HIV and AIDS - Background reading
Access to treatment of HIV and AIDS
Access is essential for effective health care. This means access to skilled people, information, materials (medicines, tests, etc.), facilities, money and various types of support. It is more than availability. The various elements of health care might be in place, but there are many reasons why an individual might have difficulty in gaining access to them.
Inevitably, people with low incomes, in low-resource areas or marginal social groups, usually have the least access to health care. Effective treatment requires good health systems, supportive communities, adequate social and economic conditions and political will. Access is a complex issue.
Access to HIV and AIDS treatment
The HIV and AIDS epidemic has brought questions about access to the fore, because
of its global spread and high impact in many countries. The impact of
HIV has been most severe on people who also lack access to clean water,
food and essential medicines. Many have already suffered more from tuberculosis
(TB) and other infections as a result of the HIV epidemic. These people
have, until recently, had little or no access to the only effective medicines
available to treat HIV – antiretrovirals (ARVs).
ARVs are only able to reduce the effects of the virus, not to eliminate it, but they make a vital difference to the lives of those who have access to them. Treatment with ARVs strengthens damaged immune systems, helping patients to resist and recover from opportunistic infections. Effective ARV treatment not only reduces the morbidity and mortality figures for HIV, it also reduces stigma and discrimination. When people see that it is possible to live a longer, healthier life with ARVs, they fear HIV less, are more willing to get tested for HIV and are more supportive of people who are using treatment.
Plans are developing in many countries to make ARVs accessible to far more people. Drug prices are falling and small pilot programmes have shown that ARVs can be used successfully in low-resource situations. The Global Fund and other donors are beginning to contribute funds and the World Health Organization (WHO) has provided guidelines for public health use of ARVs.
An integrated approach
HIV exists alongside a number of other related health issues, in particular
the TB epidemic, malaria, sexually transmitted infections (STIs) and
some significant non-infectious diseases such as diabetes, heart disease
and cancer. The needs that these health issues create co-exist with wider
needs for food, shelter, support for children and employment. HIV in
particular has major social and economic effects and is not just a health
problem. An integrated approach is, therefore, the best way forward.
For example, in some areas, tackling HIV and TB together is having a
powerful effect on the progress of both epidemics.
Barriers to HIV treatment can be related to social contexts, such as stigma, lack of confidentiality, or beliefs that prevent people from asking for treatment or create a need for secrecy about using ARVs. They may be related to personal finance – lack of money, lack of transport or the inability to take time off work. In rural areas, physical barriers, such as bad roads and lack of transport, prevent access to treatment and care.
Health systems may be lacking in resources or funding for treatment too. Lack of political understanding or will is often an overriding reason why access to treatment for HIV is limited. Failure of manufacturers to price drugs at affordable prices also remains a major barrier to the widespread use of ARVs and other new drugs.
However, there are many opportunities to reduce or avoid the barriers that stand in the way of access to ARV treatment. It is important to approach these opportunities in an integrated way that is closely related to the varied situations in which HIV-related treatment is needed.
Integration needs to happen in several ways:
- Health providers must work together to improve diagnosis, care and treatment for people with HIV and to prevent discrimination. Awareness of HIV and ARV therapy should be promoted across the whole spectrum of health services.
- Referrals for diagnosis, counselling and treatment should be made as early as possible and without discrimination. Services for prevention and treatment of related illnesses – TB, STIs, and opportunistic infections – should integrate with HIV services wherever possible to make them more effective and patient-friendly.
- Health services must work closely with the community, civil society and political structures to ensure that people can have diagnosis, counselling and treatment for HIV with full support, rather than in an atmosphere of secrecy and denial.
- Universal access to ARVs continues to be a key advocacy goal at global, national and local levels. At the same time communities and local health systems must get ready for the time when access becomes a reality. Communities and health providers need to become both ‘AIDS-competent’ and ‘ARV-competent’.
