HIV/AIDS knowledge and risk behaviour in Hong Kong Chinese pregnant women

Transcription

1 ISSUES AND INNOVATIONS IN NURSING PRACTICE HIV/AIDS knowledge and risk behaviour in Hong Kong Chinese pregnant women Choi Fung Ho BSN MSc RN 1 Nursing Officer, Department of Health, Hong Kong, China and Alice Yuen Loke BSN MN PhD RN Associate Professor, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, China Submitted for publication 24 July 2002 Accepted for publication 19 February 2003 Correspondence: Alice Yuen Loke, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, China. hsaloke@polyu.edu.hk HO C.F. & LOKE A.Y. (2003) Journal of Advanced Nursing 43(3), HIV/AIDS knowledge and risk behaviour in Hong Kong Chinese pregnant women Background. With the increase in HIV infection among childbearing aged women in Hong Kong, health department policy-makers are considering the implementation of antenatal HIV screening to identify infected mothers. However, little is known about women s understanding of HIV/AIDS, and their attitudes towards HIV screening. Aim. The aim of this study was to explore pregnant women s knowledge about HIV/AIDS, their perceptions of risk, risk behaviour and management, and their attitudes towards HIV screening. Methods. A cross-sectional study was carried out, and all Chinese pregnant women who attended an antenatal clinic of a regional hospital in Hong Kong in the month of December 2000 were invited to complete a questionnaire. Findings. Hong Kong pregnant women had fairly good general knowledge of HIV/ AIDS (mean score ¼ 4Æ8/6), but were less knowledgeable on specific mother-to-child HIV transmission (mean score ¼ 3Æ6/6). There were statistically significant differences between those with different levels of education (v 2 ¼ 19Æ81; P < 0Æ001) and between Hong Kong born residents and immigrants from the Chinese mainland (z ¼ 4Æ03; P < 0Æ001). Over a third (36Æ7%) of all pregnant women perceived a risk of contracting HIV. If HIV infection were suspected, over 70% would have HIV screening together with their spouse. If HIV was confirmed, 24% would terminate the pregnancy. As many as 78Æ5% and 72Æ8% of women believed that HIV screening should be carried out before marriage and pregnancy respectively. Only 4Æ7% would choose universal opt-out antenatal HIV testing. Recommendations. Health educators should provide tailored-made education programmes for women at risk, particularly those at lower education levels and those who have come from the Chinese mainland, to enhance their knowledge about mother-to-child HIV transmission, and to promote awareness of safe sex. Health policy-makers should consider the possibility of providing pre-marriage and prepregnancy HIV screening for women. Keywords: knowledge, HIV/AIDS, mother-to-child HIV transmission, perceived risk, risk behaviour, risk management, preference of HIV screening, nursing 238 Ó 2003 Blackwell Publishing Ltd

2 Issues and innovations in nursing practice Introduction Sexual contact is the most common mode of HIV transmission among adults. In Hong Kong (HK), sexual transmission accounts for 85% of HIV infection (Department of Health 2000). The male to female infection ratio has narrowed to 2Æ6 to 1 in 2000 from 10 to 1 in 1988 (Department of Health 2000). The increasing volume of sex trade at the HK China border and the common phenomenon of men in HK having a second wife on the Chinese Mainland (Ho & Choy 1997) have put HK women in a vulnerable position in relation to contracting HIV infection. The mean age of HIV infected women in HK was reported to be at 35 (Department of Health 2000), which is within the childbearing period. In HK, the prevalence of HIV infection of pregnant woman has been monitored by the Unlinked Anonymous Programme of neonatal cord blood testing since 1990 (Lee 2000). In the past decade, the Programme has identified a prevalence rate of HIV infection among pregnant women ranging from 0% to 0Æ03%. However, a study conducted in a local hospital in 1999 that provided voluntary