Health system strategies to increase HIV screening among pregnant women in Mesoamerica

Abstract

Background: To propose health system strategies to meeting the World Health Organization (WHO) recommendations on HIV screening through antenatal care (ANC) services, we assessed predictors of HIV screening, and simulated the impact of changes in these predictors on the probability of HIV screening in Guatemala, Honduras, Mexico (State of Chiapas), Nicaragua, Panama, and El Salvador.

Methods: We interviewed a representative sample of women of reproductive age from the poorest Mesoamerican areas on ANC services, including HIV screening. We used a multivariate logistic regression model to examine correlates of HIV screening. First differences in expected probabilities of HIV screening were simulated for health system correlates that were associated with HIV screening.

Results: Overall, 40.7% of women were screened for HIV during their last pregnancy through ANC. This rate was highest in El Salvador and lowest in Guatemala. The probability of HIV screening increased with education, household expenditure, the number of ANC visits, and the type of health care attendant of ANC visits. If all women were to be attended by a nurse, or a physician, and were to receive at least four ANC visits, the probability of HIV screening would increase by 12.5% to reach 45.8%.

Conclusions: To meet WHO's recommendations for HIV screening, special attention should be given to the poorest and least educated women to ensure health equity and progress toward an HIV-free generation. In parallel, health systems should be strengthened in terms of testing and human resources to ensure that every pregnant woman gets screened for HIV. A 12.5% increase in HIV screening would require a minimum of four ANC visits and an appropriate professional attendance of these visits.

Keywords: Antenatal care; Central America; HIV screening; Health care disparities; Human immunodeficiency virus; Mesoamerica.

Fig. 1

Distribution of differences in expected probabilities of HIV screening between (a) women who received four or more and those who received three or less antenatal care visits, (b) women who were attended by a physician or a nurse and those who were not, (c) women who received four or more antenatal care visits and were attended by a physician or a nurse, and those who received less than four antenatal care visits and were not attended by a physician or a nurse, and (d) most and least educated women (MFD: Mean first difference)Note: The area under the curve, in each panel, represents the distribution of the differences between the expected probabilities of HIV testing under two scenarios for a simulated modifiable factor. The red line represents the mean of the distribution. The x-axis represents the first differences in the expected probabilities of HIV screening and is limited to the probabilities obtained from the simulated first differences. The y-axis represents the density of the probability distribution of the first differences and is limited to the maximum observed density. For example, in panel A, the interval of the simulated first differences in the expected probabilities of HIV screening between women who received four or more and those who received three or less antenatal care visits is approximately [− 0.05 to 0.10]. However, the vast majority of this interval is [0.0 to 0.50], and the mean first difference is at 0.022