Health on the move: understanding ethical and structural challenges in HIV prevention for migrant and mobile women in South Africa during the COVID-19 pandemic

Résumé

Background Global human mobility has intensified due to globalization, economic inequality, conflict, and climate change, generating new vulnerabilities that disproportionately affect women's healthcare access. In sub-Saharan Africa, where HIV burden remains highest, migration intersects with gender and structural inequities to disrupt prevention and treatment services. South Africa—a major destination and transit country—illustrates these dynamics. Its Prevention of Mother-to-Child Transmission (PMTCT) programme, renamed in August 2023 as the Vertical Transmission Prevention programme to expand beyond HIV and reduce stigma, provides lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women. However, migrant women face barriers including documentation requirements, discrimination, cost, and fragmented continuity of care—challenges that intensified during the COVID-19 pandemic. These documented barriers are reconfigured under conditions of mobility and crisis, producing differentiated access across typologies. Objectives This study examined how mobility typologies shaped migrant women's experiences of PMTCT access during COVID-19 and what this reveals about migration-aware, ethical, and adaptable health systems. Design Qualitative, multi-level study design grounded in participatory and interpretive approaches were employed. The study explored individual, organizational, and policy-level experiences to understand how mobility, health systems, and crisis conditions interacted to influence service utilization. Setting Data were collected at antenatal and postnatal clinics and wards within the Departments of Obstetrics and Gynecology and Pediatrics at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa. The hospital serves a highly mobile population, including internal migrants, cross-border migrants, refugees, and asylum seekers, making it a critical site for examining migration-health intersections. Method Between 2020 and 2022, in-depth interviews were conducted with 40 migrant women living with HIV accessing PMTCT services, alongside 12 healthcare workers (4 policy makers). A document and policy review complemented interview data. Analysis was guided by the Migration-Aware Adaptable Health Systems for PMTCT framework and used iterative thematic coding with reflexive and participatory validation. Results Mobility patterns significantly shaped PMTCT access. Undocumented cross-border and documentation-precarious migrants faced the greatest exclusion, driven by legal status, documentation barriers, fear of deportation, language challenges, and COVID-19-related cost reclassifications that shifted refugees and asylum seekers to private patient status. In contrast, internal migrants experienced transport disruptions, inconsistent messaging, and fragmented referral pathways. Across all groups, systemic communication gaps undermined understanding of lifelong antiretroviral therapy. Healthcare workers, despite reporting moral distress, staff shortages, and policy ambiguity, adapted through multi-month dispensing, digital communication, and bundled or informal care coordination. COVID-19 functioned as a system-wide stress test, both exacerbating existing inequities and accelerating adaptive responses, some of which persisted beyond the pandemic, while structural barriers—including documentation requirements, inconsistent policy implementation, and xenophobic practices—remained entrenched. Conclusion Mobility is both a determinant and dimension of health within unequal, crisis-prone systems requiring responsive and inclusive design. Migration-aware, adaptable health systems—grounded in participatory ethics, flexible delivery models, and inclusive governance—are essential to sustaining HIV prevention gains and ensuring equitable PMTCT access for migrant women.

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