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Background: The COVID-19 pandemic has interrupted the prevention of mother-to-child transmission of HIV (PMTCT) programming in South Africa. In 2020, it was estimated that there were 4 million cross-border migrants in South Africa, some of whom are women living with HIV (WLWH), who are highly mobile and located within peripheral and urban areas of Johannesburg. Little is known about the mobility typologies of these women associated with different movement patterns, the impact of the COVID-19 pandemic on mobility typologies of women utilising PMTCT services and on how changes to services might have affected adherence. Objective: To qualitatively explore experiences of different mobility typologies of migrant women utilising PMTCT services in a high mobility context of Johannesburg and how belonging to a specific typology might have affected the health care received and their overall experiences during the COVID-19 pandemic. Methods: Qualitative semi-structured interviews with 40 pregnant migrant WLWH were conducted from June 2020-June 2021. Participants were recruited through purposive sampling at a public hospital in Johannesburg. A thematic approach was used to analyse interviews. Results: Forty interviews were conducted with 22 cross-border and 18 internal migrants. Women in cross-border migration patterns compared to interprovincial and intraregional mobility experienced barriers of documentation, language availability, mistreatment, education and counselling. Due to border closures, they were unable to receive ART interrupting adherence and relied on SMS reminders to adhere to ART during the pandemic. All 40 women struggled to understand the importance of adherence because of the lack of infrastructure to support social distancing protocols and to provide PMTCT education. Conclusions: COVID-19 amplified existing challenges for cross-border migrant women to utilise PMTCT services. Future pandemic preparedness should be addressed with differentiated service delivery including multi-month dispensing of ARVs, virtual educational care, and language-sensitive information, responsive to the needs of mobile women to alleviate the burden on the healthcare system.
Rahima Moosa Mother and Child Hospital (RMMCH) is a public hospital that provides PMTCT services in Coronationville and western Johannesburg catchment areas in Region B (Figure 1) [26,27]. Region B is often associated with more developed areas and suburbs, but this is not the case in Coronationville, where vast patterns of migration occur [26,27]. In the early 1990s, Coronationville experienced rapid urbanisation, resulting in the establishment of informal settlements [26,27]. Coronationville has a population of 7348 people, comprised of 2500 people, of whom 60.8% are females living in informal settlements [26,27]. Forty-four percent of its entire population is unemployed, of whom 68% are internal migrants [26,27]. Regional Map, Region B, Rahima Moosa Mother and Child Hospital In 2015, RMMCH was the first to implement PMTCT lifelong treatment [13]. RMMCH is a site associated with high mobility and different migration patterns in Gauteng, where many WLWH use services outside of their districts/catchment areas and it informs the conditions for applicability to the broader migrant population in SA. Approximately 25 clinics refer patients to the ANC, no matter their nationality or legal status, and 87% of women using the ANC and post-natal care (PNC) are recorded as non-SA citizens. It is a busy maternal healthcare environment where HCWs see more than 36,000 outpatients and more than 12,000 births annually [6]. RMMCH had adopted the national guidelines for PMTCT lifelong treatment and was in its monitoring stage, providing a platform to analyse different mobility typologies and migrant experiences in the programme during the pandemic. Data were collected for 13 months (June 2020-June 2021) during the COVID-19 pandemic. This qualitative study consisted of 40 semi-structured interviews where data saturation was reached [28]. Interviews uncovered WLWH and their experiences utilising PMTCT services at RMMCH. Typologies were used to specifically analyse different migrant WLWH and their movement patterns, referred to as mobility typologies [14]. The different mobility typologies that surfaced and how belonging to a specific typology may have affected the healthcare received were examined. To avoid narrow conceptualisations of migrants, the wide range of typologies occurred was identified, where different classifications assigned to the participants based on socio-demographics, clinical characteristics, and their overall experiences shared in the utilisation of PMTCT services were used. Study participants were recruited from the ANC. Participants had to be of the reproductive age of 18 years or older; HIV-positive; you cannot be pregnant and newly delivered, or in post-natal follow-up. WLWH had to be enrolled in the PMTCT service and already initiated onto ART at RMMCH to be eligible for inclusion. Participants were not excluded based on language, and a translator was used on-site. WLWH were initially identified and asked by the nurse if they would like to participate in the study on a voluntary basis when conducting their follow-up assessments. If the individual woman agreed, they were referred to the research assistant/translator and PI in a private room within the ANC. The names and contact details of those who agreed were then shared with the research team. Participants were provided the study information. Approximately 35 women were approached but declined, mainly due to the peak of the second wave of COVID-19. These individuals were concerned with staying longer at the hospital because of the risk of contracting SARS-CoV-2. A purposive sample approach was used to recruit patient participants on PMTCT at RMMCH [28]. Due to the hospital regulations and the implementation of COVID-19 protocols and procedures, data collection was delayed because of the lack of space to follow social distancing protocols in the hospital. A tent was set up outside the ANC to provide a ventilated area for patients to sit and wait until their number was called to enter the facility to receive their care. The recruitment of participants had to be adjusted for the first 2 months because potential participants would have to return outside or move to another area of the hospital to complete the interview process to maintain