Understanding patterns of health system utilisation among people living with HIV/Aids attending rural HIV services

Following the successful introduction of antiretroviral therapy (ART) in resource-limited settings, we have observed an unprecedented explosion in the expansion of ART programs throughout sub-Saharan Africa, resulting in a 13-fold increase in coverage since 2004. In spite of these achievements, uptake of ART remains low. The gap in treatment coverage is approximately 50% of those who need ART in South Africa, while the country boasts the largest ART program worldwide. Rural areas are particularly prone to lower ART coverage rates, largely a result of existing health care inequities. The ART coverage gap will widen given the recent introduction of new treatment guidelines, which allows for ART commencement at CD4 350 cells/mm3. Furthermore, approximately one-third of ART patients are lost to follow up after two years of treatment initiation in sub-Saharan Africa. This study explores factors associated with ART access and utilisation in a rural area, in order to reduce the gap in knowledge on patient and health system factors. Unaddressed, these factors may continue to hinder adoption of rigorous interventions to improve ART uptake and retention. This research employs the A-Framework to conceptualize access to health care, where dimensions of access include availability (physical access), affordability (financial access), and acceptability (cultural access). A data triangulation approach was adopted as very little was known on the utilization patterns of health care by HIV/AIDS patients. Quantitative research (2008-2010) employed a four-site rural-urban comparative analysis of 1266 participants, and was part of a 5-year project Researching Equity and Access to Health care (REACH).This was complemented by a more in-depth qualitative assessment (2006-2007) that followed the treatment experience of 32 patients before and after ART initiation in the rural Bushbuckridge site. We found plural utilisation of health care to be a cross-cutting theme throughout this thesis. While the movement of patients between providers at various levels within the traditional and formal health sector may be a sign of agency, it may also result in excessive health costs that threaten the livelihoods of individuals and their households. We discuss a number of strategies to improve ART initiation and adherence including the need to incorporate metrics for pluralism into routine assessments; the importance of decentralized, humane and high quality care and support services; support for efforts to enhance patient self-efficacy through education, awareness and social support interventions; the incorporation and regulation of traditional healers into the formal system; risk protection mechanisms that reduce financial barriers and consequences of HIV care including grants, subsidies and National Health Insurance, and support for wider efforts to reduce urban-rural inequalities.