title: People living with HIV travel farther to access healthcare: a population-based geographic analysis from rural Uganda.
abstract: BACKGROUND
  The availability of specialized HIV services is limited in rural areas of sub-Saharan Africa where the need is the greatest. Where HIV services are available, people living with HIV (PLHIV) must overcome large geographic, economic and social barriers to access healthcare. The objective of this study was to understand the unique barriers PLHIV face when accessing healthcare compared with those not living with HIV in a rural area of sub-Saharan Africa with limited availability of healthcare infrastructure.
  
  
  METHODS
  We conducted a population-based cross-sectional study of 447 heads of household on Bugala Island, Uganda. Multiple linear regression models were used to compare travel time, cost and distance to access healthcare, and log binomial models were used to test for associations between HIV status and access to nearby health services.
  
  
  RESULTS
  PLHIV travelled an additional 1.9 km (95% CI (0.6, 3.2 km), p=0.004) to access healthcare compared with those not living with HIV, and they were 56% less likely to access healthcare at the nearest health facility to their residence, so long as that facility lacked antiretroviral therapy (ART) services (aRR=0.44, 95% CI (0.24 to 0.83), p=0.011). We found no evidence that PLHIV travelled further for care if the nearest facility supplies ART services (aRR=0.95, 95% CI (0.86 to 1.05), p=0.328). Among those who reported uptake of care at one of two facilities on the island that provides ART (81% of PLHIV and 68% of HIV-negative individuals), PLHIV tended to seek care at a higher tiered facility that provides ART, even when this facility was not their closest facility (30% of PLHIV travelled further than the closest ART facility compared with 16% of HIV-negative individuals), and travelled an additional 2.2 km (p=0.001) to access that facility, relative to HIV-negative individuals (aRR=1.91, 95% CI (1.00 to 3.65), p=0.05). Among PLHIV, residential distance was associated with access to facilities providing ART (RR=0.78, 95% CI (0.61 to 0.99), p=0.044, comparing residential distances of 3-5 km to 0-2 km; RR=0.71, 95% CI (0.58 to 0.87), p=0.001, comparing residential distances of 6-10 km to 0-2 km).
  
  
  CONCLUSIONS
  PLHIV travel longer distances for care, a phenomenon that may be driven by both the limited availability of specialized HIV services and preference for higher tiered facilities.
authors: Institute for Disease Modeling, Bellevue, WA, USA; aakullian@intven.com.
authors: Adam N
authors: AN
authors: Akullian
authors: Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
authors: Aggrey
authors: A
authors: Mukose
authors: Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA.
authors: Gillian A
authors: GA
authors: Levine
authors: Global Medicines Program, Department of Global Health, University of Washington, Seattle, WA, USA.
authors: Joseph B
authors: JB
authors: Babigumira
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019380:Anti-HIV Agents / Q000627:therapeutic use; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000628:therapy*; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D012424:Rural Population; D014195:Travel; D014454:Uganda
chemical_list: D019380:Anti-HIV Agents
keywords: HIV antiretroviral drugs; Uganda; access to HIV services; geographic information systems; health systems; spatial analysis