confidentiality. Those who provided consent then completed an in-depth interview (IDI) in a private room. This research on sensitive migrant/WLWH participants ensured the protection of human subjects, and a distress protocol was followed for participants who became distressed by the nature of telling their story. An interview guide was informed by the conceptual framework and was used to collect data on 1) migrant status, 2) geography, 3) mobility history/temporality, 4) motivations/casual classifications, 5) socio-demographics, and 6) users clinical characteristics [25,28–31]. Interviews were audio-recorded and conducted in Tswana, Sotho, Zulu and Xhosa, Shona, Ndebele, Tumbuku, Changana, Chichewa, Afrikaans, and English and then were transcribed verbatim by one research assistant/translator and 1–2 interviewer(s). One counsellor who spoke Chichewa fluently only assisted the translator in Chichewa interviews if the participant struggled to communicate at times. To ensure participant confidentiality and anonymity, all results were aggregated and assigned a unique identification number that only the PI had access to, to ensure that participant responses could not be linked to them [28]. Demographic information, observations of participant behaviour, and journal memos were entered into NVivo 12.0 (QSR International Pty Ltd., 2018). To explore any preconceived notions from the research team, interviews used reflective journaling as an opportunity to engage with the data collected and daily journal entries more critically to enhance authenticity and learn from past experiences of the research process and findings [28,32]. Memos and journaling were used to maintain a process log, capture any observations, and maintain a record of analytic decisions throughout data collection and analysis between the research team [28,32]. The Utilisation of PMTCT Healthcare Services Conceptual Framework (Figure 2) was developed to provide guidance in exploring utilisation experiences of PMTCT and migration in a high mobility context [6,28–31]. The Utilisation of Prevention of Mother-to-Child Transmission (PMTCT) Services Conceptual Framework McIntyre et al.’s Accessibility framework informed this framework, highlighting that by using ‘access’ as a concept, this would not include those migrants who have not accessed PMTCT services for comparison [6,16,29]. Utilisation is defined as the WLWH experiences/perceptions of their interactions with the PMTCT programme components and to the service providers within a high mobility context [16,29]. The framework was applied to explore accessibility and adherence barriers and facilitators in relation to PMTCT services and how the individual story of migration, and the mobility typology, has impacted their overall healthcare experience. The concept of utilisation is made up of 1) adherence issues to the programme and 2) access composed of four dimensions: availability, affordability, acceptability, and adaptability [6,16,29]. Adherence is conceptualised as the long-term ability of these different women to follow the PMTCT programme including taking medication routinely, not missing dosages and attending follow-up appointments. Accessibility refers to the equality and equity of PMTCT care in the healthcare facilities these women utilise, no matter their nationality and legal status [6,16,29]. Availability dissects the factors such as the range of maternal healthcare and PMTCT services relative to the need. This includes the hours of operation, ARV supply, and willingness of service provider to provide information in a demanding clinical environment [6,16,29]. Affordability refers to both the financial costs, which include transport, medicine charges, diagnostic tests, and childcare costs, and the opportunity costs, which refer to the time a woman can afford to take time from work to get to the hospital to receive PMTCT services [6,16,29]. Acceptability refers to whether the expectations of the women are met, including age, gender, race, ethnicity of provider, decision-making, and whether culturally appropriate services (e.g. multi-lingual counselling) are offered [6,16,29]. Acceptability also includes the woman’s non-medical expectations of HCWs’ treatment, dignity, and respect of their culture [6,16,29]. Adaptability refers to the sustainability and scalability of the PMTCT programme for all women, no matter their nationality and legal status [6,16,29]. Analysis Data were compared to draw similarities and differences amongst participants [28,30–32]. First, the dimensions of adherence and access were used to dissect and draw relationships to each of the participants’ experiences. The typologies of migrants that surfaced were grouped based on their experiences that were similar or different. Second, the data on 1) migrant status, 2) geography, 3) mobility history/temporality, 4) motivations/casual classifications, 5) socio-demographics, and 6) users’ clinical characteristics were analysed to help guide and categorise the different typologies that arose. Typologies are different classifications assigned to the participants based on the six categorical variables (Table 1) that provided a profile for the participant to draw further relations with the participants’ utilisation experiences of PMTCT services [25]. Examples of the factors/variables involved in the development of migrant typologies. A thematic analysis was used to analyse the semi-structured interview transcripts to examine and identify common themes, topics, ideas, and patterns of meaning that were repetitive [28,30–32]. Interviews were approximately 25–35 minutes. The process of analysis began with open coding directly from the data [28,30–32]. Codes were grouped into sub-themes that emerged from the data and then organised into the themes of adherence and the four dimensions of accessibility. Two researchers in the team coded individually. The consensus was reached at the third version of the coding scheme among three researchers in the team. The categories were reduced to identify key themes. Any commonalities and differences between utilisation experiences across WLWH were noted. Triangulation of data was used to ensure that different experiences of study participants were presented [28,30–32]. Descriptive statistics were reported for the demographics of the participants, including frequencies and proportions for categorical variables using Stata 14 [28,30–32].
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