universal HIV screening confirmed that 3 of 5000 expectant mothers tested were sero-positive, which brought the prevalence rate of HIV to 0Æ055% (Department of Health 2000). This is nearly double to that of the Unlinked Anonymous Screening Programme. Mother-to-child (MTC) transmission is a major route of HIV infection among children throughout the world (World Health Organization 2000), and these infected children are likely to die before their teens. According to the Report of the Joint United Nations Programme on HIV/AIDS (UNAIDS 2000), the global estimation of newly HIV infection of children was at the end of In HK, there are 10 children who have been infected with HIV (Department of Health 2000), and most of these acquired HIV during the intrauterine or intrapartum periods, or postnatally via breastfeeding. Mother-to-child HIV transmission is preventable. If infected expectant mothers could be identified and treated early, their chances of giving birth to an infected baby would be greatly reduced. Since 1994, studies have shown that antiretroviral therapy can reduce MTC HIV transmission effectively (Connor et al. 1994, Guay et al. 1999, Dabis & Leroy 2000, Maitlin & Dlamini 2000). If antiretroviral therapy is used, combined with Caesarean section delivery and avoidance of breastfeeding, the chances of passing on HIV infection to babies can be cut down to one-fourth of the expected transmission rate (Watson 1998). Antenatal screening is the most direct and effective way on identifying HIV-infected women and preventing MTC infection. While the Centers for Disease Control and Prevention (CDC) recommended voluntary antenatal HIV testing for pregnant women, others have argued that mandatory testing is more effective at reducing MTC HIV transmission (Kass 2000). Whether the women in HK are receptive to antenatal HIV testing is unknown. If women at risk of HIV infection are to be identified, policies on antenatal screening should be acceptable to them. Public health efforts to protect women and their offspring from HIV infection and to design appropriate health policy and screening services for this vulnerable population, requires an understanding of women s knowledge of HIV, their perceptions of risk, risk behaviour and management, as well as their attitudes towards HIV screening. The study Aim The aim of this study was to explore pregnant women s knowledge about HIV/AIDS, their perceptions of risk, risk behaviour and management, and their attitudes towards HIV screening. The results of this study will provide health policymakers on developing HIV/AIDS prevention services that are acceptable by women, especially for the prevention of MTC HIV infection. Design This was a cross-sectional exploratory study. An antenatal clinic of a major regional hospital in HK was selected as the setting. The clinic covered the whole territory of HK and served over 4000 pregnant women in the year 1999, about one-twelfth of the annual total pregnant women population in HK (Department of Health 2001). The study was targeted to survey approximately 5% of the total annual number of pregnant women attending the clinic. Sample All Chinese pregnant women who attended the antenatal clinic of the regional hospital in the month of December 2000 were invited to participate. Only those who were able to read Chinese were recruited. Self-administered questionnaires were distributed to eligible women after they registered at the clinic. The researcher was present to distribute and collect all questionnaires in person. Ethical considerations HIV/AIDS knowledge and risk behaviour Ethical approval was received from the university where the study was based. Approval for access was obtained from the Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(3),

