Provision and Access

Gaps in Research

1.
Barriers such as cost of medications, lack of food, and child-care responsibilities may discourage women living with HIV from accessing antiretroviral therapy.
2.
Initiatives that provide for early diagnosis and appropriate longitudinal care prior to treatment eligibility are needed to reduce mortality rates and costs among adults accessing treatment.
3.
Well-functioning laboratory systems are needed to measure viral load via PCR to assess effectiveness of treatment.
4.
Interventions are needed to ensure that prisoners have ongoing access to HIV treatment and care.
5.
Outreach programs are needed for patients who miss ART clinic visits or fail to initiate treatment.
6.
Scale up of testing is needed with competent staff and labs in order to assess CD4 counts and link those who test HIV-positive to treatment.
7.
Increased links are needed for women who access treatment to receive counseling concerning desired children and family planning.
8.
Treatment programs need strategies to retain patients on treatment for humanitarian, refugee and IDP settings.
9.
Research is needed on treating anemia, malnutrition and other dietary conditions as well as on optimum micronutrients for patients accessing HAART and for patients prior to accessing treatment.
10.
Pregnant women living with HIV need timely access to CD4 count testing and results to access treatment.
11.
Adolescents living with HIV need information and services through adolescent-friendly HIV and family planning services.

1. Barriers such as cost of medications, lack of food, and child-care responsibilities may discourage women living with HIV from accessing antiretroviral therapy. A study found that patients who were HIV-positive but did not access antiretroviral therapy were twice as likely as patients on antiretroviral therapy to report not having enough food to take with treatment as a concern, in addition to concerns about cost barriers. Another study found that cost of ARVs, with direct out of pocket payment at point of care delivery decreased access to ARVs. Another study found transport costs and waiting time a barrier to access to treatment.

Gap noted, for example, in Zambia (Fox et al., 2010a); Burkina Faso (Kouanda et al., 2010b); India (Thomas et al., 2009); Mozambique (Posse and Baltussen, 2009); Uganda (Geng et al., 2010b; Tuller et al., 2010); Zimbabwe (Skovdal et al., 2011c); Colombia (Arrivillaga et al., 2009); Tanzania (Wringe et al., 2009 cited in Geng et al., 2010a); Indonesia (Riyarto et al., 2010); sub-Saharan Africa (Mills et al., 2006).

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2. Initiatives that provide for early diagnosis and appropriate longitudinal care prior to treatment eligibility are needed to reduce mortality rates and costs among adults accessing treatment. A review found that early mortality among adults accessing antiretroviral therapy can be attributed to late diagnosis of HIV. Another study found that more than a quarter of HIV patients in care prior to ART initiation did not start ART according to national guideline criteria. Another study found that women did not know where to go to access treatment. A review found that a process is needed to optimize transfers of care without treatment interruption and with appropriate medical documentation.

Gap noted, for example, review and meta-analysis of 29 studies for sub-Saharan Africa (Mugglin et al., 2012b); review of resource-limited settings (Geng et al., 2010a); in a review of 18 published cohort studies in Africa (Lawn et al., 2008); Malawi and Kenya (Zachariah et al., 2011b); China (Zhou et al., 2011); Ethiopia (Alemayehu et al., 2009; Mulissa et al., 2010; Assefa et al., 2011b); Vietnam (Nam et al., 2010); Uganda (Wakeham et al., 2010; Miiro et al., 2010); Mozambique (Auld et al., 2011); Malawi (McGrath et al., 2010); Kenya (Tayler-Smith et al., 2011; Guthrie et al., 2011); East Africa (Mujugira et al., 2012); South Africa (Faal et al., 2011).

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3. Well-functioning laboratory systems are needed to measure viral load via PCR to assess effectiveness of treatment. However, adequate clinical results can also be cost-effective and meet patient needs. A study in sub-Saharan Africa found that more than half of test results for viral load were invalid or inaccurate. A review done in low and middle-income countries showed that lack of routine virologic monitoring in resource limited ART programs led to the development of cross-resistance to the NRTI component of second-line treatment. Even where virological monitoring is available and demonstrates virological failure, delayed switching of patients to alternative antiretroviral therapy regimens occurs.

