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Abstract
Objectives Wealth-related inequality across the South African antenatal HIV care cascade has not been considered in detail as a potential hindrance to eliminating mother-to-child HIV transmission (EMTCT). We aimed to measure wealth-related inequality in early (before enrolling into antenatal care) uptake of HIV testing and identify the contributing determinants.
Design Cross-sectional survey.
Settings South African primary public health facilities in 2012.
Participants A national-level sample of 8618 pregnant women.
Outcome measures Wealth-related inequality in early uptake of HIV testing was measured using the Erreygers concentration index (CI) further adjusted for inequality introduced by predicted healthcare need (ie, need-standardised). Determinants contributing to the observed inequality were identified using the Erreygers and Wagstaff decomposition methods.
Results Participants were aged 13 to 49 years. Antenatal HIV prevalence was 33.2%, of which 43.7% came from the lowest 40% wealth group. A pro-poor wealth-related inequality in early HIV testing was observed. The need-standardised concentration index was −0.030 (95% confidence interval −0.038 to −0.022). The proportion of early HIV testing was significantly better in the lower 40% wealth group compared with the higher 40% wealth group (p value=0.040). The largest contributions to the observed inequality were from underlying inequalities in province (contribution, 65.27%), age (−44.38%), wealth group (24.73%) and transport means (21.61%).
Conclusions Our results on better early uptake of HIV testing among the poorer subpopulation compared with the richer highlights inequity in uptake of HIV testing in South Africa. This socioeconomic difference could contribute to fast-tracking EMTCT given the high HIV prevalence among the lower wealth group. The high contribution of provinces and age to inequality highlights the need to shift from reliance on national-level estimates alone but identify subregional-specific and age-specific bottlenecks. Future interventions need to be context specific and tailored for specific subpopulations and subregional settings.
- wealth-related inequality
- early HIV testing
- pregnant women
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Footnotes
Contributors NKN conceptualised the manuscript aims, carried out the analyses and wrote the manuscript. CVM and NS trained and supervised the analyses methods, assisted with interpretation of the results and reviewed the manuscript drafts. AG contributed to conceptualising the manuscript aims and in writing and reviewing the manuscript drafts.
Funding This work was supported by the President’s Emergency Plan for AIDS Relief under the Cooperative Agreement between CDC and MRC (1U2GPS001137-02 and 1U2GPS001137-03)- A, The United Nations Children's Fund (UNICEF) - A, National Department of Health, South Africa—A, South Africa National Research Foundation—D. The funders had no role in study design, data collection and analysis,decision to publish, or preparation of the manuscript. The contents of the manuscript are solely the responsibility of the authors and do not necessarily represent the official views of CDC. NKN and AG were supported by the South African Medical Research Council.
Competing interests None declared.
Patient consent Obtained from participating mother/caregivers.
Ethics approval The South African Medical Research Council Ethics Committee and the Centers for Disease Controland Prevention approved the final protocol for the PMTCT survey.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data are bound by ethical and legal restrictions. To access the data of the South Africa's Prevention of Mother to Child Transmission Effective study, investigators who are not part of the study team should submit a concept proposal to AG (South Africa Medical Research Council (MRC), principal investigator), Debra Jackson (University of the Western Cape/UNICEF, principal investigator) and Thu-Ha Dinh, MD, MS (US Centers for Disease Control and Prevention (CDC), principal investigator) for approval. Investigators with an approved concept proposal must apply for guest researcher status to obtain access to a workstation and the data. Additionally, they will need to complete data security and confidentiality training, and to sign data use and non-disclosure agreements. The data are not yet available in a stable public repository. Researchers who meet criteria to access the data should contact the author AG at Ameena.Goga@mrc.ac.za.