3 C.F. Ho and A.Y. Loke appropriate regional hospital. Women were given an explanation on the purposes of the study, and they signed a consent form before completion of questionnaire. After they completed the questionnaires, they were given an information leaflet specially designed to provide further information on free HIV counselling and testing. The researcher was available to answer any questions or concerns regarding HIV and screening services. Questionnaire A self-administered questionnaire was developed based on a literature review of relevant studies. A panel of experts including a senior medical officer (obstetrician), nurse specialist in obstetrics and gynaecology, and a nurse specialist in AIDS were invited to validate the questionnaire. All questions were judged by the three experts as appropriate and valid for the study, with the content validity index calculated as 1 (good) (Polit & Hungler 1999). A pilot study was conducted to examine the test retest reliability and internal consistency of the questionnaire (Portney & Watkins 2000). Internal consistency was measured by the Intra-Class Correlation Coefficient and Kappa analysis of the categorical items. The Intra-Class Correlation Coefficient for the questions on HIV knowledge was calculated to be 0Æ97 and Kappa analysis of the categorical items on the questionnaire ranged from 0Æ7 to 0Æ9. The test retest reliability was established, with Cronbach a s of 0Æ72 and 0Æ55 for the items on general knowledge of HIV and specific knowledge on MTC HIV infection, respectively. The questionnaire consisted of four parts. The first part was designed to collect demographical information. The second part, consisting of 12 questions, aimed to measure general knowledge on HIV/AIDS and specific knowledge on MTC HIV infection. The third part, consisting of three questions, was to identify women s perceptions of risk of HIV, their risk behaviour, and risk management when facing possible infection. The fourth part explored their attitudes towards HIV screening. Data analysis All data collected were analysed using SPSS version 9. Descriptive statistics were used to show the demographics of the pregnant women, their knowledge about HIV/AIDS, perceived risk, risk behaviour and management, and attituteds towards HIV screening. Non-parametric tests (Kruskal Wallis test and Mann Whitney) were used to compare the ranked knowledge scores between those of different residence status and different education level. Results A total of 406 pregnant women attended the antenatal clinic during the time of the study: 81 were non-chinese or illiterate and were excluded. As a result, 325 pregnant women were recruited and 126 refused to complete the questionnaire, giving a response rate of 61Æ2%. Eight of 199 questionnaires were discarded as incomplete. As a result, 191 questionnaires were analysed for this study. Demographics of women Table 1 shows the demographics of women in the study, who were years old, with mean age of 29Æ6. More than half (n ¼ 120, 62Æ8%) were primipara. The vast majority were married (n ¼ 186, 97Æ4%), and had received secondary education or above (n ¼ 185, 96Æ9%). About 40% (n ¼ 76, 39Æ8%) were housewives. Among these Chinese pregnant women, 157 (82Æ2%) were HK residents (lived in HK for more than 7 years) and 33 (17Æ3%) were immigrants from the Chinese mainland and had lived in HK for less than 7 years. About one-tenth (n ¼ 20, 10Æ5%) of their husbands jobs required frequent travel crossing the HK China border. Table 1 Demographic characteristics of pregnant women (n ¼ 191) Characteristics n % Years of age (mean ± SD) 29Æ61 ± 4Æ61 Number of pregnancies Primipara Æ8 Multipara 71 37Æ2 Marital status Married Æ4 Not married 5 2Æ6 Education level No schooling/ primary school 6 3Æ1 Secondary school Æ0 University or above 38 19Æ9 Working status Working woman Æ2 Housewife 76 39Æ8 Residence status in Hong Kong Hong Kong born residents Æ2 Immigrants from China 33 17Æ3 Missing 1 0Æ5 Husband s job required frequent travel crossing HK China border No Æ5 Yes 20 10Æ5 240 Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(3),

