Menu
Menu
Menu
Menu
Background: In March 2020, COVID-19 entered South Africa, resulting in 2.9 million cases, the country took preventative and precautionary measures to control the spread of COVID-19 infection. These measures limited population mobility especially for migrant women living with HIV (WLWH) and the provision of PMTCT services. The purpose of this research was to explore the challenges of the COVID-19 pandemic on PMTCT provision by healthcare providers and understand what strategies could be implemented with lifelong antiretroviral therapy (ART) for migrants to better manage the program. Methods: Twelve in-depth interviews were conducted with healthcare providers across city and provincial levels on how the changes to the healthcare system with COVID-19 affected highly mobile patients’ adherence and utilization of PMTCT services. A thematic content analysis was used for emerging themes and guided by The Utilization of PMTCT Services conceptual framework. Results: Five main themes emerged: (1) Facilitators and barriers to adherence, which included the need for multi-month dispensing for the long term supply of antiretrovirals (ARVs) and the fear of contracting COVID-19 at the hospital that disrupted patients’ continuum of care; (2) Healthcare providers work environment, where participants felt overwhelmed with the high patient demand and the lack of infrastructural resources to follow social distancing protocols; (3) Financial challenges and opportunity costs, PMTCT proved difficult for migrants due to border closures and documentation required to receive care, this resulted in treatment interruption and left many unable to receive support at the facility due to capacity restrictions; (4) Interpersonal interactions, mistreatment, and xenophobic attitudes existed toward the migrant HIV population; and (5) “Program sustainability” revealed three key areas for strengthening: longer duration of time allocated with counseling for same-day initiation, the increased use of technology, and translation services for migrants. Conclusions: It is important to take what was learned during the pandemic and integrate it into routine service delivery, which includes long-term medication supply to reduce risk with multiple visits to collect medication, and the use of technology to alleviate the high-burden of patient demand. Healthcare policies that work toward inclusion and sustainability for migrants are needed to improve the integration of safer and practical methods of PMTCT provision into health systems.
This qualitative study included in-depth interviews (IDIs) conducted with healthcare providers across different units of RMMCH that provided PMTCT services or interacted with service users, specifically migrant women. IDIs were aimed to investigate healthcare providers perceptions on challenges of the COVID-19 pandemic on PMTCT provision and understand what strategies could be implemented with lifelong ART for the highly mobile population. This design was chosen to stimulate interaction and discussion, creating an opportunity for open input on the challenges and strategies related to the Utilization of PMTCT Services conceptual framework during the pandemic based on participants’ experiences. 19 The Utilization of PMTCT Services conceptual framework (Figure 1) was used to explore healthcare providers’ experiences of providing PMTCT services to highly mobile users during the COVID-19 pandemic. Utilization is defined as the healthcare users’ experiences and perceptions of their interactions with the PMTCT program components (i.e., healthcare providers’ treatment of them, and interactions with any hospital staff from point of entry). This includes their perceptions regarding accessibility of the service as well as adherence of their patients to the PMTCT lifelong care. Utilization is made up of (1) adherence issues to the program and; (2) access which comprised of 4 dimensions: availability; affordability; acceptability; adaptability. 20 Adherence is conceptualized as the long-term ability for these women to follow the PMTCT program which includes the ability to take medication routinely, not miss dosages, and attend follow-up appointments. Accessibility is a component of utilization that refers to the equality and equity of care in the healthcare facilities in which these women utilize PMTCT, no matter their nationality and legal status.18,20 Availability dissects the factors such as the range of maternal, newborn child health services (MNCH)/PMTCT services relative to the need that is, hours of operation, ARV supply, willingness of service provider, and information provision.18,20 Affordability refers to costs of PMTCT services and opportunity costs (time a woman can afford to take time from work to get to the hospital), including transport costs, medicine charges, diagnostic tests, special diets, and childcare costs.18,20 Acceptability refers to whether the expectations of the women are met, which includes age, gender, race, ethnicity of provider, decision making, and whether culturally appropriate service are offered.18,20 Acceptability also includes the individuals’ non-medical expectations of healthcare providers’ treatment of dignity and respect of their culture.18,20 Adaptability, however, refers to the sustainability and scalability for the PMTCT program for all women, no matter nationality and legal status.18,20 The Utilization of PMTCT Services Conceptual Framework. IDIs were conducted in the privacy of participants offices at RMMCH or on an audio recording platform (Zoom) where consent was provided due to capacity restrictions of COVID-19. Participants were recruited through purposive sampling and had to meet the following inclusion criteria: had to be 18 years or older; a healthcare provider at RMMCH; works in the public healthcare sector at district, provincial, or national level and; had to have contact with service users on PMTCT since its initiation in 2015 at RMMCH. Participants were not excluded based on race or language. Participants were only excluded if they were newly employed with no previous interaction with patients on PMTCT. A semi-structured interview guide was used that comprised of the following main topics: (1) adherence, (2) access, (3) availability, (4) affordability, (5) acceptability, and (6) adaptability. For example, some questions asked were, “What documents are needed to utilize PMTCT at RMMCH for non-national women? What ways would you improve the services made available for PMTCT at RMMCH? Specifically for mobile populations? What strategies would you implement at RMMCH to improve PMTCT use? Do you think mobility has an effect on a women’s uptake/adherence with the PMTCT lifelong treatment program? Why?” The guide was developed by the researchers, which consisted of an HIV medical specialist, migration, and public health epidemiologists who had experience in this field. The topics in the interview guide were structured in a logical and constructive way and were based on findings from literature review and information on the framework. Participants were recruited consecutively until data saturation occurred where the principal investigator and research team were no longer hearing or seeing new information emerging from the data. To establish rapport, interviews started with demographic questions, then moved to challenging topics (i.e. any mistreatment toward patients) with open-ended questions. IDIs were audio recorded and transcribed verbatim, all transcripts were anonymized but roles and perspectives that were important to answering the question. A thematic content analysis was used to analyze the data using NVivo QSR 12 (QSR International Pty Ltd., 2018). The round of open coding was completed by two authors independent of each other, after which the codes were discussed and re-coded until consensus was reached. 19 A triangulation technique was used to crosscheck and validate IDIs and ensured the credibility of the findings amongst the research team that reviewed the findings from transcription along with literature journaling for social cues, reflection, and continuous refinement to hone the most prominent themes and relationships. 19 Descriptive statistics were reported for demographics of the participants including proportions for categorical variables using Stata 14. The Human Research Ethics Committee (HREC) at the University of Witwatersrand, South Africa approved this study in 2019. Provincial clearance was obtained by Gauteng Province and The National Health Research Database (NHRD No: GP_201912_003) and the City of Johannesburg. Authorization from RMMCH was granted to conduct the study in Coronationville (HREC Protocol No: M190816 MED19-07-084). Participants gave verbal informed consent before the start of the IDI was audio recorded.
N/A
