). In addition, a
non-identifying unique survey ID code (HSS number) pre-printed on barcode stickers was
assigned to each prospective survey participant found to be eligible.
The surveillance questionnaire was developed in English, translated into Swahili, and then
back-translated into English by a third party to verify the accuracy of the translation. A trained
RCH provider, using an electronic tablet loaded with an open data kit (ODK), a data collection
software, administered the questionnaire. It captured the HSS number, ANC number, age,
marital status, gravidity, education level, residence, employment, HIV status, ART use, and
HIV test results. Electronic data were uploaded to a password-protected server at the end of
each day. Details about the training of the study personnel have been described elsewhere [20].
HIV testing procedures

Following the interview, all participants, including those who knew their HIV status, were
offered HIV counselling and testing according to the national guidelines and the national
rapid testing algorithm [21]. The provider conducted HIV and syphilis testing using rapid SD
Bioline HIV/ Syphilis Duo test kits, followed by a Unigold test to confirm any HIV-positive
results. The SD Bioline HIV/ Syphilis Duo test kit offers similar sensitivity and specificity for
HIV as the single HIV SD Bioline [22–25]. This allows for comparability with the results of the
previous rounds of this surveillance. The Ministry of Health (MOH) adopted the kit owing to
its cost-effectiveness in testing for both HIV and syphilis and enables broader syphilis testing
coverage [23, 24]. Each participant received their result in a post-test counselling session and
was referred to HIV prevention, care, treatment, and support services as appropriate. Partici-
pants with positive syphilis test results were treated according to National STI Management
Guidelines [26]. HIV test result data were recorded on a register and entered into an ODK
form.
Data management and analysis

Sociodemographic data and routine HIV testing data collected were uploaded daily to a pass-
word-protected cloud storage system by each survey team member to allow for real-time data
monitoring. To minimize data entry errors, questions in the ODK had prompts and checks for
data validation and correction of identified errors. Data registries at the facility and monthly
reports submitted to the MoH were also referred to ensure the quality of the study data
entered.
Analysis was conducted using Stata Statistical software ver. 17 (College Station, TX: Stata
Corp LLC.). The proportion of women who were infected with HIV was calculated at the
national and regional levels and was also disaggregated by demographic characteristics. These
estimates, and the logistic regression estimates, considered the survey design of this surveil-
lance (clustering at the health facility level and stratification by locality—rural, semi-urban,
and urban). The estimates were also weighted using inverse probability weights based on the
total number of women who attended ANC during the study period at each region. Weights
did not take into account non-response since it was so low (<2%). To compare with previous
surveys, crude estimates (unweighted and not considering the survey design) of HIV infection
at the national level were calculated and presented. Multivariable logistic regressions were
used to examine the independent association between HIV infection and various independent
variables including age, marital status, parity, education level, source of income, and locality.
All the variables that attained a p-value <0.2 in the univariable analysis were included in the
multivariable models. The level of statistical significance was set at p<0.05.

We also estimated the proportion of HIV-positive status awareness among women living
with HIV in the survey and the ART coverage among those aware of their HIV-positive status.
These estimates were disaggregated by regions and by demographic characteristics of the
women. Because the HIV status awareness and ART coverage were self-reported, and no
efforts were made to verify the responses, we conducted and presented the sensitivity analysis
of their estimates. For ART coverage, we estimated and presented estimates where 10% of
those who reported being aware of their status but not on ART were considered to be on ART,
and 5% of those who reported being aware of their HIV status and on ART were considered to
be not on ART [11]. For HIV-positive status awareness, 10% of those who reported being
unaware of their HIV-positive status were considered to have previously been diagnosed.
These estimates were derived from the 2016/17 Tanzania HIV Impact survey [11].
Ethical consideration
Study staff sought informed consent from potential participants before they engaged them in
the survey. Pregnant women who did not consent to participate in the survey received routine
ANC care as expected. Participants were assured that their responses would be kept confiden-
tial and that no harm would come to them because of agreeing or not agreeing to participate
in the survey. Approval to conduct this study was provided by the MUHAS Institutional
Review Board (MUHAS-REC-07-2020-298). Strict protection ensured data security and confi-
dentiality. The ANC HSS survey did not collect any personally identifiable information other
than what was essential to meet the assessment objectives.
Results
Demographic characteristics
Of the 39,516 pregnant women included in the 2020 ANC HSS surveillance, 38,783 (98.1%)
consented to participate in the surveillance and had their HIV results. The median age (IQR)
of the participants was 25 (21–30) years, and a third of them (33.2%) were aged between 20–24
years. Over three-quarters of the participants (78.5%) reported being married, and 61.0% had
attained primary school education. About half of the participants (48.8%) were housewives,
while 44.5% had at most two previous pregnancies, and a quarter of all participants (26.3%)
were primigravids. Almost half of the participants, 48.2%, were recruited from facilities located
in urban areas—Table 1.
Prevalence of HIV by demographic characteristics of participants

