Globally, the uptake of the prevention of mother to child transmission (PMTCT) programme has significantly improved from 49% in 2010 to 82% in 2018 [1]. To achieve the elimination of mother-to-child transmission (MTCT), HIV-positive women and their babies must be enrolled and retained in PMTCT programmes and must adhere to ART [2]. In 2013 the World Health Organization (WHO) recommended that countries consider moving from Option A or B to Option B+, an option advocated for developing countries. In Option B+, women are initiated on life-long combined antiretroviral therapy (ART) as soon as they test positive, regardless of their CD4 count or clinical staging. Option B+ differs from previous policies in that PMTCT services are integrated into routine antenatal care (ANC) to strengthen linkages between reproductive health and ART programmes at all service delivery levels for HIV-positive and HIV-negative women. In Option B+, there is a complete integration of ART and PMTCT programmes, and lifelong ART is offered to all pregnant and breastfeeding women with HIV. HIV-exposed infants also receive Nevirapine from birth until 6 weeks [3]. Many countries across sub-Saharan Africa (SSA) have shifted towards the Option B+ strategy [4].

Eswatini is one of the countries that adopted the PMTCT Option B+ approach as a national strategy for the prevention of mother-to-child transmission of HIV in 2013. Following the roll-out of PMTCT option B+, the country has made significant progress in increasing the uptake of PMTCT among HIV-positive women [5, 6]. However, there are concerns in relation to initiation into care, retention in care once initiated on ART though option B+, and adherence to ART [7]. In a pilot study on the implementation of PMTCT option B+ in the first implementation regions in Eswatini, only half of the women initiated on ART had been retained at two years [8].

Research conducted in SSA has documented several challenges encountered during the early implementation of PMTCT option B+. Studies have reported that the initiation of ART on the same day as the HIV diagnosis was associated with a higher risk of disengagement from care in pregnant women in the first six months after ART initiation [8-11]. The same-day HIV testing and ART initiation also contributed to the low uptake of ART under Option B+ [12]. Additionally, early ART-related side effects influenced women’s ART adherence [11, 13, 14].

Studies conducted in countries such as Malawi and Tanzania have identified various barriers to the implementation of PMTCT Option B+ [11, 13, 14]. The lack of male involvement has been considered one of the main barriers against the utilisation of PMTCT services in several studies [7, 12, 13, 15]. The stigma associated with HIV is a key social barrier against the successful implementation of PMTCT interventions. Stigma and discrimination from significant others decrease the willingness to undergo HIV testing, the uptake of PMTCT and adherence to ART, and negatively affect retention in PMTCT care [14, 16-21]. Women are afraid of unintended disclosure or of being publicly identified as living with HIV because they are receiving PMTCT and of subsequently being stigmatised by community members [15].

Suryanti et al. [21] concluded that it would be challenging to implement the PMTCT programme if HIV-positive pregnant women did not disclose their HIV status to significant others. Disclosure to partners and family leads to social support, increased retention in care, increased adherence to ART, increased adherence to breastfeeding regimen, and facilitated childbirth [22-25]. However, many HIV-positive women in PMTCT experience difficulty disclosing their HIV status to their partners [11, 13, 21, 26]. The reasons most commonly given for non-disclosure are fear of anticipated rejection by the partner, fear of being blamed for introducing the infection into the family, fear of HIV-related stigma, fear of domestic violence, and fear of divorce [15, 23, 24, 27]. Non-disclosure, particularly to male partners, is a factor that may contribute to the non-retention of women in PMTCT Option B+ [7, 12]. It is important that issues of partner disclosure are taken seriously when scaling up PMTCT option B+ [27].

Interactions between HIV-positive women and Health Care Workers (HCWs) play a pivotal role in PMTCT service use and contribute to retention to care [28]. Yet, several studies report that HIV-positive women receive discriminatory care and harsh, undignified treatment from HCWs, which leads to disengagement from care [13, 17, 20, 28, 29]. Women who initiated treatment during Option B+ found traveling to health facilities difficult because of the long distances involved and their lack of transport money [11, 28]. Furthermore, evidence suggests that long waiting time is a barrier against the uptake of and retention in PMTCT care [15, 16, 18].

