Disability grant for people living with HIV/AIDS in the Eastern Cape of South Africa

“I’m suffering for food”: Food insecurity and access to social protection for TB patients and their households in Cape Town, South Africa

Background

Tuberculosis (TB) is a major health concern and the number one cause of death in South Africa. Social protection programmes can strengthen the resilience of TB patients, their families and households. This study aimed to get a better understanding of the role of social protection and other forms of support in relation to the burden of TB on patients and their households in South Africa.

Methods

This is a cross-sectional exploratory qualitative study using a phenomenological approach to focus on the lived experiences and perceptions of TB patients and healthcare workers. We interviewed 16 patients and six healthcare workers and analysed data thematically.

Results

The challenges faced by participants were closely related to household challenges. Participants reported a heavy physical burden, aggravated by a lack of nutritious food and that households could not provide the food they needed. Some needed to resort to charity. At the same time, households were significantly affected by the burden of caring for the patient—and remained the main source of financial, emotional and physical support. Participants reported challenges and costs associated with the application process and high levels of discretion by the assessing doctor allowing doctors’ opinions and beliefs to influence their assessment.

Conclusion

Access to adequate nutritious food was a key issue for many patients and this need strained already stretched households and budgets. Few participants reported obtaining state social protection support during their illness, but many reported challenges and high costs of trying to access it. Further research should be conducted on support mechanisms and interventions for TB patients, but also their households, including food support, social protection and contact tracing. In deciding eligibility for grants, the situation of the household should be considered in addition to the individual patient.

Income security during periods of ill health: a scoping review of policies, practice and coverage in low-income and middle-income countries

The COVID-19 pandemic is a reminder that insufficient income security in periods of ill health leads to economic hardship for individuals and hampers disease control efforts as people struggle to stay home when sick or advised to observe quarantine. Evidence on income security during periods of ill health is growing but has not previously been reviewed as a full body of work concerning low-income and middle-income countries (LMICs). We performed a scoping review to map the range, features, coverage, protective effects and equity of policies that aim to provide income security for adults whose ill health prevents them from participating in gainful work. A total of 134 studies were included, providing data from 95% of LMICs. However, data across the majority of these countries were severely limited. Collectively the included studies demonstrate that coverage of contributory income-security schemes is low, especially for informal and low-income workers. Meanwhile, non-contributory schemes targeting low-income groups are often not explicitly designed to provide income support in periods of ill health, they can be difficult to access and rarely provide sufficient income support to cover the needs of eligible recipients. While identifying an urgent need for more research on illness-related income security in LMICs, this review concludes that scaling up and diversifying the range of income security interventions is crucial for improving coverage and equity. To achieve these outcomes, illness-related income protection must receive greater recognition in health policy and health financing circles, expanding our understanding of financial hardship beyond direct medical costs.

Economic strengthening for HIV testing and linkage to care: a review of the evidence

Delayed HIV diagnosis and enrollment in HIV care can lead to negative health outcomes for individuals and pose major barriers to achieving the UNAIDS 90-90-90 treatment targets. Household economic strengthening (HES) initiatives are increasingly used to alleviate the direct and indirect costs of HIV testing and linkage to care for those who are diagnosed. The evidence linking HES with a range of HIV outcomes is growing, and this evidence review aimed to comprehensively synthesize the research linking 15 types of HES interventions with a range of HIV prevention and treatment outcomes. The review was conducted between November 2015 and October 2016 and consisted of an academic database search, citation tracking of relevant articles, examination of secondary references, expert consultation, and a gray literature search. Given the volume of evidence, the results are presented and discussed in three papers. This is the second paper in the series and focuses on the 20 studies on HIV testing, diagnosis, and enrollment in care. The results indicate that financial incentives are consistently and independently linked with higher testing uptake and yield among adults. Limited evidence indicates they may also be beneficial for enrollment in care. Evidence for other HES interventions is too sparse to identify clear trends.

People with disabilities and income-related social protection measures in South Africa: Where is the gap?