The overall prevalence of HIV infection among first-visit ANC attendees in Tanzania main-
land was 5.9% (95%CI: 5.3% - 6.6%). The prevalence of HIV was highest among women aged
45 years and above (18.2%), widowed women (23.0%), and divorced/separated women
(22.4%). Women in semi-urban areas were observed to have a higher prevalence (7.3%) com-
pared to those in urban (6.4%) and rural areas (4.3%). Women in their first pregnancy had the
lowest prevalence compared to women with previous pregnancies—Table 1. The crude preva-
lence of HIV was 6.3% (95%CI: 6.0%- 6.5%).
Prevalence of HIV infection by regions

The prevalence of HIV infection was unevenly distributed ranging from the lowest in the Man-
yara region (2.0%) to the highest in the Njombe region (16.4%)—Table 2.

Table 1. Prevalence of HIV among pregnant women initiating ANC by their demographic characteristics
(N = 38783).
Variable Total HIV Infection
Age group (years) N (%) Prevalence (%) (95% CI)
15–24 17,766 (45.8) 3.0 (2.6–3.4)
25–34 15917 (41.0) 7.4 (6.6–8.2)
35–44 4746 (12.2) 11.2 (9.9–12.7)
45+ 354 (0.9) 18.2 (12.1–26.4)
Education level
None 4,896 (12.6) 7.2 (6.2–8.4)
Primary 23,627 (60.9) 6.8 (6.1–7.5)
Secondary 9,035 (23.3) 4.9 (4.1–5.9)
Post-secondary 1,225 (3.2) 4.7 (3.5–6.1)
Marital status
Single 2,835 (7.3) 10.4 (8.7–12.4)
Divorced/separated 308 (0.8) 22.4 (16.3–29.9)
Widowed 113 (0.3) 23.0 (16.5–31.2)
Co-habiting 5,081 (13.1) 6.8 (5.9–8)
Married 30,446 (78.5) 5.6 (5.1–6.3)
Employment status
Employed 2,014 (5.2) 7.7 (6.2–9.5)
Housewife 18,956 (48.9) 5.4 (4.9–6)
Self-employed 15,032 (38.8) 7.5 (6.6–8.5)
Unemployed 2,781 (7.2) 5 (3.7–6.7)
Total number of previous pregnancies
0 10,199 (26.3) 2.7 (2.3–3.1)
1–2 17,285 (44.6) 7.1 (6.4–7.8)
3–4 7,916 (20.4) 9.6 (8.6–10.8)
>4 3,383 (8.7) 6.0 (5.1–7.0)
Locality
Rural 6,925 (17.9) 4.3 (3.4–5.3)
Semi-urban 13,020 (33.6) 7.3 (6–8.9)
Urban 18,838 (48.6) 6.4 (5.6–7.3)
Health facility level
Dispensary 6,131 (15.8) 5.5 (4.3–6.9)
Health Centre 23,837 (61.5) 5.9 (5.2–6.8)
Hospital 8,815 (22.7) 8.0 (6.7–9.7)
ANC- Antenatal clinic, CI- Confidence Interval
https://doi.org/10.1371/journal.pone.0285962.t001
Factors associated with HIV infection among pregnant women

Table 3 shows the results of logistic regression analyses. The odds of being HIV positive
increased with age (trend z = 26.02, p<0.001). Pregnant women aged 25–34 years had 2.2
times higher odds of having HIV than pregnant women aged 15–24 years (aOR = 2.2, 95% CI:
1.9–2.5). Similarly, women aged 35–44 years (aOR = 3.9, 95% CI: 3.2–4.6), and women of 45
years and above (aOR = 7.0, 95% CI: 4.4–11.1) had respectively almost 4 and 7 times higher
odds of having HIV infection compared to pregnant women aged 15–19 years (Table 3). The
odds decreased with an increase in education level (trend z = -4.54, p<0.001).

