Provision and Access
Evidence has repeatedly demonstrated that antiretroviral therapy has been successfully accessed by both men and women with near perfect adherence, good patient retention, and good clinical outcomes in resource-poor settings common to many developing countries; results have been similar to those achieved in resource-rich countries. A systematic comparison of 4,810 treatment-naïve adult patients (51% female) from 18 HAART treatment programs in Africa, Asia and South America (low-income settings) with 22,217 treatment-naïve adults (25% female) in 12 HIV cohort studies from Europe and North America (high-income settings) found that antiretroviral therapy is feasible and effective in low-income settings. Mortality was higher in the first few months of treatment for patients in low-income settings. Those in low-income settings started treatment with considerably more advanced immunodeficiency than those from industrialized countries, but virological and immunological response to HAART were similar in both settings (ART-LINC & ART-CC, 2006). A review of nine articles and 18 abstracts until 2006 from sub-Saharan Africa, with 12,116 patients found favorable levels of adherence, with 77% of patients achieving 95% adherence according to patient self-reports. Adherence from studies in sub-Saharan Africa showed that that more patients were adherent than patients in North America, based on 31 studies with 17,537 patients (Mills et al., 2006).
Treatment Has Been Successfully Administered in a Range of Situations and Populations
Treatment has been successfully administered with good adherence (95% in 92% of patients) in internally displaced camps in Uganda (Kiboneka et al., 2008b). In the United States, treatment has also been successful in postmenopausal women (Patterson et al., 2009). Youth-friendly treatment services, such as the “girls-only day” at a youth program in Kenya, can increase the numbers of HIV-positive youth—especially girls—accessing treatment (Otieno et al., 2008). Further, accelerating treatment access for adults with young children can reduce the numbers of orphans, and improve pediatric mortality and social wellbeing. [See Chapter 12B. Care and Support: Orphans and Vulnerable Children]
Access to Treatment Must Be Equitable
To date, more women than men have accessed treatment. “Women are often more likely than men to attend health services because of dedicated provision of reproductive and child health clinics” (Braitstein et al., 2008b: 53). Data disaggregated by sex show that adult women are slightly advantaged over adult men in access to antiretroviral therapy in low- and middle-income countries. About 60% of adults receiving antiretroviral therapy in reporting countries were women, who represent 55% of the people in need (UNAIDS, 2009e).
Gender norms may make it less likely for men to seek health care as well. More attention needs to be paid to ensuring that HIV-positive men know their serostatus, have access to condoms and understand the need for consistent and correct condom use, and have equitable access to treatment. However, it is unclear whether access for women is higher simply because PMTCT programs facilitate HIV testing and treatment or whether HIV-positive women who do not want or are unable to get pregnant still have more access than men to treatment (Eyakuze et al., 2008). Still, “the need for increased and equitable access to AIDS treatment cannot be overstated” (UNAIDS and WHO, 2004 cited in UNAIDS et al., 2004a).
Furthermore, some studies have found that women are more likely than men to be asymptomatic when accessing treatment for the first time (Makwiza et al., 2009). A study with 65,000 patients at 18 sites in Kenya found that men were more likely to be WHO stage 3/4 with lower CD4 counts and less likely to have disclosed their serostatus. Men were 34% more likely to be lost to follow-up, defined as being absent from the clinic for more than three months if on ARVs and more than six months if not on ARVs, even with adjusting for CD4 count and other factors (Ochieng et al., 2008). A study in Uganda with 20,900 clients, of whom 9,387 were in WHO stage 3 at the time clients sought treatment, found that women are less likely than men to be in WHO stage four (with the lowest CD4 counts) (Sebuliba et al., 2008). A cross-sectional study of clinic data from 86 facilities in Uganda, along with exit interviews with 2,285 clients and 389 service providers found that women comprised 1.4 times more clients than men and women were more likely to adhere to ARVs (Kirungi et al., 2008a).
Other studies have found that equity in access differs by age group: In Malawi, 10,000 people are on treatment, with proportionately more females accessing treatment than men. However, in the 15 to 19 year age group, more men are proportionately on treatment despite the fact that HIV prevalence in this age group is higher among women. There were more women than men on treatment for ages 30 to 39, yet HIV prevalence in this age group is higher in men as compared to women.
Despite having better access to treatment, a study in Chile that evaluated quality of life for 409 people living with HIV in public hospitals, of whom fewer than 19% were women, found that women have a worse quality of life (Sgombich Mancilla et al., 2008). One study in rural India found that rural women were 30% less likely than men to initiate antiretroviral medication (Ramchandani et al., 2007 cited in Sinha et al., 2009).
Cost is another factor in treatment access. A study of AIDS-related deaths in Addis Ababa, Ethiopia found that following the launch of no-cost antiretroviral therapy in 2005, women died from AIDS at almost the same rate as men. Prior to no-cost antiretroviral therapy, more women than men died of AIDS, possibly due to sex differences in access to resources for financing treatment (Reniers et al., 2009). Treatment provided at no cost can substantially increase both women and men’s access to life-saving therapy.