4 Issues and innovations in nursing practice Women s knowledge of HIV/AIDS Women had fairly good knowledge of HIV/AIDS. Table 2 shows that majority knew that AIDS is an infectious disease (n ¼ 175, 91Æ6%), recognized that the appearance of HIV carriers is no difference from that of the normal population (n ¼ 161, 84Æ3%), disagreed with the statement that women with only one sexual partner will not get AIDS (n ¼ 151, 79Æ1%), knew that using condoms can reduce the chance of getting AIDS (n ¼ 170, 89Æ0%), and realized that there is no medication to cure AIDS (n ¼ 150, 78Æ5%). However, nearly half (n ¼ 83, 43Æ5%) of the women thought that mosquitoes are carriers of HIV. Women were less knowledgeable about specific knowledge on MTC HIV transmission. Only a small number disagreed with the statements If a father is infected with HIV, then the mother will inevitably be infected (n ¼ 74, 38Æ7%), If a mother is infected, there is no means to reduce the chance of HIV transmission to her baby (n ¼ 30, n ¼ 15Æ7%), and knew that Babies may be infected if breastfed by HIV infected mothers (n ¼ 80, 41Æ9%). The majority of women knew that HIV infection may be transmitted from mother to foetus during pregnancy (n ¼ 185, 96Æ9%), HIV infected mothers may transmit HIV virus to newborns during delivery (n ¼ 172, 90Æ1%), and that HIV can be transmitted to the baby through casual kissing, (n ¼ 150, 78Æ5%). HIV/AIDS knowledge and risk behaviour Knowledge about HIV/AIDS and women s demographic characteristics Table 3 the compares knowledge on HIV/AIDS among women with different levels of education and residence status using Kruskal Wallis and Mann Whitney tests. The results show that there are statistically significant differences between recent immigrants from the Chinese mainland and HK residents (z ¼ 4Æ03; P < 0Æ001), and among pregnant women with different levels of education (v 2 ¼ 19Æ81; P < 0Æ001). Women from the Chinese mainland had a lower mean score for general knowledge about HIV/AIDS (3Æ97 vs. 4Æ98, z ¼ 3Æ50, P < 0Æ001) and a lower mean score for specific MTC HIV knowledge (3Æ09 vs. 3Æ73, z ¼ 2Æ86, P ¼ 0Æ004). Women with primary or below education, compared with those with secondary education and tertiary education, had a lower mean score for general knowledge on HIV/AIDS (3Æ83, 4Æ66, 5Æ45, respectively, v 2 ¼ 15Æ85, P < 0Æ001) and a lower mean score for specific MTC HIV knowledge (2Æ67, 3Æ54, 4Æ05, respectively, v 2 ¼ 12Æ93, P ¼ 0Æ002). Perceptions of risk, risk behaviour and management Of 191 pregnant women, 116 (60Æ7%) believed that there was no chance that they could contract HIV, and 70 (36Æ6%) perceived that they had a slight chance or could possibly be Table 2 Pregnant women s knowledge on HIV/AIDS (n ¼ 191) Knowledge on HIV/AIDS Correct answer n % General knowledge on HIV/AIDS Q1 AIDS is an infectious disease Æ6 Q2 Mosquitoes are vectors of HIV Æ5 Q3 The appearance of HIV carriers are no difference from normal Æ3 population Q4 Women with only one sexual partner will not get AIDS Æ1 Q5 Condom usage can reduce the chance of contracting AIDS Æ0 Q6 There are medications available to cure AIDS Æ5 Specific knowledge on mother-to-child HIV infection Q7 HIV infection may transmit from mother to fetus during pregnancy Æ9 Q8 If a father is infected with HIV, then the mother is inevitably 74 38Æ7 be infected Q9 HIV infected mother may transmit HIV virus to newborn during Æ1 delivery Q10 If a mother is infected, there is no means to reduce the chance 30 15Æ7 of HIV transmission to her baby Q11 Baby may be infected if breastfed by HIV infected mother 80 41Æ9 Q12 HIV can be transmitted to baby through casual kissing by an infected mother Æ5 Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(3),

