The number of people infected with human immunodeficiency virus (HIV) in China has increased in recent years. It is estimated that in 2009 there were 740,000 people living with HIV in China, with 48,000 new infections and 105,000 alive AIDS patients [1]. The transmission mode of HIV in China has changed over the recent years. While injecting drug use-related HIV infection used to be the major transmission mode, the epidemic has already started to spread from high-risk populations to the general population in recent years, and sexual transmission is currently the primary mode of transmission. Among those infected with HIV in China reported in 2009, about 30.5% were women, so there is potential for mother-to-child transmission of HIV [1]. In 1995 the first case of mother-to-child transmission in China was identified in Yunnan province [2]. Since then, the proportion of reported cases of HIV infection caused by mother-to-child transmission has increased from 0.1% in 1997 to 1.2% in 2007 [3,4].

It has been recognized that mother-to-child transmission of HIV is the major cause of child HIV infection. Mother-to-child transmission of HIV can occur during pregnancy, during the labor and delivery, or after delivery. The most important postnatal transmission of HIV is through breastfeeding, which accounts for about 44% in children where breastfeeding to two years is the norm [5]. In industrialized countries, the rates of mother-to-child transmission of HIV in untreated non breastfeeding populations range from 14% to 32%, but the rates are from 25% to 48% among breastfeeding populations in resource-poor settings [6]. Currently in the United States, with the practice of universal prenatal HIV counseling and testing, antiretroviral prophylaxis, elective cesarean delivery, and avoidance of breast feeding, perinatal HIV infection has decreased to less than 2% [7]. In the United States, lack of identification of maternal HIV infection status has been found to be responsible for new infant HIV infections [8]. Universal HIV testing of pregnant women is currently recommended by the Centers for Disease Control and Prevention as part of standard care in the United States [9]. Universal HIV testing of pregnant women may allow identification of the women who are infected with HIV but are not aware of their infectious status, and may benefit the health of both the mother and her infant [10]. The importance of reducing mother-to-child transmission of HIV has recently started to be recognized in China. In 2006 China developed the "Prevention of mother-to-child transmission guidelines", and activities to prevent mother-to-child transmission of HIV were performed in 271 counties in 2007 [4], and expanded into 453 counties in 2009 [1]. Recently the Ministry of Health of the People’s Republic of China started promoting blood tests for syphilis, HIV and hepatitis B virus as a routine examination for all pregnant women [11]. The reported number of pregnant women being screened for HIV in China was about 4 million in 2009 [1], but in the same year the newborn number in the nation was 13.8 million [12]. The gap between the number of pregnant women screened for HIV and the total number of pregnant women is still obvious.

The Xinjiang Uyghur Autonomous Region is located in the north-western part of China. While only a little more than 1% of China’s population live in this region, it accounts for about 10% of estimated HIV cases of China. In 2006, the confirmed cases of HIV infection in Xinjiang reached 16,035, but the estimated number of people actually infected with HIV was around 60,000 [13]. After the first case of mother-to-child transmission in Xinjiang was identified in 1996, the prevalence of child HIV infection caused by mother-to-child transmission in Xinjiang exceeded 1% in 2004, and in some areas this number was as high as 5.3% [13]. Although significant efforts have been made for the prevention and treatment of HIV in Xinjiang, many remote areas need additional help to promote universal HIV testing in pregnant women. With the help of a humanitarian grant from the College of American Pathologist Foundation, free HIV screening was offered to pregnant women in Burqin County and Jeminay County in Xinjiang from July 2009 to June 2010. A survey for the knowledge about HIV infection and mother-to-child transmission of the pregnant women was also performed.

