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Objectives. We examined changes in socioeconomic status (SES) and Black to White inequalities in HIV/AIDS mortality in the United States before and after the introduction of highly active antiretroviral therapy (HAART). Methods. Taking a fundamental cause perspective, we used negative binomial regression to analyze trends in county-level gender-, race-, and age-specific HIV/ AIDS mortality rates among those aged 15 to 64 years during the period 1987-2005. Results. Although HIV/AIDS mortality rates decreased once HAART became available, the declines were not uniformly distributed among population groups. The associations between SES and HIV/AIDS mortality and between race and HIV/AIDS mortality, although present in the pre-HAART period, were significantly greater in the peri- and post-HAART periods, with higher SES and White race associated with the greatest declines in mortality during the post-HAART period. Conclusions. Our findings support the fundamental cause hypothesis, as the introduction of a life-extending treatment exacerbated inequalities in HIV/AIDS mortality by SES and by race. In addition to a strong focus on factors that improve overall population health, more effective public health interventions and policies would facilitate an equitable distribution of health-enhancing innovations. (Am J Public Health. 2010;100:1053-1059. doi: 10.2105/AJPH.2009.170241)

This study identifies, ranks, and compares factors perceived as barriers to accessing antiretroviral treatment (ART) in urban and rural settings in Mozambique. Data were collected between March and July 2008. It consisted of 13 focus group discussions and a structured questionnaire administered to 252 people living with HIV/AIDS (PLWHA) and 28 health workers in the districts of Beira and Buzi. Data analysis was performed using content analysis, factor analysis, and percentages of the maximum attainable scores. The data analysis revealed six clusters of factors, which were ranked according to the percentages of the maximum attainable scores between brackets: (1) patient resource availability, in which distance from home to the health facility, transportation and food availability were rated below 40%; (2) community information (47%), and (3) service availability (53%), in which the waiting time to receive the results of CD4 analysis and the sufficiency of doctors/nurses at the health facility were both rated at 45%; (4) patient information and attitudes toward treatment (74%); family support (77%) and health personnel confidentiality (79%). Policy makers, in efforts to further improve the access to ART may decide to target their attention in designing interventions to improve specific aspects of patient resource availability, community information, and service availability in both urban and rural settings. DOI: 10.1089/apc.2009.0050

The interaction between limited resources, living in conflict areas, and complexity of HIV treatment may impact negatively on adherence to antiretroviral therapy (ART). Nonadherence may lead to development of resistant strains that may further increase the costs of management. The aim of this study was to compare the level of adherence to ART among internally displaced persons (IDPs) and non-IDPs and determine the factors associated with nonadherence. A cross-sectional study was conducted from January to February 2008 among adults receiving ART from Lacor Hospital. Systematic sampling was used to select 200 participants. Adherence was assessed through patients' self-reports over a 4-day period. Data were collected using an interviewer-administered questionnaire and analyzed in SPSS version 12 (SPSS Inc, Chicago, IL). Patients were considered to be adherent if they took 95% or more of their medicines. Adherence rates among IDP and non-IDP patients were compared using Mann-Whitney U test. Factors associated with nonadherence were determined using logistic regression. The overall mean 4-day adherence was 99.5%. There was no significant difference in adherence between IDPs and non-IDPs (99.6% and 99.5%, respectively). Being on first-line regimen of ART (odds ratio [OR] = 22.22, 95% confidence interval [CI] = 1.48-333.33) and feeling that staff at the health centre were condemning (OR = 22.22, 1.53-333.33) were independently associated with nonadherence. Our study was limited in using only self-reports to assess adherence. In conclusion, patients in conflict areas can achieve high levels of adherence. Interventions to reduce nonadherence should address health provider-patient interaction and patients on first-line regimens.

Despite the acceleration of antiretroviral therapy (ART) scale-up in sub-Saharan Africa, little is known about the social and economic effects of ART on individuals and households. In January 2008, we conducted semi-structured interviews with 24 adult ART clients attending urban and rural HIV clinics operated by Joint Clinical Research Center in Uganda. Using content analysis we explored changes in physical health, work activity and asset management from before HIV to after ART. Twenty-one (88%) participants were working prior to HIV (mostly microenterprises and subsistence farming), of whom 18 had to stop work at least temporarily after onset of HIV. After ART, 20 (83% of the sample) were engaged in some type of work, but for many it was not at the same level as before HIV. Also, most that previously had salaried employment were unable to return to the formal labor market. Two thirds of the sample reported having to sell off at least some of their land, capital, or household property after HW, and few were able to buy it back after ART. A majority (67%) reported that economic support from family was instrumental after the onset of HIV, and for 38% this support continued to be necessary after ART. These findings highlight that while ART helps people to regain a capacity to work, other economic supports are needed to enable individuals and households to reestablish their livelihoods, especially in resource-constrained settings.

Two years after the introduction of free antiretroviral therapy (ART) in Tanzania and in spite of the logistical support provided to facilitate clinic attendance, a considerable level of attrition from the program was identified among clients from a semi-rural ward. Qualitative research on ART patients' health-seeking behavior identified factors affecting sustained attendance at treatment clinics. A mix of methods was used for data collection including semi-structured interviews with 42 clients and 11 service providers and 4 participatory group activities conducted with members of a post-test group between October and December 2006. A socio-ecological framework guided data analysis to categorize facilitators and barriers into individual, social, programmatic, and structural level influences, and subsequently explored their interaction and relative significance in shaping ART clients' behavior. Our findings suggest that personal motivation and self-efficacy contribute to program retention, and are affected by other individual-level experiences such as perceived health benefits or disease severity. However, these determinants are influenced by others' opinions and beliefs in the community, and constrained by programmatic and structural barriers. Individuals can develop the requisite willingness to sustain strict treatment requirements in a challenging context, but are more likely to do so within supportive family and community environments. Effectiveness and sustainability of ART roll-out could be strengthened by strategic intervention at different levels, with particular attention to community-level factors such as social networks' influence and support.