Drivers of Human Immunodeficiency Virus among Pregnant Women in Conflict and Non-conflict Zones of Nigeria

INTRODUCTION

Human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS) remains a significant public health challenge in sub-Saharan Africa, particularly among women of reproductive age.^[1] In Nigeria, approximately 1.2 million women aged 15 and over were living with HIV in 2023, with a prevalence rate of 1.7% among women aged 15–49.^[2] HIV among women significantly increases the chance of vertical transmission, also known as mother-to-child transmission (MTCT) during pregnancy, labor, and breastfeeding.^[3]

Despite the widespread scale-up of prevention of MTCT (PMTCT) services, coverage remains suboptimal, with only 33% of pregnant women receiving antiretroviral therapy (ART) in 2023.^[2] This has contributed to continued vertical transmission, with an estimated 8,200 new HIV infections averted due to PMTCT programs that year,^[2] while advancements in highly active ART have significantly improved survival and quality of life for people living with HIV, challenges, including armed conflict continue to affect equitable access to prevention and treatment services.^[4] Conflict-affected settings exacerbate women’s vulnerability to HIV infection through mechanisms such as gender-based violence, family disintegration due to displacement, and the collapse of healthcare systems.^[4] Understanding the unique drivers of HIV among pregnant women in these volatile settings is essential for designing targeted interventions that can mitigate disparities and improve outcomes.

Recent literature has drawn attention to the destabilizing effect of conflict on HIV care services. Armed conflicts often disrupt epidemiological patterns by displacing large populations, eroding healthcare infrastructure, and increasing the risk of HIV transmission through violence and limited access to care.^[5] In some war-torn areas of sub-Saharan Africa, viral load non-suppression rates have increased up to 30%, with loss to follow-up as high as 43.5%.^[6] However, despite the tremendous challenges associated with health care in war-torn zones, experiences from organizations such as Médecins Sans Frontières have demonstrated that continuity of ART is feasible through innovative strategies like the distribution of run-away bags containing several months of ART medication.^[7] Nevertheless, significant gaps remain in our understanding of how conflict interacts with social determinants, such as education, poverty, and stigma, to influence HIV risk among vulnerable populations. Pregnant women in conflict zones may face unique exposures and barriers that are often reported in existing epidemiological studies.

This study explores predictors of HIV infection among pregnant women in Nigeria, including conflict zone residence as the key variable. The findings provide population-level evidence to guide HIV prevention strategies in high-risk settings.

METHODS

Data Analysis

All analyses were conducted using R software (version 4.4.3). Survey weights were applied to account for the complex sampling design, including stratification, clustering, and post-stratification adjustments. The survey package in R was utilized, specifically the “svydesign” function, to ensure accurate variance estimation and population-level inference.

Descriptive statistics were used to summarize demographic and behavioral characteristics by conflict and non-conflict zones. Categorical variables were compared using Chi-square tests and Fisher’s Exact tests as appropriate, while continuous variables (non-normally distributed) were analyzed using Wilcoxon rank-sum tests. Survey-weighted logistic regression models were fitted to assess the predictors of HIV among pregnant women including conflict or non-conflict zone residence. Covariates included both socio-demographic and sexual behavior and risk factors variables. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were generated, and a forest plot was used to visualize the regression results [Figure 1].

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Figure 1:

Adjusted odds ratios for factors associated with human immunodeficiency virus status among pregnant women aged 15–49 in Nigeria.

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RESULTS

A total of 7,678 pregnant women were analyzed unweighted, with 875 (11.4%) from conflict zones and 6,803 (88.6%) from non-conflict zones. While the weighted sample comprised 3,879,192 pregnant women – 459,135 (11.8%) from conflict zones and 3,420,057 (88.2%) from non-conflict zones – the unweighted figures provide clarity on the actual number of participants assessed. The distribution of languages spoken differed significantly between the zones (p < 0.001). In conflict zones, Hausa was the predominant spoken language (88.5%), followed by English (10.8%). In non-conflict zones, Hausa was less pronounced as the dominant spoken language (56.7%), followed by Igbo (17.0%), Yoruba (16.8%), and English (9.6%). Religious affiliation also showed significant variation (p < 0.001), with a higher proportion of Muslims in conflict (70.0%) compared to non-conflict zones (58.8%). Christianity was more common in non-conflict areas (41.2%) than in conflict zones (30.0%). A larger proportion of pregnant women in conflict zones had no formal education (42.3%) compared to those in non-conflict zones (27.4%). Tertiary education was more prevalent in non-conflict (9.0%) than in conflict zones (2.8%) (p < 0.001).

Most women in both settings were married or cohabiting though the proportion was slightly higher in conflict (96.3%) than in non-conflict (92.3%) zones. Never-married status was more common in non-conflict areas (6.4% vs. 3.4%, p < 0.001). Polygynous marriages were more prevalent among women in conflict (37.2%) than those in non-conflict (31.4%) zones (p < 0.001). Wealth distribution also showed significant differences (p < 0.001), with 30.6% of pregnant women in conflict zones being in the lowest wealth quintile, compared to 21.1% in non-conflict zones. Only 3.7% of women in conflict zones were in the highest quintile, versus 17.7% in non-conflict areas.

No significant difference was observed in the average number of previous pregnancies between the two zones (4 ± 2.6 vs. 4 ± 2.4; p = 0.31). However, a higher proportion of pregnant women in non-conflict zones reported having sex with a non-marital, non-cohabiting partner in the past year (6.5% vs. 0.8%; p < 0.001). Condom use at last sex was low in both groups, with no significant difference (2.3% in conflict vs. 2.6% in non-conflict; p = 0.52). HIV positivity during the last pregnancy was slightly higher in conflict (0.2%) than in non-conflict (0.1%) zones although not statistically significant (p = 0.32). Similarly, current HIV-positive status was higher among pregnant women from conflict (1.7%) compared to those from non-conflict (1.1%) (p = 0.22) zones [Table 1].

