Background: The impact of the rapid scale-up of vertical antiretroviral treatment (ART) programs for HIV in sub-Saharan Africa on the overall health system is under intense debate. Some argue that HIV treatment programs are draining resources for the treatment of other diseases, while others have claimed that the investments through ART programs benefitted the health system. To establish the population-level impact of ART programs on health care utilization in the public-sector health system, we compare trends in health care utilization among HIV-infected people receiving and not receiving ART with HIV-uninfected people during a period of rapid ART scale-up.
Methods: We used data from one of Africa’s largest population-based cohorts, the longitudinal surveillance conducted by the Wellcome Trust Africa Centre for Health and Population Studies, which annually elicits information on health care utilization from all surveillance participants over the period 2009-2012 (N=44,461). We determined trends in hospitalization, and public and private primary health care (PHC) clinic visits for HIV-infected and -uninfected people over the period 2009-2012, and regressed utilization rates by HIV and ART status over time, controlling for sex, age, time on ART, and area of living.
Results: The proportion of people who reported to have visited a PHC clinic in the last 6 months increased significantly over the period 2009-2012, for both HIV-infected people not on ART (from 53% to 60%; p<0.001), and HIV-uninfected people (from 41% to 47%; p<0.001) (figure 1A). In contrast, the proportion of HIV-infected people not on ART visiting a private physician declined from 21% to 13% (p<0.001) (figure 1B) and hospitalization rates declined from 100 to 71 per 1000 PY (p<0.001) (Figure 1C). For HIV-uninfected people, the proportion visiting a private physician declined from 15% to 9%, and hospitalization rates declined from 78 to 44 per 1000 PY (p<0.001). All trends were sustained when controlling for potential confounders.
Conclusions: Our results do not support the claim that ART program scale-up lead to reduced access to care for other diseases. In contrast, the ART program has freed up secondary care capacity and has likely improved both the effectiveness and efficiency of the public-sector health system by channelling utilization from secondary to primary care in this setting. Future health systems interventions should build on these trends to improve the performance of chronic disease management in public-sector primary care.
Figure 1. Trend in age-standardized self-reported health care utilization by HIV and ART status over the years 2009 to 2012 in rural KwaZulu-Natal, South Africa. A. Proportion of people reporting to have visited a public PHC clinic in the last 6 months. B. Proportion of people reporting to have visited a private PHC clinic in the last 6 months. C. Self-reported hospitalization rates over the last 12 months