5 C.F. Ho and A.Y. Loke Table 3 Relationship between knowledge on HIV/AIDS and women s demographic characteristics General knowledge Mother-to-child transmission knowledge Total knowledge Knowledge on HIV/AIDS n Mean SD Mean SD Mean SD All pregnant women 191 4Æ79 (1Æ25) 3Æ62 (1Æ11) 8Æ41 (1Æ96) HK born residents 157 4Æ98 (1Æ08) 3Æ73 (1Æ05) 8Æ71 (1Æ76) Immigrants from China 33 3Æ97 (1Æ59) 3Æ09 (1Æ28) 7Æ06 (2Æ29) Mann Whitney test z ¼ 3Æ50, P < 0Æ001 z ¼ 2Æ86, P ¼ 0Æ004 z ¼ 4Æ03, P < 0Æ001 Education level Primary or below 6 3Æ83 (1Æ72) 2Æ67 (0Æ52) 6Æ50 (1Æ87) Secondary 147 4Æ66 (1Æ28) 3Æ54 (1Æ17) 8Æ20 (1Æ99) Tertiary or above 38 5Æ45 (0Æ72) 4Æ05 (0Æ77) 9Æ50 (1Æ31) Kruskal Wallis test v 2 ¼ 15Æ85, P < 0Æ001 v 2 ¼ 12Æ93, P ¼ 0Æ002 v 2 ¼ 19Æ81, P < 0Æ001 Mann Whitney test A(z ¼ 1Æ37, P ¼ 0Æ172) A(z ¼ 2Æ31, P ¼ 0Æ021) A(z ¼ 2Æ12, P ¼ 0Æ034) B(z ¼ 2Æ68, P ¼ 0Æ007) B(z ¼ 3Æ49, P < 0Æ001) B(z ¼ 3Æ24, P < 0Æ001) C(z ¼ 3Æ64, P < 0Æ001) C(z ¼ 2Æ46, P ¼ 0Æ014) C(z ¼ 3Æ77, P < 0Æ001) A significant difference between primary or below and secondary, B significant difference between primary or below and tertiary or above, C significant difference between secondary and tertiary or above. at risk (Table 4). Among those women who perceived this risk to exist, their fears were because of the fact that either they or their husbands had had multiple sexual partners (eight women, 11Æ4%, and 19 husbands, 27Æ1%), and that they had received a blood transfusion (16 women, 22Æ9% and four husbands, 5Æ7%). None reported use of intravenous drugs. When HIV infection was suspected, about three quarters of the women would take HIV screening, together with their husband (n ¼ 135, 70Æ7%). Nearly half would verbalize their concern to their husband (n ¼ 82, 42Æ9%). However, four women (2Æ1%) would remain silence to avoid conflicts. Only 44 (23%) would use a condom when having sexual contact. If husband was confirmed to have HIV infection, 176 women (92Æ1%) would seek medical advice and one-fourth (n ¼ 45, 23Æ6%) would choose to terminate the pregnancy. Attitudes towards HIV screening Table 5 shows women s preference for HIV screening. Most of them would prefer to this before registering their marriage (n ¼ 150, 78Æ5%), followed by before pregnancy (n ¼ 139, 72Æ8%). The remainder indicated that they would prefer testing before delivery (n ¼ 47, 24Æ6%). When were asked about voluntary antenatal HIV screening, 78 (40Æ8%) preferred universal mandatory testing, and 75 (39Æ3%) preferred universal testing with prior consent; only nine (4Æ7%) preferred universal, opt-out testing. If antenatal HIV screening was provided, 147 (77Æ0%) would choose to take this, while 14 (7Æ3%) would not. Thirty women (15Æ7%) did not indicate whether or not they would take the test. Discussion The 61% response rate in this study of the sensitive topic of AIDS is considered acceptable, and is comparable with that of two other studies in HK. A survey on AIDS by the HK AIDS Foundations in 1992 had a response rate of 47% (1996) and another on AIDS by the St John s Cathedral HIV Information & Drop-In Center targeting the whole HK female population in 1998 had a similar response rate of 63% (Fung & Chung 1998). The response rates of these studies reflect the reluctance of HK Chinese women to discuss matters related to this sensitive topic. During recruitment for this study, the researcher observed that women who refused to take part in the study were mostly emigrants from the Chinese Mainland, who expressed worries about upsetting their husbands if they completed the questionnaire. The pregnant women in this study match the profile and characteristics of pregnant women in HK. They are married, aged between 26 and 35 years, primipara, had secondary education or above, were working outside the home, and one-tenth were married to men whose job required them to cross the HK China border frequently. The women had fairly good general knowledge of HIV/ AIDS: more than 80% answered correctly five of six questions, with a mean score of 4Æ8 of the possible 6. Only 108 (56Æ5%) knew that mosquitoes are not carriers of HIV. However, this is an improvement on the 7% correct rate in 1992 (AIDS Foundation 1996) and 53% in Fung and Chung s (1998) study in This result indicates that 242 Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(3),

