Equity and HIV/AIDS

This Environmental Scan covers three broad research areas: clinical research (prevention of mother to child transmission, or PMTCT, and paediatric treatment), clinical research (women and antiretroviral therapy) and operations research (delivering treatment to women). A parallel consultative process, led by UNICEF, addressed operations research/implementation science questions related to PMTCT, including paediatric care, treatment and support. The report found that there has been substantial progress in improving access to anti-retroviral therapy (ART) in low- and middle-income countries in recent years. The need to better understand the potential role of sex differences in HIV disease progression and treatment response is being increasingly recognised by the research community as an understudied area of inquiry. To date, there is no evidence to support differential treatment strategies for men and women. Clinical trials addressing this question are still too few and too small to provide definitive answers. Women face greater threats to personal safety and financial security than men do and as a result, they experience HIV stigma more forcefully. Some studies have identified failure to successfully integrate HIV treatment programmes with other women’s health services as a particular barrier to accessing ART.

All people with HIV/AIDS should have equal opportunity to access effective and appropriate treatment. However, in the context of existing social and health inequities, widespread poverty, high rates of new HIV infections, famine and budgetary constraints, increasing access to HIV care and treatment must be organised in a manner that balances HIV prevention and treatment efforts; HIV interventions and the broader strengthening of the health system as a whole; and HIV care and treatment with other public health and social needs.

This paper discusses the issue of equity in the distribution of ARV drugs in the Malawi health system. Malawi is one of the countries most severely affected by HIV/AIDS in southern Africa. It is also one of the poorest countries in the world.ARV drugs are expensive.The Malawi government, with assistance from the Global Fund on Tuberculosis, Malaria and HIV/AIDS, started providing free ARV drugs to eligible HIV-infected people in September 2004.The provision of free drugs brought the hope that everyone who was eligible would access them. Based on data collected through a qualitative research methodology, it was found that achieving equity in provision would face several challenges including policy, operational and socio-economic considerations. Specifically, the existing policy framework, shortage of medical personnel, access to information and inadequacy of effective community support groups are some of the key issues affecting equity.

About half a million people in South Africa are deprived of antiretroviral therapy (ART), and there is little systematic knowledge on who they are – e.g. by severity of disease, sex, or socio-economic status (SES). The authors performed a systematic review to determine the current quantitative evidence-base on equity in utilisation of ART among HIV-infected people in South Africa. The authors conducted a literature search based on the Cochrane guidelines. A study was included if it compared for different groups of HIV infected people (by sex, age, severity of disease, area of living, SES, marital status, ethnicity, religion and/or sexual orientation (i.e. equity criteria)) the number initiating/adhering to ART with the number who did not. The authors considered ART utilisation inequitable for a certain criterion (e.g. sex) if between groups (e.g. men versus women) significant differences were reported in ART initiation/adherence. Twelve studies met the inclusion criteria. For sex, 2 out of 10 studies that investigated this criterion found that men are less likely than women to utilise ART, while the other 8 found no differences. For age, 4 out of 8 studies found inequities and reported less utilisation for younger people. For area of living, 3 out of 4 studies showed that those living in rural areas or certain provinces have less access and 2 out of 6 studies looking at SES found that people with lower SES have less access. One study which looked at the marital status found that those who are married are less likely to utilise ART. For severity of disease, 5 out of 6 studies used more than one outcome measure for disease stage and reported within their study contradicting results. One of the studies reported inconclusive findings for ethnicity and no study had looked at religion and sexual orientation. It seems that men, young people, those living in certain provinces or rural areas, people who are unemployed or with a low educational level, and those being unmarried have less access to ART. As studies stem from different contexts and use different methods conclusions should be taken with caution.