Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa.
Sex Transm Infect. 2012 Mar;88(2):141-6. doi: 10.1136/sextrans-2011-050136.
South Africa has the world's largest antiretroviral treatment (ART) programme. While services in the public sector are free at the point of use, little is known about overall access barriers. This paper explores these barriers from the perspective of ART users enrolled in services in two rural and two urban settings.
Using a comprehensive framework of access, interviews were conducted with over 1200 ART users to assess barriers along three dimensions: availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between sites were explored using multivariate linear and logistic regressions.
While availability access barriers in rural settings were found to be mitigated through a more decentralised model of service provision in one site, affordability barriers were considerably higher in rural versus urban settings. 50% of respondents incurred catastrophic healthcare expenditure and 36% borrowed money to cover these expenses in one rural site. On acceptability, rural users were less likely to report feeling respected by health workers. Stigma was reported to be lowest in the two sites with the most decentralised services and the highest coverage of those in need.
While results suggest inequitable access to ART for rural relative to urban users, nurse-led services offered through primary healthcare facilities mitigated these barriers in one rural site. This is an important finding given current policy emphasis on decentralised and nurse-led ART in South Africa. This study is one of the first to present comprehensive evidence on access barriers to assist in the design of policy solutions.
南非拥有全球最大的抗逆转录病毒治疗（ART）项目。虽然公共部门的服务在使用时是免费的，但对于整体获取障碍知之甚少。本文从在两个农村和两个城市地区接受服务的 ART 用户的角度探讨了这些障碍。
使用全面的获取框架，对 1200 多名 ART 用户进行了访谈，以评估可用性、可负担性和可接受性三个方面的障碍。计算了汇总统计数据，并使用多元线性和逻辑回归探索了站点之间获取障碍的比较。
虽然在一个地点通过更分散的服务提供模式减轻了农村地区的可用性获取障碍，但农村地区的可负担性障碍明显高于城市地区。在一个农村地区，50%的受访者发生了灾难性的医疗支出，36%的人借钱来支付这些费用。在可接受性方面，农村用户不太可能报告受到卫生工作者的尊重。在两个服务最分散、最需要覆盖的地区，报告的耻辱感最低。
尽管结果表明农村地区相对于城市地区的 ART 获取存在不平等，但通过初级保健设施提供的护士主导服务在一个农村地区减轻了这些障碍。鉴于南非目前对分散和护士主导的 ART 的政策重点，这是一个重要的发现。这项研究是首次提供全面的获取障碍证据的研究之一，以帮助设计政策解决方案。