6 Issues and innovations in nursing practice HIV/AIDS knowledge and risk behaviour Table 4 Pregnant women s perceived risk, risk behaviour and management on HIV/AIDS (n ¼ 191) n % Perceived risk of contracting HIV No chance at all Æ7 Slight chance 63 33Æ0 Could be 7 3Æ6 Likely 0 0 Do not know 5 2Æ6 Risk behaviour (among women who perceived risk, n ¼ 70) Risk behaviour of woman: received blood transfusion 16 22Æ9 multiple sexual partners 8 11Æ4 contacted with HIV carriers 4 5Æ7 used intravenous drug 0 0 Risk behaviour of husband: multiple sexual partners 19 27Æ1 received blood transfusion 4 5Æ7 contacted with HIV carriers 3 4Æ3 used intravenous drug 0 0 Risk management If husband is suspected to have HIV infection, the woman would: take HIV screening together with spouse Æ7 verbalize her concern to spouse 82 42Æ9 take HIV screening on her own 37 19Æ4 ask husband to use condom when 44 23Æ0 having sexual contact refuse to have sex with spouse 20 10Æ5 separate with spouse 9 4Æ7 remain silent to avoid conflicts 4 2Æ1 no response 4 2Æ1 If husband is confirmed to have HIV infection, the woman would: seek medical advice Æ1 terminate the pregnancy 45 23Æ6 seek help from psychologist 1 0Æ5 seek support from others 1 0Æ5 do not know what to do 4 2Æ1 Table 5 Pregnant women s preference towards HIV screening (n ¼ 191) n % Preferred time for receiving HIV screening Before matrimony registry Æ5 Before pregnancy Æ8 Before delivery 47 24Æ6 Whenever deem needed 44 23Æ0 Regular/annual check up 3 1Æ6 No special preference 3 1Æ6 Preferred type of antenatal HIV screening Universal test; mandatory 78 40Æ8 Universal test; opt-out 9 4Æ7 Universal test; prior consent 75 39Æ3 Test by request 5 2Æ6 Test by request; for risk group only 3 1Æ6 Option for taking Antenatal HIV Screening if provided Yes Æ0 No 14 7Æ3 Not decided 30 15Æ7 pregnant women in HK are now more aware of the possible routes of HIV transmission. Nonetheless, there is room for improvement. Women were less knowledgeable about MTC HIV transmission, and only answered correctly on three out of the six questions, with a mean score of 3Æ62 of the possible 6. Although majority knew that HIV could be transmitted to the foetus by an infected mother during pregnancy (96Æ9%) and delivery (90Æ1%), 84Æ3% did not know that there are means to reduce MTC HIV transmission and 58Æ1% did not know that HIV can be transmitted through breastfeeding. The results show that pregnant women have relatively little knowledge about specific MTC HIV transmission and do not know about the means to reduce MTC HIV infection. New immigrant women from the Chinese mainland, in comparison with women from HK, had an overall lower mean score for general knowledge on AIDS/HIV (3Æ97 vs. 4Æ98) and specific MTC HIV knowledge mean score (3Æ09 vs. 3Æ73). According to these results, immigrant women and those with lower education are more likely to have misconceptions about routes of HIV transmission and prevention, and are more vulnerable to HIV infection. About 61% of pregnant women did not think they had any chance at all of contracting HIV. While on one hand this is good news in the sense that they believed they were immune because of safe sexual practices or having one stable sexual partner, on the other hand no one can be sure about the faithfulness of their husband and other risks. It is of concern that only 36Æ6% perceived that they had a risk of contracting HIV. However, these women who were aware of the risk might take precautions when in doubt. Seventy (36Æ6%) women who perceived themselves to be as risk were asked about their risk behaviours, and 23 27% of these worried because of previous blood transfusion. Others reported that either they or their husband had had multiple sexual partners (11Æ4% and 27Æ1%, respectively) or had been in contact with HIV carriers (5Æ7% and 4Æ3%). None admitted to using intravenous drugs. These women aware that, as well as blood transfusion, sexual contact was a major risk behaviour for HIV/AIDS. Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(3),