Table 2. Prevalence of HIV infection among pregnant women initiating ANC in Tanzania mainland by regions
(N = 38783).
Region Total N HIV Infection
n %, (95% CI)
Arusha 1,542 51 3.3 (1.7–6.4)
Dar es Salaam 2,874 167 5.8 (4.3–7.9)
Dodoma 1,749 68 3.9 (3.5–4.3)
Geita 3,460 231 6.7 (5.6–8)
Iringa 882 120 13.6 (10.9–16.9)
Kagera 1,481 73 4.9 (3.2–7.5)
Katavi 1,224 72 5.9 (4.3–8.1)
Kigoma 1,372 29 2.1 (1.1–4.1)
Kilimanjaro 968 68 7 (4.3–11.2)
Lindi 508 36 7.1 (5.7–8.8)
Manyara 924 18 1.9 (1.0–3.6)
Mara 1,509 83 5.5 (2.8–10.5)
Mbeya 2,032 241 11.9 (9.7–14.4)
Morogoro 728 35 4.8 (2.2–10.4)
Mtwara 814 39 4.8 (3.9–5.9)
Mwanza 2,232 128 5.7 (4–8.1)
Njombe 670 110 16.4 (11.2–23.5)
Pwani 1,841 149 8.1 (3.8–16.5)
Rukwa 1,265 80 6.3 (4.6–8.7)
Ruvuma 1,119 105 9.4 (4.6–18.2)
Shinyanga 1,477 102 6.9 (3.9–11.8)
Simiyu 1,956 85 4.3 (2.7–6.8)
Singida 1,549 67 4.3 (2.4–7.8)
Songwe 1,902 132 6.9 (5.3–9.1)
Tabora 1,408 96 6.8 (4.6–10.1)
Tanga 1,297 71 5.5 (4.4–6.8)
Total 38,783 2456 5.9 (5.3–6.6)
ANC- Antenatal Clinic, CI- Confidence interval
Marital status was also a significant predictor of HIV infection among women in this survey.
Widowed women were 3.4 times more likely to test HIV positive compared to those who were mar-
ried (aOR = 3.4, 95%CI: 2.2–5.4). Similar findings were observed for those who were divorced/sepa-
rated (aOR = 4.8, 95%CI): 3.2–7.1). Single women were three times more likely to test positive for
HIV compared to married women (aOR = 3.3, 95%CI: 2.7–4.0). Compared to women in rural
areas, women residing in urban and suburban areas had 50% higher odds of HIV infection Table 3.
Awareness of HIV-positive status and ART coverage

HIV status awareness among pregnant women who tested positive was 70.9% (95% CI: 67.5%-
74.0%). ART coverage among pregnant women aware of their status was 91.6% (86.5%-
94.9%). Overall, 66.6% (95% CI: 62.4%- 70.6%) of all pregnant women who tested positive for
HIV in this survey knew their HIV status and were on ART—Fig 1.
In the sensitivity analysis of HIV status awareness, the HIV status awareness was 73.7%
when 10% of HIV-positive women who reported being unaware of their HIV-positive status
were considered to be aware of their HIV-positive status. And ART coverage was 87.1% in the

