Social Determinants of HIV Health Care: A Tale of Two Cities

Abstract

Despite unprecedented scale up and advances in the treatment of HIV/AIDS in the last fifteen years, the great majority of individuals around the world who need antiretroviral therapy (ART) are not receiving it. Furthermore, it has now become apparent that even in locations where there is access to treatment, segments of the population do not engage in care because of multiple barriers that prevent them from accessing care, thus losing the potential benefits of ART. A social ecological framework can be applied to understand the multiple layers of factors at the individual, interpersonal and structural levels, that affect HIV clinical outcomes and consequently transmission (Stokols 1996). The institutional barriers include those imposed by the very institutions developed to care for people with HIV. Beyond institutional barriers, factors related to poverty and economics, politics, and the sociocultural and psychological context of the individual all contribute to the challenges faced by people seeking treatment. Acknowledging the difficulties that HIV-infected individuals confront, the World Health Organization (WHO) has put forth the goal of universal access to HIV/AIDS prevention, treatment, and care (WHO 2010). In addition to improving the individual’s personal health, access and treatment with subsequent virologic suppression on a population level may help decrease transmission of HIV (Das et al. 2010). Until a cure for HIV is found, individuals infected with HIV face a lifetime of requiring health care access and antiretroviral drug therapy to control the virus, in addition to the comorbidities associated with chronic HIV infection. For those able to enter and remain in care, additional obstacles can prevent them from maintaining high levels of adherence to the available therapies. In this chapter, we will explore how the sociocultural context of a particular region can influence health care outcomes for individuals living with HIV. First, we exemplify two epidemics and two health care systems separated geographically and culturally from one another, Atlanta, Georgia, United States, and Durban, KwaZulu-Natal, South Africa, in order to illustrate how these factors can impede a successful response to ART. Following this description, we describe efforts that have been undertaken to address some of these barriers to improve engagement in health care within and beyond these settings. We also review creative approaches that can be used to maximize adherence to treatment. Finally, a course for the ultimate way forward is chartered, detailing steps necessary to address these barriers in a variety of settings around the world.