HIV and Syphilis Test Positivity Among Pregnant Women Tested in Health Facilities and Through Traditional Birth Attendants in Three Nigerian States: Analysis of Program Data and a Community-Based Case-Control Study

Background: Integrating prevention of mother-to-child transmission services with Traditional Birth Attendant services is critical for addressing gaps in HIV and syphilis care in rural Nigeria where many pregnant women continue to seek antenatal care from Traditional Birth Attendants and miss prevention of mother-to-child transmission services. This study compares HIV and syphilis test positivity among pregnant women who seek antenatal care in health facilities and from Traditional Birth Attendants in Akwa Ibom, Cross River, and Taraba states and examines characteristics associated with HIV positivity among pregnant women seeking care from Traditional Birth Attendants. Methods: We compared HIV and syphilis test positivity among 83,602 pregnant women tested in health facilities and 67,708 tested through Traditional Birth Attendants (TBAs) between January 2022 and June 2024, using routine program data and state-specific and Mantel–Haenszel odds ratios. A community-based case–control study compared 503 women with a positive HIV result and 496 HIV-negative controls aged 18 years or older attending the same TBAs. The primary analysis was a prespecified logistic regression model of characteristics fixed before testing, with community-clustered standard errors and multiple imputation. Results: HIV positivity was higher in health facilities (4.1%) than in TBA-led community services (1.0%), as was syphilis positivity (1.2% vs. 0.4%), but the difference between settings varied markedly by state (HIV odds ratios 1.39 to 12.35). In the case–control study, women aged 35 years or older had higher odds of a positive HIV result (adjusted OR 1.97 (95% CI 1.21 to 3.21); 1.88, 95% CI 1.26 to 2.82, with multiple imputation). High perceived HIV risk, reported after testing, was strongly correlated with a positive result and is not interpreted as a risk factor. Conclusions: HIV and syphilis test positivity was higher among women tested in health facilities than among those tested through TBAs. This difference may reflect differences in the characteristics and underlying risk of the women reached by each setting, rather than differences in test performance. Older maternal age was associated with HIV positivity among women attending TBAs. Integrating TBAs into a supervised referral network provides a route to testing for women attending community-based antenatal care; its clinical value depends on confirmation, linkage to treatment and follow-up, which future evaluations should measure.