Table 3. Factors associated with HIV infection among pregnant women initiating ANC in Tanzania mainland, (N = 38783).
Variable Positive n (%) cOR (95% CI) aOR (95% CI) p-value
Age group (years)
15–24 582 (3.3) Ref Ref
25–34 1246 (7.8) 2.6 (2.3–2.8) 2.2 (1.9–2.5) <0.001
35–44 557 (11.7) 4.1 (3.5–4.7) 3.9 (3.2–4.6) <0.001
45+ 71 (20.1) 7.2 (4.4–11.7) 7.0 (4.4–11.1) <0.001
Education level
None 353 (7.2) 1.6 (1.2–2.2) 2.3 (1.6–3.4) <0.001
Primary 1599 (6.8) 1.5 (1.1–2) 1.9 (1.3–2.6) <0.001
Secondary 447 (5.0) 1.1 (0.8–1.5) 1.2 (0.9–1.7) 0.227
Post-secondary 57 (4.7) Ref Ref
Marital status
Single 294 (10.4) 1.9 (1.6–2.3) 3.3 (2.7–4.0) <0.001
Co-habiting 348 (6.9) 1.2 (1–1.5) 1.4 (1.2–1.7) 0.001
Divorced/separated 69 (22.4) 4.8 (3.2–7.2) 4.8 (3.2–7.1) <0.001
Widowed 26 (23.0) 5 (3.2–7.7) 3.4 (2.2–5.4) <0.001
Married 1719 (5.7) Ref Ref
Employment status
Employed 155 (7.7) 1.6 (1.2–2.2) 1.7 (1.1–2.4) 0.008
Housewife 1032 (5.4) 1.1 (0.8–1.5) 1.2 (0.9–1.7) 0.262
Self-employed 1131 (7.5) 1.6 (1.1–2.1) 1.6 (1.1–2.2) 0.012
Unemployed 138 (5.0) Ref Ref
Total number of previous pregnancies
0 271 (2.7) Ref Ref
1–2 1219 (7.1) 2.8 (2.4–3.2) 2.2 (1.9–2.6) <0.001
3–4 763 (9.6) 3.9 (3.3–4.6) 2.2 (1.8–2.6) <0.001
>4 203 (6.0) 2.3 (1.9–2.9) 1.1 (0.8–1.4) 0.479
Locality
Rural 296 (4.3) Ref Ref
Semi-urban 954 (7.3) 1.8 (1.3–2.4) 1.5 (1.0–2.2) 0.030
Urban 1206 (6.4) 1.5 (1.1–2.1) 1.5 (1.1–2.1) 0.012
Health facility level
Dispensary 335 (5.5) Ref Ref
Health Centre 1412 (5.9) 1.1 (0.8–1.5) 1.1 (0.8–1.4) 0.669
Hospital 709 (8.0) 1.5 (1.1–2.1) 1.4 (0.9–2.0) 0.099
ANC- Antenatal clinic, cOR- Crude Odds Ratio, aOR- Adjusted Odds Ratio, CI- Confidence interval
sensitivity analysis when 10% of those who reported being aware of their HIV-positive status
but not on ART were considered to be on ART, and 5% of those who reported being aware of
their HIV status and on ART were considered to be not on ART.
Awareness of HIV Positive Status and ART coverage by regions

None of the regions has attained the first 95% target. The proportion of HIV-positive pregnant
women attending ANC who knew their status varied among regions ranging from 92% in
Ruvuma to 44% in Manyara and 47% in Katavi—Fig 2.
Eleven regions had already attained the second 95% target. These were Kigoma, Morogoro,
Shinyanga, Simiyu, Tanga, Kagera, Mara, Mbeya, Arusha, Singida, and Katavi. Three regions,
Pwani (51%), Manyara (75%), and Mtwara (77%), had the lowest ART coverage. Dar Es

Fig 1. Progress on the global fast-track targets among pregnant women attending ANC in Tanzania’s mainland.
https://doi.org/10.1371/journal.pone.0285962.g001
Salaam (87%), Geita (86%), Lindi (89%), Njombe (83%), and Rukwa (87%) had ART coverage
below 90% among women living with HIV who knew
their status—Fig 3.
HIV Status awareness and ART coverage by demographic characteristics

Among pregnant women who tested positive for HIV, the HIV-positive status awareness was
lowest (56.6%) among women aged 15–24 years, while the highest (80.4%) was among women
aged 35–44 years. Less than half (46.6%) of primigravids who tested positive were aware of their
HIV-positive status while over 70% of women with at least one previous pregnancy were aware
of their HIV-positive status. Three-quarters (75.5%) of the pregnant women in semi-urban
areas were aware of their HIV-positive status whereas, in comparison, two-thirds of those resid-
ing in the rural (66.4%) and urban areas (68.2%) were aware of their HIV-positive status.
ART coverage was highest among rural (97.1) residents and lowest among semi-urban
dwellers (88.1%). ART coverage was lowest (30%) among pregnant women of 45 years and
above. Women with secondary (85.5%) or post-secondary education (86.0%) had ART cover-
age lower than 90%. Primigravids had the lowest ART coverage (80.0%) compared to women
with at least one previous pregnancy who had over 90% coverage—Table 4.
Fig 2. Percentage of HIV-positive women attending ANC who knew their status by region.

