Akullian Adam N, Mukose Aggrey, Levine Gillian A, Babigumira Joseph B
Institute for Disease Modeling, Bellevue, WA, USA;
Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
J Int AIDS Soc. 2016 Feb 10;19(1):20171. doi: 10.7448/IAS.19.1.20171. eCollection 2016.
The availability of specialized HIV services is limited in rural areas of sub-Saharan Africa where the need is the greatest. Where HIV services are available, people living with HIV (PLHIV) must overcome large geographic, economic and social barriers to access healthcare. The objective of this study was to understand the unique barriers PLHIV face when accessing healthcare compared with those not living with HIV in a rural area of sub-Saharan Africa with limited availability of healthcare infrastructure.
We conducted a population-based cross-sectional study of 447 heads of household on Bugala Island, Uganda. Multiple linear regression models were used to compare travel time, cost and distance to access healthcare, and log binomial models were used to test for associations between HIV status and access to nearby health services.
PLHIV travelled an additional 1.9 km (95% CI (0.6, 3.2 km), p=0.004) to access healthcare compared with those not living with HIV, and they were 56% less likely to access healthcare at the nearest health facility to their residence, so long as that facility lacked antiretroviral therapy (ART) services (aRR=0.44, 95% CI (0.24 to 0.83), p=0.011). We found no evidence that PLHIV travelled further for care if the nearest facility supplies ART services (aRR=0.95, 95% CI (0.86 to 1.05), p=0.328). Among those who reported uptake of care at one of two facilities on the island that provides ART (81% of PLHIV and 68% of HIV-negative individuals), PLHIV tended to seek care at a higher tiered facility that provides ART, even when this facility was not their closest facility (30% of PLHIV travelled further than the closest ART facility compared with 16% of HIV-negative individuals), and travelled an additional 2.2 km (p=0.001) to access that facility, relative to HIV-negative individuals (aRR=1.91, 95% CI (1.00 to 3.65), p=0.05). Among PLHIV, residential distance was associated with access to facilities providing ART (RR=0.78, 95% CI (0.61 to 0.99), p=0.044, comparing residential distances of 3-5 km to 0-2 km; RR=0.71, 95% CI (0.58 to 0.87), p=0.001, comparing residential distances of 6-10 km to 0-2 km).
PLHIV travel longer distances for care, a phenomenon that may be driven by both the limited availability of specialized HIV services and preference for higher tiered facilities.
在撒哈拉以南非洲农村地区，对艾滋病病毒（HIV）的专门服务供应有限，而这些地区的需求却最为迫切。在有HIV服务的地方，HIV感染者（PLHIV）必须克服巨大的地理、经济和社会障碍才能获得医疗保健服务。本研究的目的是了解在撒哈拉以南非洲农村地区，医疗基础设施有限的情况下，与未感染HIV者相比，PLHIV在获得医疗保健服务时面临的独特障碍。
我们在乌干达布加拉岛对447户家庭户主进行了一项基于人群的横断面研究。使用多元线性回归模型比较获得医疗保健服务的出行时间、成本和距离，使用对数二项模型检验HIV感染状况与获得附近医疗服务之间的关联。
与未感染HIV者相比，PLHIV为获得医疗保健服务要多走1.9公里（95%可信区间（0.6，3.2公里），p = 0.004），并且只要其住所最近的医疗机构缺乏抗逆转录病毒疗法（ART）服务，他们在该机构获得医疗保健服务的可能性就会降低56%（调整风险比（aRR）= 0.44，95%可信区间（0.24至0.83），p = 0.011）。我们没有发现证据表明，如果最近的医疗机构提供ART服务，PLHIV会为了就医而走更远的路（aRR = 0.95，95%可信区间（0.86至1.05），p = 0.328）。在报告在岛上提供ART的两个医疗机构之一接受治疗的人群中（81%的PLHIV和68%的HIV阴性个体），PLHIV倾向于在提供ART的更高层级医疗机构寻求治疗，即使该机构不是离他们最近的机构（30%的PLHIV比离他们最近的ART医疗机构走得更远，而HIV阴性个体中这一比例为16%），并且相对于HIV阴性个体，他们要多走2.2公里（p = 0.001）才能到达该机构（aRR = 1.91，95%可信区间（1.00至3.65），p = 0.05）。在PLHIV中，居住距离与获得提供ART的机构的服务相关（相对风险（RR）= 0.78，95%可信区间（0.61至0.99），p = 0.044，比较居住距离3 - 5公里与0 - 2公里；RR = 0.71，95%可信区间（0.58至0.87），p = 0.001，比较居住距离6 - 10公里与0 - 2公里）。
PLHIV为了就医要走更远的距离，这一现象可能是由专门HIV服务供应有限以及对更高层级医疗机构的偏好共同导致的。
