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.
OOTCOME 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, needstandardised).
Determinants contributing to the observed
inequality were identified using the Erreygers and Wagstaff
decomposition methods.
RRSULTS 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 needstandardised
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.