Fig 3. Percentage of HIV-positive women attending ANC who knew their status that were on ART by region.
Table 4. HIV Status awareness and ART coverage by demographics.

Variable Total Aware Status % (95% CI) On ART % (95% CI)
Positive N = 2456 N = 1708
Age group (years)
15–24 582 56.6 (51.1–62.0) 90.9 (85.9–94.3)
25–34 1246 73.1 (69.1–76.7) 92.9 (89.3–95.4)
35–44 557 80.4 (75.7–84.3) 94.3 (88.9–97.1)
45+ 71 68.8 (59.5–76.8) 30.3 (05.3–77.0)
Education level
None 353 69.7 (63.4–75.4) 92.8 (86.2–96.4)
Primary 1599 72.1 (68.6–75.4) 93.1 (89.7–95.5)
Secondary 447 69.1 (63.2–74.5) 85.5 (71.2–93.3)
Post-secondary 57 55.6 (37.5–72.3) 86.0 (68.1–94.6)
Marital status
Single 294 72.7 (59.0–83.1) 91.0 (62.5–98.4)
Co-habiting 348 64.9 (58.3–71.1) 94.9 (89.7–97.5)
Married 1719 72.1 (68.4–75.5) 91.0 (84.1–95.0)
Divorced/separated 69 72.3 (64.9–78.6) 91.7 (84.2–95.8)
Widowed 26 57.3 (33.5–78.1) 90.9 (71.0–97.6)
Total number of previous
pregnancies
0 271 46.6 (39.7–53.6) 80.0 (66.6–88.9)
1–2 1219 70.0 (66.0–73.6) 90.2 (84.1–94.1)
3–4 763 78.5 (74.6–81.9) 95.6 (91.7–97.8)
>4 203 81.6 (74.7–86.9) 93.9 (87.3–97.1)
Locality
Rural 296 66.4 (59.9–72.3) 97.1 (91.9–99.0)
Semi-urban 954 75.5 (70.0–80.4) 88.1 (76.2–94.5)
Urban 1206 68.2 (63.3–72.8) 93.4 (89.3–96.0)
ART- Anti-retroviral therapy, CI- Confidence interval

Discussion
HIV infection was prevalent in 5.9% of pregnant women attending ANC in Tanzania with a
marked regional variation. This study further revealed that Tanzania is still far behind in
attaining the first fast-track targets among pregnant women. HIV status awareness among
pregnant women living with HIV in this survey was only at 70.9%, also with a wide regional
variability. Among pregnant women who knew their HIV status, 91.6% were on ART. Age,
marital status, education level, number of pregnancies, and locality were significant predictors
of HIV infection among pregnant.
To compare the prevalence of HIV infection among pregnant women across rounds of
HSS, we used the crude estimate. The crude prevalence in this survey was 6.3%, which is higher
compared with the prevalence of the preceding survey of 6.1% reported in 2017 (unpublished).
The trend of HIV prevalence has been continually declining from 9.6% in the year 2001 to
5.6% in 2011 [16]. However, in the subsequent surveys including this one, the prevalence has
been inclining. In the 2017 HSS, HIV prevalence was 6.1%, and it is 6.3% in the current HSS.
The incline in prevalence after 2011 may indicate ART-associated improved survival as a result
of the introduction of Option B+ in Tanzania in September 2013. Option B+ recommended
initiating ART to all pregnant women living with HIV regardless of their CD4 count [15, 16,
27]. Option B+ is also an intervention behind the global reduction of MTCT and indeed this
has also resulted in increased fertility among women living with HIV [11, 13, 28, 29].
Improved survival and fertility among women living with HIV may also be evident in this sur-
vey as 70% of pregnant women living with HIV initiating ANC knew their HIV-positive
status.
It is critical to realize that the increasing prevalence is also driven in part by the new infec-
tions. Tanzania is among the countries with the highest HIV incidences worldwide, most of
which occur among females 15–24 years old [7]. As seen in this HSS, although pregnant
women 15–24 years had the lowest prevalence their HIV status awareness was also lowest and
we speculate the majority may be new HIV infections. Trends of HIV prevalence among 15–
24 years old from several sentinel surveillances has been used as a proxy to monitor HIV inci-
dence [30, 31]. In Tanzania, HIV incidence has been declining and similarly HIV prevalence
among pregnant women 15–24 years has been continually declining from 7.6% in 2001 to 3%
in this survey [16]. However, it is worth noting that the changes in the survival of PLHIV may
have affected the reliability of the proxy [31]. An updated assessment of the prevalence of HIV
among young women as a proxy of incidence is needed to ensure its applicability in the cur-
rent era.
HSS has also been used to inform on the prevalence and trend of HIV infections in the gen-
eral population [14]. In this survey, the prevalence of HIV infection among pregnant women
in Tanzania mainland was 5.9%. It was higher compared to that of the general population
(4.7%), but lower than that of women (15–49 years) in the general population (6.4%) as
reported in the population-based survey in 2017 [11]. HSS normally would overestimate the
prevalence in the general population and among women of reproductive age, especially adoles-
cents because of differences in the levels of sexual activity [18]. Indeed, the prevalence of HIV
infection among pregnant women aged 15–49 in Tanzania mainland from 2003/04 and 2006/
07 HSS were higher than those of women from the parallel population-based surveys [15, 27,
32–34]. Conversely, during 2011, 2017, and the current HSS, the HIV estimates among preg-
nant women were lower than that of women in the parallel population surveys [11, 16, 27, 32].
The lower prevalence in the recent HSS than in the general population surveys may also reflect
ART-associated survival of women living with HIV. As a result, HIV infections are more pro-
nounced in the population-based surveys than in the surveillance of pregnant, because HIV