Several studies have noted that women perceive PMTCT as a good programme that protects their babies from acquiring HIV and preserves their own health [10, 30-33]. These benefits motivate women to enroll in PMTCT and come for follow-up care, especially postpartum [13, 17, 20, 34]. The integration of services in the PMTCT option B+ prevents accidental disclosure and promotes retention in PMTCT [20]. In contrast, some women reported negative experiences during their participation in PMTCT. They felt obliged and overwhelmed to test for HIV and started ART on the same day [29, 35].

A Zimbabwean study suggests that the perceptions and experiences of women about the PMTCT programme influence their uptake in PMTC and their retention to care [20]. But, little is known about the perceptions and experiences of HIV-positive women after the adoption of the PMTCT Option B+ approach in Eswatini. Previous research on Option B+ conducted elsewhere in SSA provided context for the current study. However, women in Eswatini, a country with strong patriarchal norms and cultural practices which subordinate women [36], may possibly experience the PMTCT option B+ approach differently. The Kingdom of Eswatini is a small Southern African landlocked country of about 1.25 million people. Its two neighbouring countries are Mozambique and South Africa. The HIV prevalence in Eswatini is estimated at 31% among adults (18–49 years old) and 41.1% among pregnant women [5].

Studies on the early implementation experience of PMTCT B+ in Eswatini used quantitative data to assess the challenges related to lifelong ART initiation [37-39]. Therefore, this study explored how Swazi pregnant women perceive the option B+ PMTCT programme, their experiences while participating in the programme, and the challenges they faced in disclosing their status to their partners. Understanding what Swazi women are concerned about will assist in strengthening PMTCT interventions by making it possible to design appropriate and effective counselling structures [26]. This is particularly important in a country such as Eswatini, where women are regarded as minors and their minority being reinforced by marriage and deeply entrenched beliefs about the role and position of women in society [36].

The sample consisted of 15 HIV-positive pregnant women, five of whom were pregnant for the first time. Their participation in PMTCT ranged from two to seven months. Their ages ranged from 21 to 38 years. Seven were single, and eight were living with their parents or in-laws. Just above half (8) were employed, and nine had attained high school education. Most (13) had disclosed their status to their partners, but nine of them did not know their partners’ HIV status. Of those who knew the partner’s status, two of them were in a serodiscordant relationship (Table 1).

This study describes the experiences of HIV-positive pregnant Swazi women participating in PMTCT Option B+ in Eswatini and the challenges they experienced in disclosing their HIV-positive test results to their sex partners. HIV testing serves as an entry point to the PMTCT programme and is being routinely offered to all pregnant women on their first ANC visit [45]. The participants perceived HIV testing on their first ANC visit as a mandatory entry requirement to access PMTCT services. Other studies also reported that pregnant women perceived HIV testing during their first ANC as compulsory and a prerequisite to receiving any ANC services [10, 46-48].

The pregnant women in this study perceived the routine HIV testing and same-day ART initiation as coercive, and felt that it took away their ability to make an informed decision about testing. In a recent study conducted in Lesotho, pregnant adolescents and young women felt that they had no choice in HIV testing in the PMTCT option B+ [47]. Researchers from studies conducted elsewhere in SSA argue that women view the mandatory HIV testing and prompt ART initiation in the PMTCT programme as violating their rights to autonomy [10, 27, 35, 46, 49]. HIV-positive women who struggle to accept their new HIV status and need to initiate ART may require additional counselling sessions to accept their HIV status. As Eswatini continues to roll out Option B+, there is a need to consider providing individualised counselling sessions to meet the individual needs of women [26].

Despite the participants’ discontent with the mandatory testing, overall, they viewed PMTCT as a good programme that protects their babies from acquiring HIV and provides a gateway to early treatment for the mothers. The positive perception about PMTCT served as a motivation for them to enroll in PMTCT. In this study and prior studies in SSA, the drive to enroll in PMTCT arose from the mother’s desire to protect their babies from HIV infection [7, 19, 20, 34, 48]. The women enrolled in PMTCT understood that they could prevent HIV from transmitting from the mother to the baby by taking and adhering to ART. Health care providers should use the women’s desire to protect the unborn infant from HIV transmission to develop appropriate health messages around PMTCT B+.

