South Africa: Women of lower socio-economic status have greater needs for services to prevent mother-to-child HIV transmission

Pregnant women of lower socio-economic status are more likely to take up early HIV testing and to have HIV-exposed infants, according to findings of a study presented by Nobubelo Ngandu at the 7^th South African AIDS conference last month in Durban.

There was a significant difference in the proportion of infants that were HIV-exposed (infants born to HIV-positive women), according to socio-economic status. Infant exposure occurred in 37.9% (95% CI: 34.4 – 41.4) in the lowest 10% of the socio-economic status ranking, compared to 23.5% (95% CI: 20.5 – 26.8) in the highest 10% and 33.2% (95% CI: 32.1 – 34.3) in the sample average.

In the highest-status 10%, only 18.7% (95% CI: 16.0 – 21.7) self-initiated HIV testing before enrolling into antenatal care (early testing), compared to 23.8% (95% CI: 20.9 – 27.0) in the lowest-status 10% and 22.4% (95% CI: 21.4 – 23.4) in the sample average. However, this difference was not significant.

Socio-economic status is an important determinant of healthcare uptake. Studies have illustrated examples of wealth-related inequalities in maternal and child health care in low and middle-income countries, such as access to skilled birth attendance and antenatal care and early uptake of HIV testing. As wealth-related inequality is generally very high in South Africa, this study sought to understand if this was affecting the PMTCT programme. 

Transport, income source, the province where the mother and infant live and the education level of the mother were the main factors found to be contributing to wealth inequality. There are complex differences between provinces in terms of early HIV testing and infant HIV exposure, which weaken the reliance on national average data, often used by HIV programme planners.

Socio-economic status (wealth ranking) was measured for 8 618 mother-infant pairs and categorised into the highest 10% (n=818) and the lowest 10% (n=863), according to variations in household characteristics (such as building material, sanitation, water and fuel) and household possessions (such as car, television, radio, fridge, phone or stove), using Principal Component Analyses. The study was part of the 2012 South Africa national PMTCT cross-sectional survey, which collated data from 580 randomly selected health care facilities between October 2012 and May 2013.

When wealth-related inequality was measured using the concentration index to compare the cumulative proportion of a health outcome and individuals ranked by socio-economic status, it was found that uptake of early HIV testing is slower and that infant HIV exposure increases faster among the lower socio-economic status groups.  

However, the wealth-related inequality is underestimated by this sample, as the data is only relevant to communities using accessible public health facilities. The most remote and difficult to access rural facilities and private sector facilities are not very well represented.

“Policies for healthcare provision should consider disparities between socio-economic groups to ensure equity,” said Ngandu.

Strengthening PMTCT uptake through senior citizen involvement

Qualitative data presented by Kedibone Motapane on empowering and capacitating senior citizens to influence cultural beliefs on pregnancy and infant feeding affecting the prevention of mother-to-child transmission (PMTCT) of HIV showed positive impact.

Senior citizens are the custodians of culture in the community and the centres of influence in decision-making related to pregnancy. The prevention model aimed at addressing three main pillars of influence, namely, cultural beliefs relating to early antenatal care bookings; stigma and discrimination relating to the acceptance and uptake of ART by pregnant women; and infant feeding decisions for post-partum women.

The project model is based on strengthening linkages to care and treatment, providing training, mentorship and support to the 30 recruited senior citizen champions and facilitating dialogues and referral linkages through peer-to-peer talks and advice and information sharing in community settings. A ten-day training package with quarterly refresher training is provided and monthly debriefing meetings are held.

Makhoboshane is a traditional practitioner. Through her participation as a PMTCT champion she sent women to the clinic to do a pregnancy and HIV test, which was found to be positive. She continued to encourage the woman to adhere to treatment and breastfeed exclusively to ensure HIV-negative outcomes for the infant.  The HIV-negative infant is now 17 months old, and waiting for its 18 month PCR test.

Sanna Mngomezulu shared that in the past she was uncomfortable discussing sexual matters with her children and grandchildren. Now, with help from the project, she is now able to inform them on sexual matters.

73 year old Mntanzi, who has three family members who are on TB treatment, said that she continues to support and encourage her family to take medication regularly, and eat healthily by supplying them with vegetables from her vegetable garden.

Some of the challenges encountered in the project include the senior citizens finding it taxing to challenge past perceptions and beliefs. Additionally, they experience resistance from peers in their clubs due to prior relationships with members. A few of the champions needed to be pushed to network and link with other partners. Information needed to be continually updated, clarified and refreshed to ensure the accuracy of the information shared. The meetings also brought up emotional and disturbing psychosocial problems that are shared by the champions, which need attention, the investigators reported.