International medical and public health journals contain a growing body of writing on the practical and ethical implications of the rationing of antiretroviral (ARV) treatment around the world. The brief title of one important article neatly encapsulates the dilemma facing health professionals: “Which patients first?” Medics in most developing countries talk about “targeting priority patients” in order to emphasise that universal access to ARVs is their ultimate ambition. Campaign groups also avoid the language of rationing because they believe it undercuts their campaigns for ARVs and allows governments to retreat from universal treatment commitments.The truth, however, is that only a small proportion of those who could benefit from ARVs around the world are receiving them.
Equity and HIV/AIDS
This draft meeting report is the result of a resolution taken by the AIDS and Rights Alliance for Southern Africa (ARASA). ARASA was tasked with drawing up a code that is similar to the SADC code on HIV and Employment, but focussed specifically on gender related issues within the Aids epidemic.
South Africa, the country with the largest HIV epidemic worldwide, has been scaling up treatment since 2003 and is rapidly expanding its eligibility criteria. The HIV treatment programme has achieved significant results, and had 1.8 million people on treatment per 2011. Despite these achievements, it is now facing major concerns regarding (i) efficiency: alternative treatment policies may save more lives for the same budget; (ii) equity: there are large inequalities in who receives treatment; (iii) feasibility: still only 52% of the eligible population receives treatment. the authors argue there are two reasons for this. First, priority setting decisions on HIV treatment are argued to fail to capture the broad range of values that stakeholders have. Second, priority setting on HIV treatment is a highly political process without adequate participatory processes in place to incorporate stakeholders' views and evidence. They propose an alternative approach that integrates procedural fairness and a multi-criteria decision analysis that assesses feasibility, efficiency, and equity of programme options, including trade-offs.
This community-based, qualitative study conducted in rural Kisesa District, Tanzania, explores perceptions and experiences of barriers to accessing the national antiretroviral programme among self-identified HIV-positive persons. Part of wider operations research around local introduction of HIV therapy, the study involved consultation with villagers and documented early referrals' progress through clinical evaluation and, if eligible, further training and drug procurement. Data collection consisted of 16 participatory group discussions with community members and 18 in-depth interviews with treatment-seekers. While simple measures to reduce perceived barriers improved initial access to treatment and helped overcome anxiety among early referrals, pervasive stigma remains the most formidable barrier. Encouraging successful referrals to share their positive experiences and contribute to nascent community mobilisation could start to address this seemingly intractable problem.
Researchers in this study investigated sub-optimal patient adherence to antiretroviral therapy in 18 clinical sites in rural Zambézia Province, Mozambique. They conducted 18 community and clinic focus groups in six rural districts, interviewing 76 women and 88 men, of whom 124 were community participants (CPs) and 40 were health care workers (HCWs) who provide care for those living with HIV. CP focus groups noted a lack of confidentiality and poor treatment by hospital staff, doubt as to the benefits of antiretroviral therapy and sharing medications with family members. Men expressed a greater concern about poor treatment by HCW than women and health care workers blamed patient preference for traditional medicine and the side effects of medication for poor adherence. In conclusion, perspectives of CP and HCW likely reflect differing socio-cultural and educational backgrounds. Health care workers must understand community perspectives on causes of suboptimal adherence as a first step toward effective intervention.
Access to good quality antiretroviral treatment has transformed the prognosis for people with AIDS in the developed world. Although it is feasible and desirable to deliver antiretroviral drugs in resource poor settings, few of the 95% of people with HIV and AIDS who live in developing countries receive them. The World Health Organization has launched a programme to deliver antiretroviral drugs to three million people with AIDS in the developing world by 2005, the "3 by 5" initiative. This article identifies some of the challenges faced by the initiative, focusing on delivery of care.
This British Medical Journal article examines the challenges faced in the World Health Organization's (WHO) '3 by 5' initiative, which aims to deliver anti-retrovirals (ARVs) to 3 million people by 2005. It highlights that the focus on delivering ARVs distracts resources and attention from a broader model of health care. They argue that the initiative must develop a chronic disease model of care through a strengthened public health infrastructure. The authors also point out the exclusionary power of stigma and outline the need for training programmes for health care workers on medical ethics and human rights.
The failure to remove barriers that determine whether a person can access and use a condom is one of the biggest impediments to preventing millions more HIV infections. This advocacy briefing from International Council of AIDS Service Organisations (ICASO) examines some of these barriers and addresses what can be done to overcome them. Information was sourced from a community-led monitoring project in 14 countries undertaken in 2005 and 2006 which collected and analysed data and information on the broad response to HIV and AIDS. The report states that to overcome prominent barriers, governments and donors around the world need to commit new resources and enact and reform legislation, policy and programming that will ensure condom access and availability. It argues that a mobilised community sector that can forcefully advocate for condom access is needed now more than ever.
The aim of this study was to investigate knowledge of prevention of mother to child HIV transmission (PMTCT) programmes and to describe potential barriers that might affect their acceptability in a resource poor setting in South Africa. Based on interviews with over 1500 pregnant women, their families and five communities around the PMTCT clinic areas, the authors found that there are several major potential barriers in implementing PMTCT programmes in a resource poor setting. The authors suggest that increased access to HIV testing and counselling would be one of the most effective ways of reducing perinatal transmission. They state that this can be achieved by ensuring that expectant mothers receive antenatal care from trained staff throughout their pregnancy and have a skilled professional childbirth attendant.
This paper describes the experience of Zimbabwe in establishing a baseline for its National Action Plan for Orphans and Other Vulnerable Children (NAP for OVC) using the 10 core indicators developed by the UNAIDS Global Monitoring and Evaluation Reference Group in 2004. Through a population-based household survey in rural and urban high-density areas and the OVC policy and planning effort index assessment tool, a baseline was established. The survey found that 43.6% of children under 18 years were orphaned or made vulnerable by HIV/AIDS. Half of all households with children care for one or more OVC. While the large majority of OVC continued to be cared for by the extended family, its capacity to care for these children appeared to be under pressure. OVC were less likely to have their basic minimum material needs met, more likely to be underweight, less likely to be taken to an appropriate health provider when sick and less likely to attend school. Medical support to households with OVC was found to be relatively high (26%). Other support, such as psychosocial support (2%) and school assistance (12%), was lower. The OVC Effort Index assessment indicates that serious efforts are being made. The increase in the effort index between 2001 and 2004 in the areas of consultative efforts, planning and coordinating mechanisms reflects the strengthened commitment. Monitoring and evaluation and legislative review are the weakest areas of the OVC response. The findings of the baseline exercise point to the need for continued and additional efforts and resources to implement the NAP for OVC, the priorities of which were confirmed by the survey as critical to improve the welfare of the OVC in Zimbabwe.