Does accessibility to antiretroviral care improve after down-referral of patients from hospitals to health centres in rural South Africa?

  • Mosa Moshabela
  • Helen Schneider
  • Susan M Cleary
  • Paul M Pronyk
  • John Eyles


We conducted an evaluation of healthcare accessibility among patients taking antiretroviral treatment (ART) after they were ‘down-referred’ from hospital-based programmes to primary healthcare (PHC) centres in a rural South African setting. A cross-sectional design was used to study 109 PHC users compared to a randomly selected control group of 220 hospital-based users. Both groups were matched for a minimum duration on ART of six months. Using a comprehensive healthcare-accessibility framework, the participants were asked about availability, affordability and acceptability of their ART care in structured exit interviews that were linked to their ART-clinic record reviews. Unadjusted and adjusted regression models were used. Down-referral was associated with reduced transportation and meal costs (p ≤ 0.001) and travel time to an ART  facility (p = 0.043). The down-referred users were less likely to complain of long queues (adjusted odds ratio [AOR] 0.06; 95% confidence interval [95% CI]: 0.01–0.29), were more likely to feel respected by health providers (AOR 4.43; 95% CI: 1.07–18.02), perceived lower stigma (AOR 0.25; 95% CI: 0.07–0.91), and showed a higher level of ART adherence (AOR 8.71; 95% CI: 1.16–65.22) than the hospital-based users. However, the down-referred users preferred to consult with doctors rather than nurses (AOR 3.43; 95% CI: 1.22–9.55) and they were more likely to visit private physicians (AOR 7.09; 95% CI: 3.86–13.04) and practice self-care (AOR 4.91; 95% CI: 2.37–10.17), resulting in increased health-related expenditure (p ≤ 0.001). Therefore, the results indicate both gains and losses in ART care for the patients, and suggest that down-referred patients save time and money, feel more respected, perceive lower stigma and  show better adherence levels. However, unintended consequences include  increased costs of using private physicians and self-care, highlighting the need to further promote the potential gains of down-referral interventions in resource-poor settings.

Keywords: adherence, affordability, antiretroviral therapy, HIV/AIDS, primary healthcare, programme evaluation, resourcepoor settings, rural communities

African Journal of AIDS Research 2011, 10(4): 393–401

Author Biographies

Mosa Moshabela
University of the Witwatersrand, School of Public Health, 7 York Road, Parktown 2193, Johannesburg; Rural AIDS and Development Action Research Programme, PO Box 02, Acornhoek, Mpumalanga 1360, South Africa
Helen Schneider
University of the Western Cape, School of Public Health, Private Bag X17, Bellville 7535, Cape Town, South Africa
Susan M Cleary
University of Cape Town, Health Economics Unit, Anzio Road, Observatory 7925, Cape Town, South Africa
Paul M Pronyk
The Earth Institute, Columbia University, 405 Low Library, 535 West 116th Street, New York, New York 10027; The Interchurch Centre, 475 Riverside Drive, Suite 401, New York, New York 10115, United States
John Eyles
McMaster University, School of Geography and Earth Sciences, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada

Journal Identifiers

eISSN: 1608-5906
print ISSN: 1727-9445