infection has shifted toward older, less-fertile women [29, 35]. Although fertility among
women living with HIV has improved in Tanzania and other similar settings, it is still lower
than that of women not living with HIV, especially among older ones [36–38]. Therefore, esti-
mating HIV prevalence in the general population using the HSS findings should account for
this shift in HIV and fertility patterns [29, 35].
Similar to the previous ANC surveys and other population-based surveys, the 2020 ANC
HSS observed wide regional variations in HIV prevalence ranging from 1.9% in the Manyara
region to 16.4% in the Njombe region. Iringa region (13.6%) and Mbeya region (11.9%)
ranked second and third for HIV prevalence, in line with findings from the previous surveys
[27]. The persistently high burden in these regions could partly be explained by the continued
efforts by the Government of Tanzania and its stakeholders to address AIDS-related deaths
resulting in improved survival for people living with HIV infection. However, the persistently
high prevalence and low HIV status awareness in these regions may indicate the potential for a
high transmission rate. Consequently, the high prevalence, low HIV status awareness, and sub-
sequently low ART coverage may further fuel onward transmission and increase the incidence
of HIV infections [39].
The overall HIV status awareness has increased from 43% in 2017 to 70% in 2020, but it is
still below the 95% target. Only one region (Ruvuma) reached 90% in this survey. Although
91.6% of pregnant women who were aware of their HIV-positive status were on ART, overall,
only 66.6% of all women living with HIV in this survey were diagnosed and on ART. It is
worth stressing that the low level of HIV status awareness and ART coverage persisted even in
sensitivity analyses. Closing this gap in HIV testing and treatment is a critical part of the
response to the HIV epidemic as it has significant implications for preventing onward trans-
mission of HIV and its impact on the incidence at the population level [40]. Tanzania, which is
also among the countries with the highest HIV incidences globally, urgently needs to
strengthen the existing HIV testing services (HTS) and employ new and innovative ways to get
people tested for HIV. As revealed in this study, the expansion of HTS also needs to be done
strategically by prioritizing regions and population groups with lower coverage of HTS and
ART, such as young women and adolescents. Coverage was almost twice for non-primigravida
compared to primigravida women indicating that integration of HTS into other services
increases the uptake of HTS which is in line with the findings and recommendations of other
studies [41–43]. These should go hand in hand with linkage to treatment and care [3]. Efforts
should be directed toward the most vulnerable areas with high prevalence, low HIV status
awareness, and low ART coverage [44]. It is relatively more challenging, logistically and finan-
cially, to determine incidences, but data from surveillances such as this one may help inform
on the incidence and implement interventions. Additionally, through surveys such as this, a
score for predicting incidence using the data from surveys may be developed and validated.
The analysis of factors associated with HIV determined that older age and lower level of
education were associated with higher HIV prevalence. The age factor reflects the increased
survival of PLHIV in the era of ART. Since this was a cross-sectional survey, it is not surprising
that older pregnant women were more likely to be found with HIV infection than their youn-
ger counterparts. A cross-sectional survey, by nature of its design, studies survivors of a
chronic infection like HIV and hence high prevalence among them. The prevalence of HIV
decreased with an increase in education level like in the population-based HIV survey in Tan-
zania [11]. Education attainment delays sexual debut and keeps girls in school which offers a
protective environment against unwanted pregnancies and risky sexual behaviors [45]. Evi-
dence in the current survey is contrary to the previous surveys, where the prevalence of HIV
was higher among people with higher levels of education [15]. This was thought to be

