One quarter of pregnant women in Zambia are infected with HIV. Understanding how knowledge of HIV relates to personal risk perception and avoidance of risky behaviors is critical to devising effective HIV prevention strategies. In conjunction with a large clinical trial in Lusaka, Zambia, we surveyed postpartum women who had been tested for HIV but did not know their status before undergoing the questionnaire. Of 858 women for whom complete data were available, 248 (29%) were HIV infected. Women 22 years of age or older (adjusted odds ratio [AOR], 1.7; 95% confidence interval [CI], 1.1–2.5), women reporting ≥2 sexual partners in their lifetime (AOR, 1.8; 95% CI, 1.3–2.5), and women reporting a history of a sexually transmitted infection (AOR, 2.7; 95% CI, 1.7–4.3) were more likely to be HIV infected. Having had ≥2 lifetime sexual partners was a marker for perception of high personnel risk for HIV infection (AOR, 1.5; 95% CI, 1.1–2.1). However, there was no relationship between perceived risk of HIV infection and actual HIV status. In fact, 127 (52%) of 245 women who stated that they were at no or low risk for HIV infection were HIV infected. Living in an area of high HIV seroprevalence like Zambia seems to be the greatest risk factor for infection in unselected pregnant women. Before significant inroads can be made in decreasing the incidence of HIV infection among pregnant women, population-based strategies that involve men must be implemented.
Zambia is a highly urbanized sub-Saharan African country with a population of 10.2 million. 1 One million people live in Zambia's capital Lusaka, where >40,000 babies are born yearly. Although the national seroprevalence of HIV infection among the general population is ∼16%, 2 it exceeds 30% in some maternity centers in Lusaka. 3 Because of this high rate of HIV infection among pregnant populations and the increasing availability of interventions to block motherto-child transmission, much emphasis has recently been placed on perinatal HIV prevention programs. 4,5 An important but sometimes overlooked component of these programs is risk reduction education for women with seronegative test results.
Since the early 1990s, various programs have been ongoing to educate Zambians about HIV infection with the hope that increased knowledge of the disease and its transmission would lead to behavior change and, ultimately, fewer new infections. However, sentinel surveillance data from Zambia during this same period suggest that rates of HIV infection among urban obstetric populations remain high (in fact, unchanged) despite widespread educational and prevention messages. 6–8 Similarly, data collected between 1992 and 1998 from the Zambian Sexual Behavior Survey show that there has been little change in women's sexual behavior. 9
Traditionally, HIV messages have been targeted to “high-risk” groups; however, in areas with high prevalence, it may be that everyone who is sexually active is at “high risk” and that prevention messages need to target everyone. A major challenge for Zambia lies in translating its anti-HIV messages and outreach activities into behavior changes that reach across populations and ultimately result in a decline in the incidence of HIV infection.