Factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B for pregnant women in Nepal: a qualitative study

According to the Nepalese national guidelines, integrated screening for HIV, syphilis and hepatitis B should be offered free of charge to all pregnant women during their first antenatal visit. However, the screening uptake among pregnant women remains low in the country. Identifying factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B is essential to increase uptake and prevent mother-to-child transmission. This study investigated the knowledge, attitude, and perceptions of pregnant women, their family members, healthcare workers and decision-makers on integrated antenatal screening. On the demand side, we conducted 26 semi-structured in-depth interviews with pregnant women, their husbands, and mothers-in-law in Kapilvastu and Kathmandu. On the supply side, we conducted 11 interviews with health workers involved in antenatal screening and local and national health system decision-makers. Data were analysed using a thematic content analysis. A combination of the social-ecological model and the WHO building blocks provided a theoretical framework for interpreting the data. The analysis showed that integrated antenatal screening for HIV, syphilis and hepatitis B in Nepal involved many stakeholders and was influenced by various factors. Barriers were mainly on the supply side, including a lack of resources, a shortage of healthcare workers and a lack of training. Husbands and in-laws also play an important role in the acceptance of screening by pregnant women, mainly in rural areas. Stigma and discrimination against people with sexually transmitted diseases were reported high in the communities, and knowledge of hepatitis B and syphilis was low. Improving integrated antenatal screening will require a multi-sectoral approach with greater engagement with communities through awareness programs and enhancement of the role of health posts. This study may be useful to inform decision-makers about the challenges and enable affecting integrated screening, to guide the design of targeted interventions to improve antenatal screening rates.