Inequities in the Use of Antiretroviral Therapy in Southern Africa

By Desire Rwodzi, Nitaya Vajanapoom, Marc Van der Putten, Stephen J. Artwood, William Aldis

Remarkable progress has been made worldwide regarding the provision of antiretroviral therapy (ART). However, epidemiologic studies revealed inequalities regarding use of ART, especially in settings where universal coverage is yet to be achieved.

Objective: This paper seeks to review use of public sector ART in Southern Africa through an equity lens.

Methods: Seven out of sixteen countries in Southern Africa were randomly selected for this review. Published articles and reports were searched from the following databases: PubMed, Springer link, Science Direct, Springer, OVID, Scirus, Google Scholar and Google Web. A Boolean search strategy was employed using search terms such as: ‘socioeconomic status and access to ART in + name of selected country in Southern Africa’; ‘who has access to HIV drugs in Southern Africa’; ‘access to HIV drugs/ART by socioeconomic status’; ‘inequities in access to free HIV treatment in Southern Africa’; ‘coverage of ART + name of selected country’. A decade of titles in English, published and indexed from 2003 and 2012, were considered for retrieval.   Out of the 136 titles retrieved, full text reviews were done for 14 original research articles. A total of six WHO/UNAIDS/UNICEF/UNGASS reports/publications were also reviewed.

Findings: Out of the seven countries included in this review, only Swaziland and Botswana had achieved universal access to ART as of December 2010. Epidemiological studies revealed inequalities regarding use of public sector ART by various indicators of socioeconomic status including gender and age, among others. While female to male HIV infection prevalence ratios in southern African countries ranged from 1.2:1to 1.6:1, female to male ratios using ART ranged from 0.8: 1 to 2.3: 1. Women using ART were in disproportionately large numbers compared to men. Adults were shown to be using ART in disproportionately large numbers compared to children under the age of 15. Even amongst children below 15 who were using ART, gender disparities were still significant with disproportionately more girls than boys receiving treatment, and this was not solely explained by the differences in HIV infection rates. Level of education and employment were also shown to have significant associations with use of public sector ART. People with better use of ART were most likely to have completed tertiary education, or less likely to be unemployed. In urban South Africa, there was a notable absence of public sector ART users from the highest economic quintile, whilst it was also reported that those who were most likely to use ART services were not the most impoverished social group/lowest economic quintile.

Discussion and Conclusion: One possible reason for women’s greater use of public sector ART than men may be related to their greater involvement in PMTCT. Statistics revealed that more than 50% of pregnant women get tested for HIV, and the majority (>60%) of pregnant women living with HIV actually received antiretroviral medicine recommended by WHO for preventing mother-to-child transmission. However, it is not clear from the statistics whether it is PMTCT that gets more women on public ART programmes for life. Research is also yet to answer why children are under-represented in ART programmes if women’s better use of ART is a result of PMTCT. It also remains a key question as to whether it would be possible or not, for all eligible persons to realize their right to health (including use of ART) when resources are limited. Universal access, defined as coverage of at least 80% of those eligible for ART, can be attained without any intervention amongst persons in the lowest quintile. This implies that universal access can be achieved but in a very inequitable manner. As such, governments should guard against complacency having attained universal access to ART, but should strive for full coverage by putting emphasis on targeted approaches. This review revealed that providing ART ‘freely’ is no guarantee that use would be equitable. Studies to investigate and understand the role of socioeconomic status on use of free ART could provide a foundation for the inclusion/modification of equity measures at local, national and regional levels, and eventually feeding into the WHO construct on equitable use of ART.