WINNING ENTRY - IFRTD OPINIONS FAIR (October 2007)

Global Campaign against AIDS: Towards an inter-sectoral focus on health and mobility  by Dr Andrea Gutiérrez

The eve of International Aids Day (1 December), is a good time to reflect on the relationship between AIDS and mobility.

Considerable progress has been made in the twenty-five years since the appearance of the first AIDS cases.  Effective antiretroviral treatments have now been available for ten years.  There is a bank of conclusive proofs with regard to the prevention and treatment of AIDS.  There also exists a series of international commitments – most notably the Millennium Development Goals.

However, the 2006 report by the United Nations Joint AIDS Programme (UNAIDS) draws attention to obstacles to the prevention and treatment of HIV – amongst them the inadequacy of transport.  Even though there is unanimous agreement on the necessity for inter-sector plans to deal with HIV, drawing these up and implementing them still remains difficult. 

Currently, UNAIDS’ Global Initiative “Towards providing universal access to HIV/AIDS prevention, care, support and treatment” is focusing on the question of access.  Access to AIDS prevention, care and treatment is limited by resistance to making changes to conventional approaches to certain issues.  The link between mobility and health is an example of this.

A model of an inter-sector approach to health and mobility

The “three delays” model, developed by Thaddeus and Maine in 1994 (see www.mobilityandhealth.org) identifies three key moments in the treatment of peri-natal complications, associated with delays in: the decision to seek  treatment, access to a health centre and the quality of care offered there.  This model is used today to highlight transport as a key component in this issue.

This model is applicable to emergency journeys but not to journeys for healthcare where a single visit to the doctor cannot resolve the problem.  Similarly, this model collects information on transport, where this is perceived as being a relationship between two places: home and hospital, for example.

If, in considering the impact of mobility on access to healthcare, we think of a journey as being a link between places, some relevant information will be omitted.  We will have an over-simplified view of a complex problem.  Access to healthcare needs to be evaluated in terms of healthcare services as a whole (having tests analysed, receiving medication, etc.) and not just as access to places.  The above approach is inadequate, especially in cases where long-term treatment or periodic check-ups are necessary (as with HIV/AIDS or in pregnancy).

So, the Argentinean team of the Mobility and Health Network are developing and applying this model for gathering evidence on the impact of travelling on access to public healthcare for pregnant adolescents on the outskirts of the Buenos Aires Metropolitan Region (BAMR).

In Argentina, pregnancy and HIV tests are free in the public health system, as is antiretroviral medication.  Training, awareness-raising activities and preventative treatment for the disease are also in place, as is psychological support.  National government takes the lead on this, but works in close collaboration at all levels and also with NGOs.

What are the learnings from this model?

Applying the model demonstrates that having four check-ups a year for a healthy carrier does not necessarily involve making 4 journeys.  Services for the prevention and treatment of HIV/AIDS are divided up into an inter-related series of journeys.

It is estimated that up to 2/3 of the new infections forecast for the next ten years could be avoided if preventative measures, based on tests, were carried out.  In the BAMR a laboratory test to determine the viral load or defences in the blood requires a minimum of 5 outward journeys (to collect the prescription, have it authorised, have the blood test, pick up the results and take them to the doctor, and requires the making of a telephone call to request an appointment).  This adds up to 20 journeys in the course of a year.  A healthy HIV carrier who is pregnant needs to make 35 journeys, simply for laboratory tests to decide on treatment and on mode of birth.

UNAIDS recommends extending access to treatment, including antiretroviral treatment.  In the BAMR free access to this involves a minimum of two outward journeys per month and 3 more journeys every six months (to certify the absence of medical cover under the trade union healthcare insurance or private insurance systems).  This amounts to 30 journeys per year.

HIV/AIDS care involves specialised teams and professionals and so is given only in hospitals, not in local health centres.  Travelling to a hospital in the outskirts of the BAMR involves covering distances of up to 30 kilometres, on foot and using a combination of more than one means of public transport, spending per person the equivalent of a poor household’s daily expenditure on food and taking up half a day in terms of time.

How is it useful in decision-making?

To extend access to treatment, UNAIDS recommends including antiretroviral medication.  This model demonstrates that providing this free of charge is not sufficient to guarantee access to it.  Where, when and how are questions that define the network of journeys involved in accessing medication (and tests, prevention workshops, etc.).  Owing to this, statistics on who receives treatment may mask interruptions to and/or discontinuation of treatment, which have a bearing on its effectiveness.  Similarly, the free tests may be delayed, thereby resulting in a late diagnosis in pregnancy or being useless in terms of determining the type of birth and avoiding transmission.

UNAIDS recommends the use of practical solutions.  This model enables the identification and evaluation of the effectiveness and efficiency of timely interventions, but with the use strategic thinking.  For example, considering notifying patients by telephone of the arrival of the medication at the hospital to avoid fruitless journeys or considering using social or health workers and other intermediaries, who are in contact with the local area, to deliver medicines to patients at home.  Each place would have its consignment note.

It also maintains that research is a fundamental policy action for prevention.  It is worth remembering that gathering evidence within a conceptual framework adds value to the knowledge gained.  This model enables information to be gathered using short samples of interviews and is within the possibilities even of local authorities.  We all have a role to play in attaining the MDGs.  The role of academics is “to invest in concepts”

This opinion piece was contributed by Dr Andrea Gutiérrez, Transport and Territory Programme, University of Buenos Aires, Argentina.
Contact: angut2[at]filo.uba.ar

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