attributed to a lack of access to HIV preventive methods and their positions in society ren-
dered them to risky sexual behaviors [15].
In the current survey, pregnant women in the marital union had the lowest prevalence of
HIV infection (5.7%) compared to those outside of the marital union. The highest prevalence
was observed among pregnant women reported to be widowed (23.0%), divorced or separated
(22.4%), and those who were single (10.4%). The relationship between marital status and HIV
infection is complex and largely understudied but cultures and sexual behaviors have a large
role in this interplay [46, 47]. Consistent with our findings, the recent population demographic
survey indicated a lower lifetime number of sexual partners among married women compared
to women outside the marital union. Married women are also more likely to use condoms dur-
ing sexual intercourse with a person who is not their husband or living with them compared to
unmarried women [48], preventing them from new HIV infections.
Living in urban and semi-urban areas was associated with higher HIV infections compared
to living in rural areas in this survey. A similar pattern has been observed among pregnant
women over the years in Tanzania [27]. The sexual behavioral differences between women in
urban and rural may influence this observation. Women in rural areas have a lower average
number of lifetime sexual partners and fewer have sexual intercourse outside of marital union
or with a non-cohabiting partner compared to women in urban areas [48]. However, the pro-
portion of condom use in these instances is comparable in the two settings [48].
It has been observed in several studies that individuals who are affected with HIV have
lower participation in the labor force particularly in manual labor and understandably, the
severity of the disease is associated with lower employment [49, 50]. Nevertheless, in this
nationwide survey, the prevalence of HIV was higher among those who reported being
employed or self-employed. This observation may be a result of the survival and stability of
those who are employed compared to those who are not employed. People affected with HIV
who are employed are likely to test for HIV, be diagnosed earlier, and initiate ARTs with better
adherence than people who are not employed [49, 51, 52]. This can in turn translate to better
survival and stable health among those employed compared to those who are not employed
[51, 52]. Employment increases financial and economic empowerment among women, which
may increase access to healthcare services, reduce HIV-related morbidity and mortality, and
improve the quality of life for PLHIV [51, 53].
This study is not without some limitations. Most of the sites used in this survey were inher-
ited from previous surveys and there are some demographic changes of the sites over time and
newer PMTCT sites which could have featured in the sampling frame had sampling been con-
ducted again. Thus, the choice to inherit previous PMTCT sites might have narrowed our
potency to be as representative as possible and the weights used were regional weights and due
to the lack of updated and reliable strata specific data for each region. In addition, the distribu-
tion of characteristics of non-responders were not collected which could have influenced the
results. However, the non-response rate was exceedingly low (<2%), and this survey had sub-
stantial sample size of over thirty-eight thousand pregnant women on their first ANC visit.
Conclusion
One in every twenty pregnant women attending ANC in Tanzania mainland is living with
HIV. Prevalence varies between regions, but HIV is especially prevalent among older pregnant
women, those with lower or no formal education, those outside marital unions, and those liv-
ing in urban and semi-urban areas. Only seven out of ten pregnant women living with HIV
are aware of their HIV-positive status. However, ART is covered in about nine out of ten preg-
nant women living with HIV who were aware of their HIV-positive status. Behind the global

