Research HIV Lit Review 2008

The Perception of Grants Benefits and Accessibility to Antiretroviral Treatment (ARVt) Among HIV Persons in South Africa: The Case of the KwaZulu-Natal Region

There are many studies being done on ARVt in South Africa. Each deals with different aspects of HIV and its treatment. However, living with HIV/AIDS is a challenge on its own, especially in the contexts where HIV infection still carries a stigma and consequently PLHA lack necessary social support.

One study on adherence observes that:

In such a situation adherence to therapy becomes an added challenge. Accomplishing the required near perfect adherence rate becomes all the more crucial considering the implications of drug and cross-drug resistance. Adherence to ARV treatment has been linked to, among other things, personal characteristics, patient treatment knowledge, faith in the efficacy of the drugs, social support, the relationship between the patient and the healthcare provider, drug availability, and an overall will to survive despite the odds (Cheever and Wu).

Antiretroviral therapy is characterized as complex: it requires a life long commitment, the combination of drugs to be taken at one time may be confusing and may cause side-effects, and there is usually the added burden of special dietary requirements (Cheever and Wu).

Onguro et al explains that many African countries have begun to develop large-scale prevention and treatment programmes. Governments of countries with high HIV incidence are acting in collaboration with international donor agencies to provide diagnostic treatment, drugs, laboratory infrastructure and medical personnel. Even so, the impacts are still limited and HIV patients must often fend for themselves, especially with the remaining costs of diagnostics and drug treatment.

The Public Health Matters has reported in Which Patient First? Setting Priorities for Antiretroviral Therapy Resources Are Limited that:

Developing countries now face the challenge of implementing these ARV delivery programmes. Open, public discussion about patient selection- or- rationing, has largely been avoided in recipient countries. It is possible that government officials fear the potentially divisive consequences of open discussions about who receives access to a life saving medication available in only limited quantities (Laura et al. 2008).

However, goes on Laura et al, avoiding a decision about rationing does not mean that decisions are not made, “Passive decisions”, that is limited access to patients who have already tested positive for HIV or live near a clinic site, favour those with economic, political or social power.

Yet again, with the rapid expansion of ARV therapy under new programmes such as the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR)—especially, but not only, in Sub-Saharan Africa, more patients are now or will be receiving ARV therapy. These programmes have established treatment targets that are widely regarded as ambitious and challenging, but will nonetheless reach only about 50% of those urgently needing ARV therapy.

South Africa has one of the highest HIV infections rates in the world. The HIV prevalence among pregnant women attending public sector antenatal clinics in 2004 was approximately 30% nationally, and 41% in KwaZulu-Natal, the most populous province. Several national household surveys have also reported very high prevalence: 12% among men and 20% among women aged 15-49 years in 2005, and 5% among men and 16% among women aged 14-24 years in 2003 (Welz et al 2007).

Welz et al concluded that “…the extremely high prevalence of HIV suggests an urgent need to allocate adequate resources for HIV preparation and treatment in rural areas. Effective monitoring of the epidemic in Africa needs to include efforts to strengthen sentinel surveillance in rural areas and strategies for surveillance of migrants and mobile individuals.

Report on Incentive Structures of Social Assistance Grants in South Africa, done in 2005 by the South African Department of Social Development, stated:

…The provision of social assistance benefits constitutes the largest part of the government’s poverty alleviation programme. By December 2005, a total of 10.6 million people, including approximately 7 million children, were benefiting directly from the various grant types.

The report continues on, stating that with increasing HIV/AIDS rates throughout the country, the numbers of those benefitting from social grants is likely to increase significantly. While these grants have the potential to benefit and improve the overall health and well-being of impoverished South Africans, there are many concerns related to the proliferation of social grants, especially in regards to HIV/AIDS and individuals adherence to antiretroviral treatments (ARVt).

Among the various types of social grants distributed by the Department of Social Development and the South African Social Security Agency, is the Disability Grant, which is likely the most common grant received by individuals. This particular type of grant is available to individuals who meet the following qualifications: South African citizen / permanent resident; must be resident in South Africa at the time of application; must be between 18 to 59 years of age if a female and 18 to 64 years of age if a male; must submit a medical / assessment report confirming disability; and spouse must meet the requirements of the means test; must not be maintained or cared for in a State Institution; must not be in receipt of another social grant in respect of yourself; must submit 13 digit bar coded identity document (SASSA).

