Access to healthcare : investigating the barriers to accessing antiretroviral treatment at a public sector antiretroviral clinic in Durban, South Africa.

Abstract

South Africa has the largest HIV/AIDS epidemic in the world and due to the rapid scale up of access to antiretroviral drugs now has the largest antiretroviral program in the world. However access to antiretroviral treatment remains a challenge and the scale up of the drug programs has caused an additional burden on an already stretched and stressed public healthcare sector. At present there are only two lines of drug regimens available to the general public that rely on the public healthcare sector for the supply of their antiretroviral drugs. Resistance to the current regimens is a major concern that is not effectively being addressed. One of the major aspects that can contribute to a rise in resistance is barriers to continually accessing antiretroviral treatment. This ethnographic investigation into the barriers to accessing antiretroviral treatment was conducted in a public health sector clinic based at a large hospital in Durban. The specific objectives of the study were to elucidate the major barriers to accessing the treatment as perceived by the patients of the clinic, to understand the structural drivers behind the barriers and to capture the patients’ reactions to these obstacles that they face on a continuous basis. Unlike most studies that focuses only on adherence this study’s focus was rather on the concept of access to healthcare and how barriers perceived by the patients influence their ability to effectively access their treatment. Thus the concept of access to healthcare is explored in detail and an argument is made for the importance of understanding and applying the holistic concept of access to healthcare within the ART setting. An ethnographic approach was adopted to conduct this study, and the study utilized a triangulation of data collection techniques including participant observation, in-depth interviews, focus groups and a questionnaire. The research was done over a period of seven months and focused on adults who were already part of a regimen for a period of at least one year. Antiretroviral treatment regimens are for life and once people start with these regimens they cannot stop. However this study found that a range of barriers exist that present obstacles for patients to continually access ART drugs. Structural violence theory provided the framework for contextualizing the specific barriers that were reported and is important in terms of situating the barriers within the larger structures that create them. What is evident is that poor healthcare related policies, stigma, discrimination, economic inequality, gender and poverty are the structural drivers behind barriers to accessing ART. By incorporating a broader understanding of access to healthcare a deeper understanding of the barriers is gained and better interventions can be created to prevent disengagement from life-long ART services.