Increased Access Must Also Include Respect for Human Rights
Expanding comprehensive medical services for HIV-positive women and providing multiple entry points for care—including antenatal, family planning and other sexual and reproductive health care services and psychosocial support—will be essential to increase women’s access to optimal ARV treatment. The benefits of treatment access go beyond improvements in health status and can include increasing employment and income for people living with HIV. [See Chapter 11D. Strengthening the Enabling Environment: Promoting Women’s Employment, Income and Livelihood Opportunities] However, fear of stigma and discrimination associated with HIV/AIDS may deter HIV-positive women from seeking ARV therapy as women living with HIV are at increased risk for being blamed as the source of infection and face more severe consequences of stigma (Hong et al, 2004; Maman et al, 2001a).
Regardless of who has better access to treatment, human rights must be respected. Requiring HIV-positive people to disclose their serostatus to sexual partners and/or community members in order to receive treatment, care or support is a human rights violation (Niyirenda et al., 2008). Further, requiring a “treatment buddy” or “medical companion” to access ARV therapy may place undue burdens on women and their children: a study of 1,453 patients in Uganda (71% female) on the impact of requiring patients to disclose their HIV status and have a “treatment buddy” or “medical companion” to access ARV therapy found that of the women, 41% chose a child as their medical companion versus 14% of the men (Amuron et al., 2008). Finally, coercing women to accept contraception in order to access treatment violates women’s rights to make their own fertility choices. [See Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV]
HIV Prevention is Needed As Well As Universal Access to Treatment
Universal access to antiretroviral therapy in low-income countries can be achieved. A number of countries from Brazil to Ethiopia to Thailand are achieving progress in increasing the numbers of those initiating ARV treatment at recommended CD4 thresholds (Messou et al., 2008, Marcellin et al., 2009, The ART-LINC Collaboration of the International Databases to Evaluate AIDS (IeDEA), 2008, Kloos et al., 2007, WHO, 2007c). Studies in Tanzania and Kenya have shown that treatment, including the availability of fixed-dose combination antiretroviral therapy, can also be effectively used for children in resource-poor settings with good outcomes in CD4 counts and nutritional status (Ble et al., 2007; Nyandiko et al., 2006; Jadhav et al., 2008; Calmy et al., 2006).
WHO has issued new guidance to initiate treatment for those whose CD4 counts are below 350, raising this level from earlier guidance that recommended initiating treatment when CD4 counts went below 200 (WHO, 2009j). However, the optimal time to initiate treatment is still a subject of considerable debate. Guidelines from the U.S. and Europe now recommend considering initiation of treatment when CD4 counts are between 350 and 500 (Wilken and Glick, 2008 cited in Dieffenbach, 2009). Recent studies in developed countries have found that patients starting antiretroviral treatment with CD4 counts greater than 350 are significantly more likely to achieve normalized CD4 counts than those starting later (Gras et al. and the AIDS Therapy Evaluation Project (ATHENA), 2007; Moore and Keruly, 2007 cited in Dieffenbach, 2009). A large clinical trial of 8,362 in the U.S. and Canada found a 69% higher risk of death for patients who deferred rather than initiated antiretroviral therapy at a CD4 count between 351-500 (Kitahata et al., 2009).[1] However, “whatever the side effects of HAART, side effects are not as deleterious as untreated HIV infection” (Sax and Baden, 2009: 2).[2] It is clear that there still is a paucity of data from developing countries on early initiation of treatment at CD4 counts over 350. A randomized clinical trial started in March 2009 with sites in 23 countries in North and South America, Europe, Africa, the Middle East and Asia is assessing whether immediate initiation of antiretroviral treatment is superior to deferral of treatment until the CD4 count declines to below 350. The pros and cons on initiating treatment when CD4 counts are over 350 must be weighed (Dieffenbach, 2009). [See also Chapter 9C-2. Safe Motherhood and Prevention of Vertical Transmission: Treatment]
Progress is being made with treatment access. However, caution is warranted. …Mathematical modeling using surveillance and census data between 1986 and 2004 from Uganda found that as a result of population growth, by 2008, a similar number of people will be HIV-positive (1.1 million) as during the peak of the epidemic in 1994. More effective prevention programs are still needed (Hladik et al., 2008a). A recent consultation at WHO in Geneva, Switzerland (Nov. 2-4, 2009), noted that “In 2007 alone, there were 2.7 million new HIV infections. By the end of 2008, more than 4 million people were accessing antiretroviral therapy in low-and middle-income countries. That same year, an estimated 5.5 million in immediate need of treatment could not access it. Current efforts to treat HIV are not keeping pace with all those who need therapy. Without a dramatic reduction in new HIV infections, this trend will continue (WHO, 2009j).
[1] Note: As this is a new study, it is unclear how this will change clinical guidelines in the U.S. and Canada, as well as whether WHO will revise guidelines and whether patients in developing country contexts will be able to initiate treatment earlier.
[2] Study authors receive consulting fees from many of the companies who manufacture and market antiretroviral therapy drugs. The funding for the study, however, came from NIH and other U.S. government agencies.