7 C.F. Ho and A.Y. Loke What is already known about this topic Little is known about Hong Kong pregnant women s perceived risk of contracting HIV. There is no previous study of women s risk management behaviour when facing possible HIV infection. It is recommended that pregnant women should be tested for HIV infection during antenatal period, either by voluntary or mandatory testing. What this paper adds Majority of pregnant women in Hong Kong (93Æ7%) perceived either no risk or only a slight chance of contracting HIV infection. About 70% of women would take HIV testing if their husband was suspected to have HIV infection, and 92% would seek medical advice if their husband was confirmed to have HIV infection. Hong Kong pregnant women preferred to have HIV testing before marriage (78Æ5%) or pregnancy (72Æ8%) rather than in the antenatal period, as suggested by health policy-makers. Women in this study appeared capable of handling suspected and confirmed situations of HIV infection. If HIV infection was suspected, over 70% of women would take HIV screening together with their spouse, and 19Æ4% would take the test on their own. However, only 23% would ask their husband to use condoms with sexual contact, and 10Æ5% would refuse to have any sexual contact with their husband. Four actually reported that they would keep silence to avoid conflicts, and these women were at risk as they were less likely to take action to protect themselves. Once HIV infection was confirmed, 92% of these pregnant women would seek medical advice, and 24% would terminate the pregnancy. Again, there were four women who don t know what to do. In this study, women were asked their views on the appropriate time to have HIV screening. As many as 78Æ5% and 72Æ8% thought that HIV screening should be carried out before marriage and pregnancy, respectively. These women seemed proactive, believing that testing for HIV during the antenatal period is perhaps not as appropriate to have the testing carried out before marriage and before starting a pregnancy. Their thinking may be reasonable, since earlier identification of infection could offer choices on whether marry a person, and whether to conceive a baby. However, premarital and prepregnancy HIV screening are not available in HK. Women were also asked if they would volunteer to have HIV screening, and 77% indicated that they would do this if it was provided. Forty percentage would prefer mandatory testing, while another 40% would prefer universal testing with prior consent. Only 4Æ7% would choose universal optout testing. It should be noted that in September 2001, shortly after the completion of this study, the Department of Health and Hospital Authority of Hong Kong jointly implemented a universal opt-out HIV testing programme in all antenatal clinics in HK. Recommendations In spite of existing health education programmes on HIV/ AIDS provided by the public health sector and nongovernment organizations in HK, the knowledge of respondents in this study on MTC HIV transmission was inadequate and there was lack of awareness about practising safe sex. In addition, women with lower education and new immigrants from the Chinese Mainland were at risk. Such people are particularly vulnerable as they are also more likely to lack social support and awareness of the health services available in HK. Health care professionals have a responsibility to promote safe sexual practice, provide education programmes and support services to these women. Nurses as health educators are encouraged to use the mass media for health promotion as this has been found to be effective and efficient in reaching large numbers of people (Whitehead 2000). Nearly all families in HK have installed television and watching rates are high. A series of short films, games or health education programmes aiming at promoting HIV/AIDS knowledge might be suitable. Furthermore, community-based HIV risk-reduction programmes could be used to increase consistent condom use (DiClemente & Wingood 1995). In direct contact with women at various clinics, health professionals should approach in a subtle and caring manner. Services should be specially tailored for women with lower education and new immigrant women to assist them when facing the sensitive issue of AIDS. The results of this study provide health professionals and policy-makers with better understanding of pregnant women s preferences of HIV screening. In addressing this public health issue, health policy-makers should consider which are the most appropriate times to offering screening services to couples who are planning to get married or to have children. 244 Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(3),