Gap noted, for example, in globally in resource-limited settings (Phillips et al., 2011; Sawe and McIntyre, 2009); sub-Saharan Africa and Africa (Greig et al., 2011; Ford et al., 2009b); and India, Cameroon, Kenya, Malawi, Burkina Faso, South Africa, Nigeria and Senegal  (Luca et al., 2010); Honduras (Murillo et al., 2010); South Africa (Johnston et al., 2012).

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4. Interventions are needed to ensure that prisoners have ongoing access to HIV treatment and care. Studies found that prisoners lacked access to ARVs, or for those who accessed ARVs, faced the dangers of interrupted treatment due to prison transfers.

Gap noted, for example, in globally (Jurgens et al., 2007); Namibia (Legal Assistance Center AIDS Law Unit and University of Wyoming College of Law, 2008).

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5. Outreach programs are needed for patients who miss ART clinic visits or fail to initiate treatment. A study showed that issues such as provider to patient ratios; adherence support programs; and needing transport from rural areas were associated with lower CD4 counts at initiation of ART. Other studies showed that patients were lost between initiation and maintenance sites. Another study found that one in five treatment-eligible HIV-positive individuals refused to initiate ART (Katz et al., 2011).

Gap noted, for example in Ethiopia, Kenya, Lesotho, Mozambique, Nigeria, Rwanda, South Africa and Tanzania (Nash et al., 2011); South Africa (Katz et al., 2011; O'Conner et al., 2011; Bassett et al., 2010; Cornell et al., 2010); Botswana (Steele et al., 2011); Uganda (Nakigozi et al., 2011; Geng et al., 2012b); Latin America and the Caribbean (Crabtree-Ramirez et al., 2011).

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6. Scale up of testing is needed with competent staff and labs in order to assess CD4 counts and link those who test HIV-positive to treatment. Studies are finding that in some countries, those who test HIV-positive are presenting with AIDS and that patients do not initiate ART despite eligibility. Those who test HIV-positive yet not eligible to receive antiretroviral therapy according to their national guidelines often did not remain in care until they were eligible for treatment.

Gap noted, for example, in Uganda (Miiro et al., 2010; Chamie et al., 2012); South Africa (Lessells et al., 2011; Losina et al., 2010; Kranzer et al., 2010; Larson et al., 2010); China  (Sullivan et al., 2010b); Ethiopia, Kenya, Malawi, Mozambique, and South Africa (Rosen and Fox, 2011); South Africa (Naughton et al., 2011); Ethiopia (Assefa et al., 2010).

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7. Increased links are needed for women who access treatment to receive counseling concerning desired children and family planning. [See also Meeting the Sexual and Reproductive Health Needs of Women Living With HIV and Safe Motherhood and Prevention of Vertical Transmission ] A study with patients from multiple sites in sub-Saharan Africa found that within four years of follow up for 4,531 women, one-third experienced a pregnancy.

Gap noted, for example, in sub-Saharan Africa (Myer et al., 2010).

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8. Treatment programs need strategies to retain patients on treatment for humanitarian, refugee and IDP settings. Researchers found that patients faced challenges accessing treatment and continuing to stay on ARVs with floods, political crises and strikes.

Gap noted in Mozambique, South Africa and Zimbabwe (Veenstra et al., 2010).

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9. Research is needed on treating anemia, malnutrition and other dietary conditions as well as on optimum micronutrients for patients accessing HAART and for patients prior to accessing treatment. [See Women and Girls]

   

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10. Pregnant women living with HIV need timely access to CD4 count testing and results to access treatment. [See Antenatal Care - Treatment]

   

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11. Adolescents living with HIV need information and services through adolescent-friendly HIV and family planning services. Adolescents living with HIV need information and services through adolescent-friendly HIV and family planning services [See Increasing Access to Services]

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