Article Text

Download PDFPDF
Unequal access to ART: exploratory results from rural and urban case studies of ART use
  1. Susan May Cleary1,
  2. Stephen Birch1,2,3,
  3. Mosa Moshabela4,
  4. Helen Schneider5
  1. 1Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
  2. 2Centre for Health Economics and Policy Analysis, McMaster University, McMaster, Canada
  3. 3School of Community Based Medicine, University of Manchester, UK
  4. 4Rural AIDS and Development Action Research, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
  5. 5School of Public Health, University of Western Cape, Cape Town, South Africa
  1. Correspondence to Professor Susan May Cleary, Health Economics Unit, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa; susan.cleary{at}


Introduction South Africa has the world's largest antiretroviral treatment (ART) programme. While services in the public sector are free at the point of use, little is known about overall access barriers. This paper explores these barriers from the perspective of ART users enrolled in services in two rural and two urban settings.

Methods Using a comprehensive framework of access, interviews were conducted with over 1200 ART users to assess barriers along three dimensions: availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between sites were explored using multivariate linear and logistic regressions.

Results While availability access barriers in rural settings were found to be mitigated through a more decentralised model of service provision in one site, affordability barriers were considerably higher in rural versus urban settings. 50% of respondents incurred catastrophic healthcare expenditure and 36% borrowed money to cover these expenses in one rural site. On acceptability, rural users were less likely to report feeling respected by health workers. Stigma was reported to be lowest in the two sites with the most decentralised services and the highest coverage of those in need.

Conclusions While results suggest inequitable access to ART for rural relative to urban users, nurse-led services offered through primary healthcare facilities mitigated these barriers in one rural site. This is an important finding given current policy emphasis on decentralised and nurse-led ART in South Africa. This study is one of the first to present comprehensive evidence on access barriers to assist in the design of policy solutions.

  • STD
  • hepatitis
  • information technology

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding This work was carried out with support from the Global Health Research Initiative, a collaborative research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, the International Development Research Centre and the Public Health Agency of Canada.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval University of Cape Town, University of Witwatersrand and University of KwaZulu-Natal.

  • Provenance and peer review Commissioned; externally peer reviewed.