In this study, HIV screening for pregnant women was performed in Burqin County and Jeminay County in Xinjiang Uyghur Autonomous Region, China. These two counties are located near the northwestern border of China, about several hundreds miles away from the Region’s capital city Urumqi. The residents in this area are composed of mixed ethnic groups, including Kazakh, Han and others. HIV infection rate has been reported to be low in the general population in this area. Until 2009, only two cases of HIV infection, including one HIV related death, had been identified in Burqin County, and none in Jeminay County [14]. No mother-to-child transmission of HIV has been reported in these two counties. The HIV screening performed in this study was the first time the status of HIV infection among pregnant women had been investigated in this area. The 890 pregnant women participating in this study were estimated to represent about 60% of pregnant women in this area [14]. Because the original goal of this project was to provide free HIV screen as a humanitarian effort and to include as many pregnant women in this area as possible, bias in participant selection could not be entirely avoided. Many pregnant women were recruited during their visits to local women health centers for routine prenatal examination, and this group of women probably tended to include more people living in the town area or with better economic conditions. At the same time, local Red Cross workers also visited remote residential areas to provide HIV tests for pregnant women, which helped to include more farmers and other lower income women into the tested population. Per demographics of the participants (Table 1), 67.6% of the tested women were Kazakh, which is consistent with the ethnic group distribution in this area, but the percentage of farmers among the tested women (40.9%) was lower than the reported 51% agriculture population in this area [15]. The percentage of women with college educational background (15.4%) also appeared to be higher than that in the general population in Xinjiang (7.9% in 2005) [16].

All the 890 pregnant women were tested negative for HIV in this study, which suggested that HIV infection had not become a significant problem in pregnant women of this area. Many other areas of Xinjiang obviously have higher positive rate among pregnant women. For example, the positive HIV antibody testing rate among pregnant women in Yining City, Xinjiang rose continually between 1997 and 2008, remaining above 1% after 2003 [1]. The low positive rate among pregnant women in this area is not entirely unexpected, since these two counties are located in remote areas of China, and people living here traditionally have a conservative life style. Many residents live in remote farms and have limited contact with people from areas with high incidence of HIV infection. These factors may contribute to the low HIV infection rate at this area, as well as among pregnant women. The result of this study brought some good news to HIV control and prevention in this area, at least at this moment. However, with the economic development of recent years, especially with a fast growth of tourist business in Burqin County, the situation may change anytime. In Xinjiang Uyghur Autonomous Region’s capital city Urumqi, universal HIV screening for pregnant women has started to be enforced within the city, and will be extended into its suburb areas in the near future [17]. However, such practice was not available for most pregnant women in Burqin and Jeminay Counties until this project was done.

Education for the prevention and treatment of HIV infection is currently one of the most important parts of the local government’s effort to control the growth of HIV infection in this area. Our survey results showed that many women were familiar with the most common transmission pathways of HIV, such as sharing needles among drug abusers. This is consistent with the fact that sharing needles among drug abusers was the first major HIV transmission pathway identified in Xinjiang, and most local residents have been educated about it during the past years. Our survey also showed many women could not correctly answer some survey questions related with mother-to-child transmission of HIV (Table 2). The uncertainty about mother-to-child transmission of HIV was also seen in some similar studies performed for Chinese pregnant women [18,19]. It is noted that some surveys performed in Hong Kong, Indian or Papua New Guinea showed better knowledge of mother-to-child transmission among pregnant women [20-22], but it should be cautious to compare these results directly because of probable different settings in these surveys. In our survey, we also found women with multiple pregnancy histories did not show better HIV knowledge than the first-time pregnant women, although they had more chances to interact with health workers during their clinic visits (Table 1). If local health workers can take the full opportunity to educate the pregnant women about HIV knowledge during their clinic visits, this situation probably can be improved in the future.

In summary, in spite of the limit in the recruitment of participants discussed earlier, this study is the first report about the status of HIV infection in pregnant women in this remote area of China. The incidence of HIV infection among pregnant women in this area was still low, but at the same time the local pregnant women also showed limited knowledge about mother-to-child transmission of HIV. Additional efforts to improve the awareness about mother-to-child transmission of HIV and to prevent women becoming infected with HIV, especially during pregnancy and breast feeding, will help to keep the low prevalence of HIV infection among pregnant women in this remote area of China.