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Title: Equity in antiretroviral therapy access : an assessment of patients' experiences in Lilongwe District, Malawi
Author: Namakhoma, Ireen Rita
Awarding Body: University of Liverpool
Current Institution: University of Liverpool
Date of Award: 2012
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Background: This thesis presents and discusses the findings of a study that assessed health care seeking pathways and experiences in accessing antiretroviral treatment and continuing with treatment. The thesis explores how patients' experiences in health care were mediated by socioeconomic factors such as gender, poverty and rural/urban residence. The thesis aims to answer four main research questions: • What is the health care seeking behaviour of patients leading to the time they are eligible for antiretroviral therapy (ART) and begin the antiretroviral drug initiation process? • What are the associated direct and indirect costs of care seeking and are there inequalities in how the costs impact on different social economic groups? • Are there patients who do not initiate treatment despite knowing that they are eligible for treatment and if so, why do these patients not start treatment? • Among the patients who are lost to follow up or die whilst on ART, what are the factors that contribute to attrition? Study Methods: The study employed a mixed quantitative and qualitative research design. A survey was conducted among males and females identified as eligible for ART in seven health facilities in urban and rural Lilongwe. Patients were then followed up to identify those who started treatment or did not and those who were continuing with treatment or dropped off. Follow up qualitative interviews were conducted with different groups of patients and health workers. Findings: Patients make multiple visits to different health providers ranging from selftreating, to visiting private clinics and public hospitals and health centres which result in a delay to HIV testing and ultimately delay in initiating ART. Inequities exist in how patients experience care seeking for HIV and ART services. The health care seeking pathway is influenced by socio-economic factors which in turn affect patient treatment outcomes. The type of health facility and the direct costs of care seeking in particular have an influence on whether patients start treatment or not. Patients' perceived severity of illness plays a role in determining whether patients start or remain in HIV care. Male sex and poverty were associated with patients' loss to follow up and deaths while on ART. From the qualitative interviews, long distance to health facilities, psychosocial problems and the challenges of disclosure interplayed with other factors to cause patients to interrupt treatment. Discussion: The pathway to care seeking is influenced by the interactions at three levels - the community, the patients and their households and the health system. These interactions are mediated by gender, poverty, residence, illness meaning and stigma to determine a complex and long health care seeking behaviour, delays in HIV diagnosis, missed opportunities for HIV testing and pre-ART care, drop out from the health care seeking pathway, early mortality and survival or attrition from ART. Conclusion and recommendations: To address existing inequities in ART access, there is a need to increase the availability of services to the rural poor and strengthen health systems. Supporting community based systems have the potential to bring services closer to poor communities. However, Malawi needs to consider revisiting the ART equity policy in a way that will create new financing opportunities for HIV treatment.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available