Inequalities in access to HIV and syphilis tests in prenatal care in Brazil.

Claudia Helena Soares De Morais Freitas,Sonia Maria Ferreira Dias,Maria Helena Rodrigues Galvão,Angelo Giuseppe Roncalli,Franklin Delano Soares Forte,Ardigleusa Alves Coelho

doi:10.1590/0102-311x00170918

Abstract

This study aims to evaluate the social determinants of access to HIV and VDRL tests during pregnancy in Brazil. The dependent variables were based on prenatal care access: prenatal care appointments, no HIV and syphilis tests. The independent variables at the first level were formal education level, age, race, work and participation in the Family Income program conditional cash transfer program. The city-level variables were the human development index (HDI), Gini index, and indicators related to health services. An exploratory analysis was performed assessing the effect of each level through prevalence ratios (PR) calculation. A multilevel mixed-effect Poisson regression model was constructed for all outcomes to verify the effect of individual level and with both the individual and contextual levels. Regarding prenatal appointments, the main implicated factors were related to individual socioeconomic position (education level and participation in the Family Income Program conditional cash transfer program), however only HDI maintained significance for the city-level context. The city-level variance dropped from 0.049 to 0.042, indicating an important between-city effect. Regarding the outcomes performing tests in prenatal care, the worst conditions such as contextual (HDI > 0.694, p < 0.001; Gini index ≥ 0.521, p < 0.001) and individual (> 8 years of schooling, p < 0.001) showed a risk effect in the final model. Variables related to health services did not show significant effects. They were associated with individual socioeconomic position and a city-level contextual effect. These findings indicate the importance of strengthening HIV and syphilis infection control programs during pregnancy.

Highlights

Vertical transmission of both HIV and congenital syphilis from mother-to-child continue to be a public health concern around the world
This study aims to evaluate the social determinants of access to HIV and venereal disease research laboratory (VDRL) tests during pregnancy in Brazil, assessing whether inequalities in using health services are expressed at individual and contextual levels through a nationwide survey that was conducted in primary health care in 2013-2014
In addition to this individual effect, a citylevel contextual effect represented by human development index (HDI) and the Gini index was observed for the absence of tests in prenatal care (HIV and syphilis detection)

Summary

Introduction

Vertical transmission of both HIV and congenital syphilis from mother-to-child continue to be a public health concern around the world. Among the health targets that were established by the Millennium Development Goals (MDGs), the MDG 6 defines actions to halt and begin to reverse the AIDS epidemic, in addition to eliminating vertical transmission. The Global Plan was launched in 2011 towards eliminating new born HIV infections, but further efforts are needed to reach the Global Plan’s target of reducing new infections among children in 90% by 2015 3. Some key actions are recommended to reduce the number of HIV infected children: providing HIV testing, counseling and antiretroviral medicines in a timely manner to HIV-infected pregnant women to prevent transmission to their children

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