Multivariable analysis revealed that for pregnant women, residence in a conflict zone was associated with nearly twice the odds of HIV positivity compared to non-conflict zones, and the association showed a trend toward statistical significance (AOR = 1.93; CI: 0.98–3.82; p = 0.057). Increasing maternal age was significantly associated with a higher likelihood of HIV positivity, with each additional year of maternal age corresponding to a 6% increased likelihood of HIV positivity (AOR = 1.06; CI: 1.02–1.10; p = 0.002).

Educational level showed that women with only primary education had nearly 3 times the adjusted odds of being HIV-positive compared to those with tertiary education (AOR = 2.95; 95% CI: 0.84–10.4), although the association did not reach statistical significance (p = 0.092). Wealth status showed a significant association with HIV positivity among pregnant women. Compared to women in the highest wealth quintile, pregnant women in the middle (AOR = 4.10; CI: 1.31–12.8; p = 0.015) and fourth quintiles (AOR = 3.80; CI: 1.23–11.8; p = 0.021) had more than threefold likelihood of being HIV-positive.

Having sex with a non-marital, non-cohabiting partner in the past 12 months was associated with a nearly threefold higher likelihood of HIV positivity among pregnant women (AOR = 2.96; CI: 1.07–8.22; p = 0.037). Other factors including marital status, type of marital union, number of previous pregnancies, and condom use at last sex were not good predictors of HIV status among pregnant women [Table 2].

DISCUSSION

In this study, we found that pregnant women residing in conflict zones of Nigeria had nearly twice the likelihood of being HIV-positive compared to those in non-conflict regions, though this association slightly missed conventional alpha level of significance. Our result also revealed that increasing maternal age, lower levels of education, lower wealth quintile (Middle and Fourth), and engagement in HIV high-risk behaviors, specifically sex with non-marital, non-cohabiting partners, were important factors influencing the risk of HIV infection among pregnant women. These findings closely concord with the hypothesis that social, economic, and behavioral factors continue to drive HIV transmission risk among women of reproductive age, particularly in conflict-affected regions.

To the best of our knowledge, this study is among the few to use nationally representative data to describe the differential risk of HIV among pregnant women residing in conflict and non-conflict regions. Although previous studies had documented the link between conflict and increased vulnerability to HIV due to the destruction of essential medical infrastructure, disruption of healthcare initiatives, impeding immunization efforts, and creation of severe shortages of healthcare workers and medications,^[12,13] our study adds additional insights by identifying specific socio-economic and behavioral risk factors within this vulnerable subgroup. The association between the lower wealth quintile (Middle and Fourth) and higher risk of HIV infection among pregnant women aligns with reports from previous studies which demonstrated that individuals in the upper wealth quintile were less than half as likely than those in the lower wealth quintile to have low HIV-related knowledge (p < 0.001).^[14] This suggests that economic vulnerability limits access to HIV preventive and treatment services, while simultaneously increasing high-risk behaviors like transactional sex. Furthermore, the lower wealth quintile had been associated with reduced condom use. Research has shown that households in the fourth wealth quintile had significantly greater odds of inconsistent condom use and never using condoms (p < 0.001). Similarly, the association between increasing maternal age and with higher risk of HIV infection can be largely attributed to cumulative exposure over time. As individuals age, they have a longer period of potential exposure to HIV through various transmission routes.^[15]

Our result revealed that sex with non-marital, noncohabiting partners significantly increased the likelihood of HIV infection. This highlights the importance of behavioral risk as a major driver of HIV transmission, even in antenatal populations. In support of this, it is well documented in the literature that having multiple sexual partners significantly increases the risk of HIV transmission.^[16] Interestingly, condom use at the last sex was low in both conflict and non-conflict zones and was not found to be associated with HIV status. This could reflect broader cultural or gender-based barriers to negotiating safer sex practices, particularly within marital unions, irrespective of conflict status. Another notable finding was the lack of statistically significant difference in HIV prevalence between conflict and non-conflict zones (1.7% vs. 1.1%, p = 0.2), despite a trend reported in previous studies toward a higher rate in the general population in conflict zones.^[17] This may be partially explained by underreporting, stigma, or differential access to testing services in conflict-affected areas.

In a bivariate analysis, we observed that pregnant women resident of non-conflict zone had more favorable educational status, than those in conflict zones. While the bivariate analysis indicated significant differences in the level of education distributions (p < 0.001), a multivariable regression model revealed that these differences did not translate into significant adjusted odds of HIV infection among pregnant women after controlling for confounders. This finding was unanticipated and contrary to what we expected based on the literature, with several published studies showing that a low level of education is associated with a higher risk of HIV infection.^[18] This might be due to strong social or cultural norms and gender inequalities limiting female education. As such, it affects the relationship between education and the risk of HIV infection.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

This study highlights the complex interplay among conflict, socio-economic disadvantage, sexual behavior, and HIV risk among pregnant women in Nigeria. Interventions tailored toward high-risk subgroups, particularly pregnant women in conflict zones, those who are poverty-stricken, with limited education, and those engaging in non-marital sexual activity, are urgently needed. Policies that integrate HIV prevention with maternal health services, while addressing the social barriers in fragile, conflict-affected settings, will be essential in reducing the HIV burden among pregnant women in Nigeria and similar contexts.