Low effective coverage of HIV testing and counselling services during antenatal care in Ethiopia: evidence from the demographic and health survey and service provision assessment.

Introduction: Prevention of mother-to-child transmission contributes to avert nearly 4000 new HIV infections in 2022. HIV testing and counselling (HTC) during antenatal care (ANC) is an effective strategy to reduce the vertical transmission of HIV. While the utilisation of HTC services in Ethiopia has been explored, there is limited evidence exploring the effective coverage of HTC during ANC. We aimed to assess the quality-adjusted (effective) coverage of HTC during ANC in Ethiopia. Methods: We linked the 2016 Ethiopian Demographic Health Survey and the 2021-2022 Ethiopian Service Provision Assessment (ESPA) surveys to determine the crude coverage and assess the quality of HTC provision. The ESPA service quality framework, which has structural and process-related components, was used. We used a weighted additive approach of 61 indicators (38 structural and 23 process) to estimate the quality of care score. Administrative boundary linkage was used to link the two datasets. The effective coverage was calculated as the product of crude coverage and the quality of care score. Results: During ANC contacts/visits, 17.2% (95% CI 16.0 to 18.4) of women received HTC. The effective coverage of HTC during ANC was 10.8 (95% CI 9.8 to 11.8), with substantial disparities among administrative regions, ranging from 1.6% (95% CI 1.3, 2.0) in the Somali region to 55.5% (95% CI 53.5 to 57.5) in Addis Ababa. The overall service quality was 45.2% (95% CI 42.8 to 47.1). Health facilities in Harari (31.4% (95% CI 19.0 to 43.8)), Somali (34.1% (95% CI 26.8 to 41.6)) and Dire Dawa (34.9% (95% CI 24.71 to 45.0)) demonstrated low-quality service provision. Health posts (5.8%, SD=8.4), health facilities located in rural areas (30.6%, SD=27.3) and public health facilities (44.2%, SD=29.4) had low-quality HTC provision. Conclusion: Nearly 9 in 10 women did not receive quality HTC during ANC provision. The crude coverage, quality of services provision and effective coverage significantly vary across administrative regions. Afar and Somali regions lagged behind the Addis Ababa and Amhara administrative regions. To effectively mitigate mother-to-child transmission of HIV, policymakers need to prioritise enhancing the quality of care in HTC during ANC and expanding service delivery.