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Does accessibility to antiretroviral care improve after down-referral of patients from hospitals to health centres in rural South Africa?

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We conducted an evaluation of healthcare accessibility among patients taking antiretroviral treatment (ART) after they were ‘down-referred’ from hospital-based programmes to primary healthcare (PHC) centres in a rural South African setting. A cross-sectional design was used to study 109 PHC users compared to a randomly selected control group of 220 hospital-based users. Both groups were matched for a minimum duration on ART of six months. Using a comprehensive healthcare-accessibility framework, the participants were asked about availability, affordability and acceptability of their ART care in structured exit interviews that were linked to their ART-clinic record reviews. Unadjusted and adjusted regression models were used. Down-referral was associated with reduced transportation and meal costs (p = 0.001) and travel time to an ART facility (p =0.043). The down-referred users were less likely to complain of long queues (adjusted odds ratio [AOR] 0.06; 95% confidence interval [95% CI]: 0.01–0.29), were more likely to feel respected by health providers (AOR 4.43; 95% CI: 1.07–18.02), perceived lower stigma (AOR 0.25; 95% CI: 0.07–0.91), and showed a higher level of ART adherence (AOR 8.71; 95% CI: 1.16–65.22) than the hospital-based users. However, the down-referred users preferred to consult with doctors rather than nurses (AOR 3.43; 95% CI: 1.22–9.55) and they were more likely to visit private physicians (AOR 7.09; 95% CI: 3.86–13.04) and practice self-care (AOR 4.91; 95% CI: 2.37–10.17), resulting in increased health-related expenditure (p = 0.001). Therefore, the results indicate both gains and losses in ART care for the patients, and suggest that down-referred patients save time and money, feel more respected, perceive lower stigma and show better adherence levels. However, unintended consequences include increased costs of using private physicians and self-care, highlighting the need to further promote the potential gains of down-referral interventions in resource-poor settings.

Keywords: HIV/AIDS; adherence; affordability; antiretroviral therapy; primary healthcare; programme evaluation; resourcepoor settings; rural communities

Document Type: Research Article


Affiliations: 1: University of the Witwatersrand, School of Public Health, 7 York Road, Parktown2193,Johannesburg, 2: University of the Western Cape, School of Public Health, Private Bag X17Bellville,7535,Cape Town, South Africa 3: University of Cape TownHealth Economics Unit, Anzio Road, Observatory7925,Cape Town, South Africa 4: The Earth Institute, Columbia University, 405 Low Library, 535 West 116th StreetNew York,New York 10027, 5: McMaster UniversitySchool of Geography and Earth Sciences, 1280 Main Street WestHamilton,Ontario,L8S 4K1, Canada

Publication date: December 1, 2011

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