fast-target to end HIV/ AIDS, about a third of pregnant women living with HIV initiating
ANC were not on ART. Interventions to increase HIV testing and linkage to care among
women of reproductive age should be intensified.
Supporting information
S1 Checklist. STROBE statement—a checklist of items that should be included in reports
of observational studies.
(DOCX)
Acknowledgments
We wish to thank all regional and district medical officers, regional and district reproductive,
and sexual health coordinators for their support in the implementation of the survey. Our sin-
cere appreciation to the nurses at the facilities for their commitment throughout the study. BSJ
passed away before the submission of the final version of this manuscript. EM (Corresponding
author) accepts responsibility for the integrity and validity of the data collected and analyzed.
Author Contributions
Conceptualization: Erick Mboya, Mucho Mizinduko, Belinda Balandya, Jeremiah Mushi,
Amon Sabasaba, Davis Elias Amani, Doreen Kamori, George Ruhago, Prosper Faustine,
Veryeh Sambu, Bruno Sunguya.
Data curation: Erick Mboya, Mucho Mizinduko, Jeremiah Mushi, Amon Sabasaba, Prosper
Faustine, Veryeh Sambu, Bruno Sunguya.
Formal analysis: Erick Mboya, Mucho Mizinduko, Jeremiah Mushi, Amon Sabasaba, Prosper
Faustine, Bruno Sunguya.
Funding acquisition: Prosper Faustine, Sarah Asiimwe, Andrea B. Pembe, Bruno Sunguya.
Investigation: Erick Mboya, Mucho Mizinduko, Belinda Balandya, Jeremiah Mushi, Amon
Sabasaba, Davis Elias Amani, Doreen Kamori, George Ruhago, Prosper Faustine, Werner
Maokola, Veryeh Sambu, Mukome Nyamuhagata, Boniphace S. Jullu, Amir Juya, Joan
Rugemalila, Bruno Sunguya.
Methodology: Erick Mboya, Mucho Mizinduko, Belinda Balandya, Jeremiah Mushi, Amon
Sabasaba, Doreen Kamori, George Ruhago, Prosper Faustine, Veryeh Sambu, Boniphace S.
Jullu, Bruno Sunguya.
Project administration: Erick Mboya, Mucho Mizinduko, Belinda Balandya, Jeremiah Mushi,
Amon Sabasaba, George Ruhago, Werner Maokola, Veryeh Sambu, Boniphace S. Jullu.
Resources: Mucho Mizinduko, Jeremiah Mushi, Bruno Sunguya.
Software: Mucho Mizinduko, Amon Sabasaba.
Supervision: Erick Mboya, Mucho Mizinduko, Belinda Balandya, Jeremiah Mushi, Amon
Sabasaba, Davis Elias Amani, George Ruhago, Prosper Faustine, Andrea B. Pembe, Bruno
Sunguya.
Validation: Erick Mboya, Mucho Mizinduko, Belinda Balandya, Jeremiah Mushi, Amon Saba-
saba, Doreen Kamori.
Visualization: Erick Mboya, Mucho Mizinduko.

Writing – original draft: Erick Mboya, Mucho Mizinduko, Belinda Balandya, Bruno
Sunguya.
Writing – review & editing: Erick Mboya, Mucho Mizinduko, Belinda Balandya, Jeremiah
Mushi, Amon Sabasaba, Davis Elias Amani, Doreen Kamori, George Ruhago, Prosper
Faustine, Werner Maokola, Veryeh Sambu, Mukome Nyamuhagata, Amir Juya, Joan Ruge-
malila, George Mgomella, Sarah Asiimwe, Andrea B. Pembe, Bruno Sunguya.
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PLOS ONE

HIV burden and the global fast-track targets

Published: October 12, 2023

PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 1 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 2 / 17

Materials and methods

PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 3 / 17

HIV testing procedures

Data management and analysis

PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 4 / 17

Prevalence of HIV by demographic characteristics of participants

Prevalence of HIV infection by regions

PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 5 / 17

ANC- Antenatal clinic, CI- Confidence Interval

Factors associated with HIV infection among pregnant women

PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 6 / 17

ANC- Antenatal Clinic, CI- Confidence interval

Awareness of HIV-positive status and ART coverage

PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 7 / 17

Awareness of HIV Positive Status and ART coverage by regions

PLOS ONE | https://doi.org/10.1371/journal.pone.0285962 October 12, 2023 8 / 17

HIV Status awareness and ART coverage by demographic characteristics

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Table 4. HIV Status awareness and ART coverage by demographics.

ART- Anti-retroviral therapy, CI- Confidence interval

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