Key issues for access to HIV-related treatment
Community involvement
Preparing communities for ARV treatments requires respect for patients’ rights,
helping patients to be effective users of effective drugs and clinical
care, and ensuring that they have accessible and appropriate information.
Accessible information means that it must be written in language that the
user can understand. Information is appropriate when it is suited to the
needs of the user. A patient needs to know about his or her treatment in
order to use it correctly and to know what to do about side effects. A
doctor needs to have up-to-date clinical information, but needs also to
know what information the patient needs and how to provide it.
Making the best use of what is already available
ARV provision needs to be supported by functioning general health services,
access to essential medicines and supplies, and effective involvement
of informed communities. Existing treatment services should be made more
widely available to provide a foundation for ARV treatment.
Sustainable, appropriate and reliable supplies
Provision of medicines, tests and other materials must be assured in order
to make ARV treatment effective. The four components of access to medicines
and supplies need to in place – rational selection, affordable
prices, sustainable financing, and reliable supply systems. These must
be supported by rational use by prescribers and consumers, quality and
safety protection, and national policies, all of which are needed to
support access.
Sharing lessons learned
ARV provision and use in resource-poor settings has so far been limited.
Finding the best approaches requires creative thinking in the midst of
critical levels of need. Lessons learned need to be shared to avoid backtracking
and repetition of mistakes, and to help understanding to develop quickly.
Campaigning target
The focus continues to be on global issues such as Trade-Related Aspects
of Intellectual Property Rights (TRIPS) – especially after the
Doha Declaration (Ministerial World Trade Organisation (WTO) Conference,
held in Doha, Qatar in November 2001) – as well as on pricing
and the tensions between access to ARVs, and wider needs for access to
health rights. Targets need to be broadened to embrace local action and
to incorporate the different emphases in local advocacy, treatment ‘literacy’ and
community preparedness for ARVs.
Children and access
The present focus is on infants and the prevention of mother-to-child transmission
of HIV (PMTCT), with or without support for the parents’ treatment
needs (PMTCT-Plus). But there are other issues to address, and groups
who need special consideration, including: children who are sexually
active; children who are infected by other means, such as dirty injections;
and older children and adolescents. (Note that PMTCT is often called
prevention of parent-to-child transmission, to acknowledge the responsibility
of both parents.)
Gender and access
Differing pressures and assumptions about ARV treatment affect men and
women in different ways and need to be better explained. Disadvantaging
(or advantaging) one sex over the other can hinder or assist access and
effective treatment within different cultural contexts. For instance,
women who have had inadequate access to education and are unable to read
may not find out that treatment is available, or they may not be able
to understand written instructions on labels or instructions about their
prescribed medication. They may be rejected for ARV treatment because
of fears that they will not follow treatment guidelines properly. In
addition, when a woman and baby receive PMTCT-Plus treatment, HIV-positive
fathers may be refused treatment, even though their role as a breadwinner
is essential for survival of all the family. We need to understand much
more about the ways these and other gender issues affect public health
provision of ARV treatments.
Access is only the beginning of treatment
Now that ARVs are becoming a reality in public health treatment, it is
time to develop effective approaches to the use of treatments. What is
necessary from the individual, community and public health perspectives?
Capacity building for access and beyond needs to be:
- Rights-based (access is part of the human right to health)
- Community-based (informed, prepared, with decreased stigma and discrimination, enabling patients to play a full and informed role in their treatment)
- Technically appropriate (accessible information, effective diagnosis and treatment, management, legal support for rights and regulation)
All of this is needed in order to support sustainable access and to move forward into effective treatment using ARVs, to make a real and visible difference to the progress of the HIV epidemic.
Resources on access to treatment and other HIV and AIDS issues can be found on the Source website;
This article was written by Carolyn Green, Independent Consultant Pharmacist and HIV specialist for Healthlink Worldwide in response to requests from our partner organisations. Individuals and organisations are welcome to adapt or reproduce the article for non-profit uses, provided that Healthlink Worldwide and the individual author are clearly credited.