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

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

doi:10.1590/0102-311X00170918

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ARTICLE • Cad. Saúde Pública 35 (6) • 2019 • https://doi.org/10.1590/0102-311X00170918 copy

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

Desigualdades no acesso a testes para HIV e sífilis durante a assistência pré-natal no Brasil

Inequidades en el acceso a las pruebas de VIH y sífilis durante el cuidado prenatal en Brasil

Authorship SCIMAGO INSTITUTIONS RANKINGS

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.

Keywords:
Health Services Accessibility; Prenatal Care; HIV; Syphilis; Vertical Infectious Disease Transmission

	Outcomes
	Less than 6 prenatal care appointments			No HIV tests in prenatal care			No tests for syphilis detection in prenatal care
	n (%)	PR (95%CI)	p-value	n (%)	PR (95%CI)	p-value	n (%)	PR (95%CI)	p-value
Individual level
Age (years)
15-19	203 (19.4)	1.00		97 (8.0)	1.00		231 (21.1)	1.00
20-29	839 (17.9)	0.93 (0.81; 1.06)	0.143	302 (5.5)	0.69 (0.55; 0.86)	< 0.001	657 (13.1)	0.62 (0.54; 0.71)	< 0.001
30 and more	422 (16.8)	0.87 (0.75; 1.01)	0.067	106 (3.5)	0.43 (0.33; 0.57)	< 0.001	229 (8.2)	0.39 (0.33; 0.46)	< 0.001
Race (skin color)
White	391 (17.1)	1.00		104 (3.7)	1.00		260 (10.2)	1.00
Black or mixed	1,030 (17.9)	1.04 (0.94; 1.16)	0.439	386 (5.7)	1.53 (1.24; 1.89)	< 0.001	824 (13.3)	1.30 (1.14; 1.49)	< 0.001
Education (years of schooling)
8 and above	971 (16.7)	1.00		281 (4.0)	1.00		669 (10.4)	1.74 (1.56; 1;95)	< 0.001
Up to 8	493 (20.5)	1.23 (1.12; 1.36)	< 0.001	223 (8.0)	1.97 (1.66; 2.34)	< 0.001	447 (18.1)
Work
Yes	347 (17.5)	1.00		103 (4.2)	1.00		223 (10.0)	1.00
No	1,117 (17.8)	1.02 (0.91; 1.14)	0.743	402 (5.5)	1.23 (1.05; 1.60)	0.016	894 (13.4)	1.34 (1.17; 1.54)	< 0.001
Family Income Program
No	820 (19.2)	1.00		213 (4.1)	1.00		539 (11.3)	1.00
Yes	642 (16.2)	0.84 (0.77; 0.93)	< 0.001	290 (6.3)	1.53 (1.28; 1.81)	< 0.001	576 (14.0)	1.24 (1.11; 1.38)	< 0.001
City level
HDI
0.695 and above	771 (21.0)	1.00		162 (3.6)	1.00		412 (9.8)	1.00
Up to 0.694	691 (15.2)	0.76 (0.66; 0.79)	< 0.001	342 (6.6)	1.84 (1.53; 2.20)	< 0.001	704 (15.0)	1.52 (1.36; 1.71)	< 0.001
Gini index
Up to 0.520	726 (17.2)	1.00		216 (4.3)	1.00		483 (10.6)	1.00
0.521 and above	736 (18.4)	1.07 (0.97; 1.17)	0.156	288 (6.1)	1.41 (1.19; 1.68)	< 0.001	633 (14.6)	1.38 (1.24; 1.54)	< 0.001
Per capita income (BRL)
554 and more	782 (21.3)	1.00		157 (3.5)	1.00		405 (9.7)	1.00
Up to 553.99	680 (14.9)	0.70 (0.64; 0.77)	< 0.001	347 (6.6)	1.91 (1.59; 2.30)	< 0.001	711 (15.0)	1.55 (1.38; 1.74)	< 0.001
Poverty
Up to 13.7%	764 (21.0)	1.00		144 (3.2)	1.00		372 (8.9)	1.00
13.8% and above	698 (15.2)	0.72 (0.66; 0.79)	< 0.001	360 (6.9)	2.15 (1.78; 2.59)	< 0.001	744 (15.7)	1.77 (1,57; 1.99)	< 0.001
Health care facilities per 10,000 inhabitants
1.46 and above	693 (16.4)	1.00		250 (5.1)	1.00		538 (12.0)	1.00
Up to 1.45	768 (19.4)	1.18 (1.08; 1.30)	< 0.001	249 (5.2)	1.03 (0.87; 1.23)	0.706	571 (13.0)	1.01 (0.97; 1.21)	0.133
Investments in primary care (BRL per capita)
38.48 and above	724 (16.4)	1.00		301 (5.9)	1.00		620 (13.4)	1.00
Up to 38.47	737 (19.3)	1.17 (1.07; 1.29)	0.001	203 (4.4)	0.75 (0.63; 0.89)	0.001	496 (11.6)	0.87 (0.78; 0.97)	0.015