8 Issues and innovations in nursing practice Acknowledgements We would like to express gratitude to Ms R. Chung, Ms C. Lam and Dr K.Y. Leung for their contribution to validating the questionnaire, Dr H.K. Wong and Ms P. Yuen for approval on the access of this study, and Dr Tony Chan for his advice on statistics. Part of content of this paper was derived from Ms C.F. Ho s MSc dissertation at the Hong Kong Polytechnic University. References AIDS Foundation (1996) Report of the Knowledge, Attitude, Behaviour and Practice Survey on AIDS in Hong Kong. AIDS Foundation, Hong Kong. Connor E., Sperling R., Gelber R., Kiselev P., Scott G.O. & Sullivan M. (1994) Reduction of maternal-infant transmission of human immunodeficiency virus type-1 with zidovudine treatment. New England Journal of Medicine 331, Dabis F. & Leroy V. (2000) Preventing mother-to-child transmission of HIV: practical strategies for developing countries. The AIDS Reader 10, Department of Health (2000) Hong Kong STD/AIDS Update 6, Department of Health (2001) Department of Health Annual Report 1999/2000. Government Printing, Hong Kong Special Administrative Region, Hong Kong. 2 Department of Health of Hong Kong (2002) AIDS Situation in accessed 16 June DiClemente R.J. & Wingood G.M. (1995) A randomized controlled trial of an HIV sexual risk reduction intervention for young African-American Women. Journal of American Medical Association 274, Fung E. & Chung S.F. (1998) Survey on women & AIDS: AIDS knowledge, attitudes, opinions about condom use and practice with spouse or sexual partner(s). St John s Cathedral HIV Information & Drop-In Centre, Hong Kong. HIV/AIDS knowledge and risk behaviour Guay L., Musoke M., Fleming T., Bagenda D., Allen M., Nakabitto C., Sherman J., Bakaki B., Ducar C., Deseyve M., Emel L., Mirochnick M., Fowler M.G., Mofenson L., Miotti P., Dransfield K., Bray D., Mmiro F. & Jackson J.B. (1999) Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 354, Ho C.O. & Choy Y.L. (1997) Research Report on AIDS Awareness and Sexual Behaviour of Truck Drivers in Hong Kong. Division of Social Studies, City University of Hong Kong and AIDS Concern, Hong Kong. Kass N, (2000) A change in approach to prenatal HIV Screening. American Public Health Association, 90, Lee S.S. (2000) Assessing HIV Risk in a Population: Final Report of the AIDS Scenario and Surveillance Research Project. Government Printing, Hong Kong Special Administrative Region, Hong Kong. Maitlin S.A. & Dlamini Q.Q. (2000) HIV/AIDS in the Commonwealth 2000/1, The XIII International AIDS Conference, Durban, 3 South Africa, pp Polit D.F. & Hungler B.P. (1999) Nursing Research: Principles and 4 Methods, 6th edn. Lippincott Williams & Wilkins, Philadelphia. Portney L.G. & Watkins M.P. (2000) Foundations of Clinical Research: Applications to Practice, 2nd edn. Prentice-Hall, Englewood Cliffs, NJ. Scientific Committee on AIDS (2001) Recommended Clinical Guidelines on the Prevention of Perinatal HIV Transmission. Advisory Council on AIDS, Hong Kong Special Administrative Region, Hong Kong. UNAIDS (2000) Report on the Global HIV/AIDS Epidemic. Joint 5 United Nations Programme on HIV/AIDS, Geneva. Watson S. (1998) New HIV guidelines for pregnant women. Nursing Standard 13, 6. Whitehead D. (2000) Using mass media within health-promoting practice: a nursing perspective. Journal of Advanced Nursing, 32, World Health Organization (2000) Women and HIV/AIDS. accessed 16 June Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(3),