Similar observations were reported elsewhere in SSA [49-52]. Being diagnosed with HIV and receiving HIV-positive test results during pregnancy is a traumatic experience for women, as they also had to deal with the pregnancy, the immediate ART treatment, and issues of disclosure – all in one visit. Some of the participants in the current study experienced feelings of anger and shock, which stemmed from a sense of betrayal by their partners, as they regarded themselves as having been faithful to them. The patriarchal culture in Eswatini affords women little or no power to protect themselves from HIV infection [36]. Research suggests that women who test HIV-positive during pregnancy experience more psychological distress than those who knew about their status prior to the pregnancy [38, 53].

The participants commended the positive attitude of the HCWs, which facilitated a good provider-patient relationship, helped them to cope with the HIV-positive test results, and encouraged their continued participation in PMTCT. Similar observations were found in other studies as well [19, 28, 29]. The study found that the integration of PMTCT with other antenatal services helped to minimise the stigma associated with living with HIV. Attending antenatal care with HIV-negative women removed the stigma associated with PMTCT services rendered for HIV-positive women. Concerning negative experiences of participating in PMTCT, long waiting times due to staff shortages were a common negative experience for most of the participants. Other studies also reported similar findings [18, 30].

Even though thirteen of the women in this study had disclosed their HIV status to their partners, they did not disclose immediately after testing positive and had to delay taking their ART. A prior study on PMTCT under Option B+ in Eswatini found that the fear of disclosing one’s HIV status was one of the many challenges of accepting and initiating lifelong ART [38]. Many Swazi women continue to face gender inequality, economic dependency, and patriarchal social factors that influence accepting and initiating lifelong ART [8]. In the current study, the participating women feared accidental disclosure, whereby the partners might recognize their pills and link them to HIV. Other studies reported similar observations [7, 22].

The two women who reported that they had not disclosed to their male partners were afraid of the potential negative consequences of disclosure. The patriarchal norms and cultural practices which subordinate women in Eswatini [36, 54] might have influenced their position about withholding disclosure. The fear of negative consequences of disclosure was reported in prior studies in SSA [7, 12, 21, 27, 47]. For some of the women, the reality is that the consequences of disclosure were negative; some had been blamed for bringing the infection into the house and consequently abandoned by their partners. Research shows that increasingly, women are abandoned after disclosure [18, 38]. Stigma and discrimination from their partners and in-laws was a common reaction received by the participants following disclosure.

Some of those who had disclosed reported positive experiences of disclosure. They were accepted by their partners and helped to adhere to their ART medication and PMTCT attendance. Support from partners and significant family members has a positive impact on adherence and retention in care in PMTCT [7, 47]. Madiba and Putsoane [47], in a recent study conducted in Lesotho, reported partner’s support in the form of reminders to take their ART, providing transport money for attendance at the clinic, and accompaniment to the clinic for antenatal care. Following disclosure, the participants reported that some male partners tested for HIV and enrolled in care.

This study was limited to HIV-positive women who were currently pregnant and excluded HIV-positive women who had delivered. Including this group could have enriched the findings since post-natal women had engaged with the programme for much longer, and their experiences might have been different. Furthermore, the results may not represent health facilities outside the Manzini region and may not represent all HIV-infected women engaged in PMTCT Option B+. One other limitation of the study is that the views of women who had disengaged from the programme were not captured. They would have shed light on some of the issues that led to their disengagement from care.

This study has found that being diagnosed with HIV during pregnancy is a traumatic experience for women participating in the Option B+ programme in Eswatini. However, their drive to protect their unborn babies from HIV infection motivated their participation in and adherence to the PMTCT interventions.

The anticipation of rejection and violence from their partners led to their delaying disclosure and delaying the initiation of ART. Healthcare professionals should pay special attention to education around PMTCT Option B+ when introducing same-day ART. The PMTCT programme should consider providing additional counselling sessions before initiating ART with pregnant women newly diagnosed as HIV-positive in the PMTCT option B+ strategy to prepare them for the uptake of and adherence to ART and other interventions. Providing additional counseling sessions before initiating ART may reduce disengagement from care among women who are newly diagnosed as HIV-positive. This is crucial since, with Option B+, considerable numbers of women will begin lifelong ART.

Since disclosure is critical in the successful implementation of the PMTCT programme, health messages and education around PMTCT under Option B+ need to be shared beyond pregnant women receiving services at the facility, but also engage the community and men about the importance of lifelong ART. This underscores the increased efforts to develop culturally and practically acceptable messaging targeting Swazi men.