Background

People with disabilities are at increased risk of poverty, particularly in low-and middle-income countries. However, recent evidence suggests that this association is more nuanced than previously anticipated and that we need better data to understand the opportunity and out-of-pocket costs that diverse groups of people with disabilities may experience.

Objective

This paper discusses if disability is associated with opportunity cost and loss of income both on the individual and household level in South Africa, and if these costs differ depending on disability type and severity.

Methods

For this purpose, the paper analyses General Household Survey 2011 data (people between 15 and 59) using descriptive statistics disaggregated via disability type and severity. The paper also assesses if social grants counteract these costs and reduce economic vulnerability.

Results

The analysis of the data reveals that people with disabilities are affected by issues relating to multidimensional poverty such as lower educational attainment and fewer employment opportunities. In addition, households of people with disabilities (with the exception of milder visual problems) earn significantly less than households without people with disabilities, and this particularly applies to households with people with severe disabilities. This vulnerability also varies by disability type. The country’s social protection mechanisms, in terms of social grants, counteract economic vulnerability to some extent but do not consider the nuanced economic impact of diverse conditions nor the increased out-of-pocket costs related to disability.

Conclusions

This calls for more equitable social protection mechanisms that include accessible services, livelihood programmes and disability benefits.

It's Not Just the Pills: A Qualitative Meta-Synthesis of HIV Antiretroviral Adherence Research

Antiretroviral therapy (ART) improves the health and longevity of people living with HIV infection (PLWH) and also prevents transmission of the virus. Yet, lack of adherence to ART regimens has been a persistent problem, even with simpler regimens. Guidelines that deal with ART adherence are based almost solely on quantitative studies; this focus ignores the context and complexity of patients' lives. Guidelines are also focused on the individual. We argue that the solution is to include the broader communities in which patients live, and to deal with systemic disparities that persist worldwide; this can be done in part through demedicalizing HIV care for healthy PLWH. We present findings from a qualitative meta-synthesis of 127 studies conducted around the world on the last two pillars of the HIV treatment cascade: starting and remaining on ART until optimal viral suppression is achieved. We use Maslow's hierarchy of needs to frame our findings.

Disability Grant: a precarious lifeline for HIV/AIDS patients in South Africa

BACKGROUND

In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, we consider 1) inequalities in access to the DG for patients on ART and 2) implications of DG access for on-going access to healthcare.

METHODS

Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase.

RESULTS

Grant recipients were comparatively worse off than non-recipients in terms of employment (9.1 % vs. 29.9 %) and wealth (58.3 % in the poorest half vs. 45.8 %). After controlling for socioeconomic and demographic factors, site, treatment duration, adherence and concomitant TB treatment, the regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed (p < 0.001). Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG (significant at the 5 % level). The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships.

CONCLUSIONS

These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.

Social grants for people living with HIV and on antiretroviral therapy in KwaZulu-Natal, South Africa: a longitudinal study

The aim of this study was to assess the predictors of the receipt of a disability grant (DG) status and the impact of the DG on health outcomes of HIV patients and on antiretroviral therapy (ART) in a longitudinal study over 20 months in KwaZulu-Natal, South Africa. Consecutive patients, 735 (29.8% males and 70.2% females), who attended three HIV clinics completed the assessments (with a structured questionnaire and medical file review) prior to antiretroviral initiation, 519 after 6 months, 557 after 12 months and 499 after 20 months on ART. The results indicate that a large number of HIV or ART patients were found to be in receipt of a DG, which declined significantly over the time of being on ART (from 52.3% at 6 months on ART to 9.8% at 20 months on ART). At various stages, being in receipt of a DG was found to be associated with not being employed, higher quality of life (QoL), older age, higher alcohol use score, no formal salary as household income and higher subjective health status in multivariable analyses. A significant number of patients lost their DG status over the assessment period, which was not found to be associated with major health outcomes (CD4 cell counts, adherence to ART and HIV symptoms). In a multiple regression generalized estimating equation model, not being in receipt of a DG, health-related QoL, lower HIV symptoms and lower depression scores were associated with CD4 counts. HIV patients who no longer qualify for the DG and yet do not have adequate financial means to meet basic necessities should be put on a nutritional support programme.

