Trends and inequalities in HIV testing uptake among pregnant women during antenatal care in Ghana: a decomposition analysis from 2008 to 2022

Abstract

BACKGROUND: Human immunodeficiency virus (HIV) testing during antenatal care (ANC) is pivotal for prevention of mother-to-child transmission (PMTCT), facilitating early initiation of antiretroviral therapy, infant prophylaxis, and retention in care. While coverage has improved globally, inequalities threaten progress towards Sustainable Development Goal (SDG) 3.3 on ending the AIDS epidemic. This study examined trends and inequalities in HIV testing uptake among pregnant women during ANC in Ghana between 2008 and 2022. METHODS: Data were drawn from the 2008, 2014, and 2022 Ghana Demographic and Health Surveys, comprising a pooled sample of 41,574 women aged 15-49 years who had given birth within two years preceding each survey. The World Health Organization's Health Equity Assessment Toolkit was applied to estimate Differences (D), Ratios (R), Absolute Concentration Indices (ACI), Population Attributable Fractions (PAF), and Population Attributable Risks (PAR) across equity stratifiers which include ge, education, marital status, residence, region, and wealth. RESULTS: The study found that the national coverage of HIV testing during ANC increased from 28.9% in 2008 to 61.0% in 2014 and 72.4% in 2022. Uptake improved among women with no education (18% in 2008 to 60% in 2022) and rural women (20-70%). Nonetheless, wealth quintile, uptake in 2022 ranged from 92.3% in the richest to 51.7% in the poorest; the ACI was 8.2% (95% CI 7.2-9.1) and PAF 27.5% (95% CI 27.4-27.5). Regional disparities were largest with Volta achieving 88.9% versus 32.8% in Savannah, with D rising from 39.7% in 2008 to 56.1% in 2022, while PAF fell from 70.1% (95% CI 69.8-70.3) to 22.7% (95% CI 22.7-22.8). Educational inequalities narrowed; PAF declined from 106.0% (95% CI 105.4-106.5) in 2008 to 34.8% (95% CI 34.8-34.9) in 2022. Age-related differences were negligible, with ACI 1.8% (95% CI - 0.6 to 4.2) in 2022. CONCLUSION: Ghana has achieved substantial expansion of ANC-based HIV testing over the past decade. However, pronounced regional and socioeconomic inequalities remain. Targeted, equity-oriented interventions focusing on northern regions and poorest households are essential to prevent avoidable paediatric HIV infections and to sustain progress towards SDG 3.3.