As many countries in the developing world roll out programs for the prevention of mother to child transmission of HIV, there is need to consider the potential barriers that these programs may face. In addressing these barriers, it is crucial that any differences between rural and urban areas are addressed since the significant proportion of people in developing countries live in the rural areas. This study has shown that there are no major differences in terms of the potential barriers that might hinder the success of implementation of PMTCT programs in rural areas as compared to urban areas. This indicates that experiences learned from programs in the urban areas will apply to rural PMTCT programs.
One major challenge identified is that a significant proportion of mothers deliver outside the health facility, and this occurs more frequently in the rural areas compared to the urban areas. Health facility-based delivery is helpful to ensure compliance to infant antiretroviral dosing but also to ensure the practice of modified obstetric practices that have been shown to reduce MTCT .
Though rural and urban populations are perceived as differing in knowledge, readiness and ability to follow advice , this study suggests the contrary in regards to MTCT. The level of knowledge was high and the readiness to accept HIV testing was equally high in both rural and urban areas. This high level of knowledge may be attributed to various programs being broadcast on the radio in this district, reaching even the distant rural areas, where some of the study participants reside. Radio ownership was high in both rural and urban areas and the proportion of mothers listening to the radio was also high. PMTCT programs should utilize this medium of communication in areas where it is available.
Most of the mothers interviewed preferred same day HIV test results however some mothers preferred to receive results later. It has been shown that same day results can be provided in counseling without compromising the quality of counseling and testing . It is possible that the mothers who prefer to receive results later may be the ones who decline to test for HIV when the test offered is rapid, or may undergo the test but not receive their results. However more studies are required to explore this hypothesis. In the meantime, PMTCT programs should identify the mothers who are likely to refuse testing or would prefer to receive their results at a later date and design a customized schedule to accommodate them since they may be at a higher risk . Conversely, some studies have indicated that those who refuse testing may actually be at lower risk for HIV [22, 23].
Many mothers understand that there is a benefit in taking an HIV test as indicated by the large number who said that they would advise someone else to take an HIV test. This proportion is larger than those who said that they would accept an HIV test themselves if it were offered (98% vs. 89% respectively). There is a gap between knowledge about the benefit and acceptance to have the HIV test done. Though there is an almost universal recommendation from the mothers to take the test themselves, not all of them will choose to have the test for themselves.
Whereas some studies have shown that a lower education level is associated with higher likelihood to request for HIV testing , this study showed the opposite, with those having at least a post-primary education more likely to choose to test compared to those with lower education. These study findings are supported by a study among Hispanic farm workers in South Florida  in which participants with at least twelve years of education were four times more likely to test compared to those without the same education. In a Vietnamese study, low education was associated with not returning for results . The Universal Primary Education campaigns currently underway in some developing countries like Uganda  may facilitate implementation of health programs such as PMTCT.
This study demonstrates that male partners' attitudes are important in a woman's reported willingness to accept HIV testing. In some circumstances women have tested for HIV without their husbands consent and have suffered domestic violence . In this survey, the perception that the husband would approve of a mother's decision to test for HIV was the strongest predictor of whether the mother had the intention of testing or not. This finding highlights the importance of the male partner in the success of uptake of HIV testing within PMTCT programs. This study demonstrates that there is a tendency for more rural women to seek their husbands' approval prior to testing compared to their urban counterparts. This may be an inhibitory factor to the willingness to accept VCT. This study reinforces the recommendations made by a study in Tanzania  that emphasized the role of the male partner in PMTCT.
One limitation of this survey is that mothers were questioned regarding their willingness to accept HIV testing, but were not followed to determine those who eventually accepted the HIV test. This would have enabled us to establish the relationship between willingness to take the test if it were offered and actually taking it. Actual acceptance of HIV testing would be more informative than answers to the question about willingness to accept testing. In addition, the rural sites chosen for the survey were those that were implementing PMTCT in an ongoing scale-up program at the time the survey was conducted. Since they were not randomly selected, it is possible that these clinics may not be representative of other rural areas in the district. Additionally, the survey was based at the health facility and therefore only mothers seeking antenatal care at a health unit were eligible for the study. Whereas this may be a limitation, it may not be a strong factor in this study because over 80% of women in Uganda seek at least one antenatal visit at a health facility during their pregnancy .