Social constraints to TB/HIV healthcare: accounts from coinfected patients in South Africa

There is a growing imperative to improve the coordination and collaboration of tuberculosis (TB) and HIV healthcare services in response to escalating rates of TB/HIV coinfection. Patient-specific challenges associated with the delivery of TB/HIV care have been minimally explored in this regard. As part of a larger study conducted in South Africa, this article highlights coinfected patients' experiences with TB and HIV healthcare in light of their broader social environments. Qualitative, in-depth interviews were conducted with 40 adult, coinfected patients (24 women and 16 men) and eight key-informant healthcare workers at three urban/peri-urban, ambulatory, public health clinics in the high-burden province of KwaZulu-Natal. Transcribed interviews were analyzed under a modified grounded theory approach to capture subjective meanings of healthcare experience subsequent to patients' codiagnosis with TB and HIV. Emerging analytic themes highlighted critical sociomedical constraints to TB/HIV care in relation to patients' income and employment, eligibility for social assistance and antiretroviral treatment, fears around illness disclosure, social and material support, and treatment adherence. Patients' healthcare experiences were bound by their poor access to essential resources, multiple life responsibilities, disparate gender roles, limits within the healthcare system, and the stigmatizing social symbolism of their illness. Overlapping social inequalities perpetuated coinfected patients' experiences with stigma and collectively mediated their health decisions around disclosure, adherence, and retention in medical care. The study urges a contextualized understanding of the social challenges associated with TB/HIV healthcare and helps inform more patient-sensitive and socially responsive interventions against the co-epidemic.

Exploring antiretroviral treatment adherence in an urban setting in South Africa

Antiretroviral treatment requires high levels of adherence to be effective. This qualitative study explores the reasons for poor adherence among 22 purposively selected poor urban participants in South Africa. Over a 4-month period in 2009, we prospectively investigated experiences of HIV diagnosis and treatment, adherence, and withdrawal from treatment. Patients with no stable food sources faced significant barriers in adhering to treatment regimens and staying sufficiently healthy to search for, obtain or retain a job. The narratives also identify the influence on adherence of self-esteem and social support, vulnerability generated by ill health, gendered conflict, social inequities amplified by HIV, and exhaustion due to the social burden of the epidemic. Multi-dimensional, inter-sectoral programs that tackle the social determinants of health, such as food insecurity, poverty, gendered inequities, and treatment adherence are more likely to be successful, than single interventions to support adherence.

The symptom experience of people living with HIV and AIDS in the Eastern Cape, South Africa

Background

Symptom management for persons living with HIV (PLHIV) or AIDS is an important part of care management. Limited information about symptom prevalence exists about HIV infected persons in South Africa, in particular in the context of antiretroviral treatment (ART). The aim of this study was to assess HIV symptoms and demographic, social and disease variables of people living with HIV in South Africa.

Methods

In 2007 607 PLHIV, sampled by all districts in the Eastern Cape Province and recruited through convenience sampling, were interviewed by PLHIV at health facilities, key informants in the community and support groups.

Results

Two-thirds of the PLHIV (66%) classified themselves with being given an AIDS (advanced stage of HIV) diagnosis, 48% were currently on ART, 35% were currently on a disability grant for HIV/AIDS and for 13% the disability grant had been stopped. Participants reported that on the day of the interview, they were experiencing an average of 26.1 symptoms out of a possible 64. In a regression model with demographic and social variables, higher HIV symptom levels were associated with lower educational levels, higher age, urban residence and not on a disability grant, lack of enough food and having a health insurance, and in a regression model with demographic, social and disease variables only being on ART, lack of enough food and having a health insurance were associated with HIV symptoms.

Conclusion

Symptom assessment provides information that may be valuable in evaluating AIDS treatment regimens and defining strategies to improve quality of life. Because of the high levels of symptoms reported, the results imply an urgent need for effective health care, home- and community-based as well as self-care symptom management to help patients and their families manage and control AIDS symptoms.