	Null model (n = 8,238)		Model 1 (n = 8,226)		Model 2 (n = 8,186)
	PR (95%CI)	p-value	PR (95%CI)	p-value	PR (95%CI)	p-value
City level
HDI up to 0.694					0.72 (0.63; 0.82)	< 0.001
Gini index 0.521 and more					1.10 (0.98;1 .23)	0.093
Health care facilities/Inhabitants up to 1.45					1.09 (0.97; 1.23)	0.148
Ivenstiments in primary care per capita up to BRL 38.47					0.95 (0.82; 1.08)	0.429
Individual level
Up to 8 years of schooling			1.31 (1.17; 1.46)	< 0.001	1.32 (1.18; 1.48)	< 0.001
Family Income Program (enrolled)			0.79 (0.71; 0;88)	< 0.001	0.85 (0.76; 0.95)	0.003
Fixed effects: intercept (95%CI)	-1.75 (-1.81; -1.69)		-1.72 (-1.81; -1.64)		-1.65 (-1.78; -1.51)
Random effects	Variance (95%CI)		Variance (95%CI)		Variance (95%CI)
City level	0.049 (0.015; 0.162)		0.045 (0.013; 0.160)		0.042 (0.013; 0.130)
LR test (χ²; p-value)	3.78; 0.026		3.40; 0.033		5.02; 0.012

	Null model (n = 9,749)		Model 1 (n = 9,518)		Model 2 (n = 9,515)
	PR (95%CI)	p-value	PR (95% CI)	p-value	PR (95%CI)	p-value
City level
HDI up to 0.694					1.59 (1.22; 2.06)	< 0.001
Gini index 0.521 and more					1.48 (1.21; 1.82)	< 0.001
Ivenstiments in primary care per capita up to BRL 38.47					1.03 (0.81; 1.31)	0.799
Individual level
Black or mixed			1.39 (1.11; 1.74)	0.004	1.26 (1.01; 1.58)	0.043
Up to 8 years of schooling			1.79 (1.48; 2.16)	< 0.001	1.78 (1.47; 2.16)	< 0.001
Do not work			1.13 (0.90; 1.42)	0.277
Familiy Income Program (enrolled)			1.22 (1.01; 1.48)	0.041	1.12 (0.92; 1.36)	0.266
Fixed effects: intercept (95%CI)	-3.23 (-3.38; -3.08)		-3.88 (-4.17; -3.59)		-4.15 (-4.49; -3.81)
Random effects	Variance (95% CI)		Variance (95%CI)		Variance (95%CI)
City level	0.690 (0.463; 1.027)		0.619 (0.403; 0.950)		0.564 (0.358; 0.888)
LR test (χ²; p-value)	43.87; < 0.001		36.66; < 0.001		30.70; < 0.001

	Null model (n = 8,904)		Model 1 (n = 8,705)		Model 2 (n = 8,700)
	PR (95%CI)	p-value	PR (95%CI)	p-value	PR (95%CI)	p-value
City level
HDI up to 0.694					1.39 (1.18; 1.64)	< 0.001
Gini index 0.521 and more					1.39 (1.22;1.59)	< 0.001
Ivenstiments in primary care per capita up to BRL 38.47					1.12 (0.97; 1.31)	0.130
Individual level
Age group 20-29 years			0.62 (0.53; 0.73)	< 0.001	0.62 (0.53; 0.73)	< 0.001
Age group 30 years and more			0.37 (0.31; 0.45)	< 0.001	0.38 (0.31; 0.46)	< 0.001
Black or mixed			1.19 (1.03; 1.37)	0.016	1.11 (0.96; 1.28)	0.152
Up to 8 years of schooling			1.71 (1.50; 1.94)	< 0.001	1.70 (1.50; 1.93)	< 0.001
Do not work			1.07 (0.91; 1.25)	0.400
Family Income Program (enrolled)			1.17 (1.03; 1.34)	0.015	1.10 (0.97; 1.25)	0.139
Fixed effects: intercept (95%CI)	-2.16 (-2.24; -2.08)		-2.05 (-2.27; -1.82)		-2.33 (-2.57; -2.01)
Random effects	Variance (95%CI)		Variance (95%CI)		Variance (95%CI)
City level	0.259 (0.167; 0.404)		0.166 (0.089 ;0.309)		0.141 (0.070; 0.282)
LR test (χ²; p-value)	38.00; < 0.001		16.19; < 0.001		12.63; < 0.001

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[1] Correspondence C. H. S. M. Freitas Universidade Federal da Paraíba. Rua Poeta Luis Raimundo Batista de Carvalho 357, João Pessoa, PB 58037-530, Brasil. chsmfreitas@hotmail.com