Distribution of Disability Grants to those living with HIV & AIDS could potentially be very helpful in covering the expenses incurred by treatment. In Understanding Barriers to Community Participation in HIV and AIDS Services, a summary report put out by the Health Systems Trust and Population Council, estimates costs for treatment at: R160 per comprehensive treatment visit, of which 26 are required annually, and R235 per month for first line regimen drugs, plus additional costs for laboratory visits, additional medications, transportation to and from clinics, plus food.

Individuals who have CD4 counts below 200 are considered eligible for these grants and could potentially use these funds to access antiretroviral treatment. The Health Systems Trust believes that, “Households with social grants can/should make strategic choices about accessing health services.” However, according to the Health Systems Trust report:

Using CD4 counts as eligibility criteria for accessing grants precludes many from receiving desperately needed funds and may have several negative effects on treatment and prevention efforts. These include poor nutrition and resultant poor health outcomes for people living with HIV and lack of access to services, which potentially increases drop out rates and the number of adherence defaulters.

Despite its potential to be effective in curtailing the spread of HIV & AIDS, more often than not, perverse incentives motivate individuals to access the Disability grant. The Department of Social Development’s report on incentive structures have found that, “…Local evidence also suggests many instances where applicants change their behaviour in order to obtain the Disability Grant, although much of the evidence remains anecdotal.” The behaviours that the Department of Social Development are most concerned about in regards to accessing the Disability Grant are:

  • Self infection with infected materials;
  • Engaging in deliberately risky behaviour; and
  • Failure to take health enhancing medicines or operations in order to stay sick and continue claiming the disability grant.

Due to the fact that social grants are distributed at the governmental level, it is the responsibility of the each, under the rules put forth by the Constitution and the Municipal Systems Act (2000), “.. .compels all of South Africa’s newly demarcated municipalities to formulate Integrated Development Plans (IDPs), which must stipulate how the municipality intends to address, among other issues, the heath care needs of its population, including those related to HIV/AIDS.” KwaZulu-Natal, being the most populous province, consequently has the highest prevalence of HIV/AIDS in the country. Because of the urgency and severity of the HIV/AIDS crisis in KZN, the Msunduzi Municipality in conjunction with the Urban Management Programme, Sub- regional Office for Africa created The Msunduzi HIV/AIDS Strategy A Partnership Response to HIV/AIDS at Local Government Level, the goals of which are to:

The Msunduzi Municipality’s HIV/AIDS Strategy is one of the first attempts by local government in South Africa to actively address the HIV/AIDS epidemic. Launched in November 2001, the Strategy brings together a range of government and civil society actors within the city in a partnership. Facilitated by the municipality, the process aims to achieve a more coherent, organized and effective response to HIV/AIDS in the municipality.

It is imperative that local governments continue to be play a central role in preventing, and reducing the impacts of HIV/AIDS because, “the fact that local government is the level of government closest to the people and that it has powers assigned to it, and has unique resources at it its disposal, which can be used in efforts to prevent and mitigate the impacts of HIV/AIDS” (Msunduzi Municipality).

Reference List:

HIV and AIDS Strategy for the Province of KwaZulu-Natal 2006-2010. South Africa. Province of

KwaZulu-Natal. Office of the Premier. Pietermaritzburg, 2006. 1-87.

The Msunduzi HIV/AIDS Strategy A Partnership Response to HIV/AIDS at Local Government Level.

South Africa. Msunduzi Municipality. Urban Management Programme. Pietermaritzburg, 2003. Steele, Mark, comp. Report on Incentive Structures of Social Assistance Grants in South Africa. South

Africa. Department of Social Development. 2006. I-B-9.

Understanding Barriers to Community Participation in HIV and AIDS Services. Health Systems Trust &

The Population Council. Johannesburg, 2006.

Welz et al. (2007). Continued very high prevalence of HIV infection in Rural KwaZulu-Natal, South Africa: A Population based longitudinal study. Du