Access to antiretroviral treatment in developing countries: Which financing strategies are possible?

In low- and middle-income countries, access to combination antiretroviral therapy for all people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in need of treatment is a major public health challenge. The objective of this paper was to provide an overview of the different financing modalities of HIV/AIDS care at the microeconomic level and an analysis of their advantages and limitations. A review of the published literature using mainly the Medline and Science Direct databases for the 1990–2008 period in English and French made it possible to explore different financing strategies for the access to combination antiretroviral therapy using as case studies specific countries from different regions: Ivory Coast, Uganda, Senegal, and Rwanda for sub-Saharan Africa, Brazil and Haiti in the Latin America/Caribbean region, and Thailand for Asia. In these settings, direct payment through user fees is the most frequent financing mechanism in place for HIV/AIDS care and treatment, including combination antiretroviral therapy. Nevertheless, other mechanisms are being implemented to improve access to treatment such as community-based health insurance schemes with free care for the poor and vulnerable households and public–private partnerships. The type of financing strategy for HIV/AIDS care and treatment depends on the context. As direct payment through user fees limits access to care and does not enable program sustainability, national and donor agencies are introducing alternative strategies such as community financing systems (mutual health organizations, micro insurance, community health funds) and public–private partnerships. Finally, access to combination antiretroviral therapy has improved in resource-limited settings; however, there is a need to introduce alternative financial mechanisms to ensure long-term universal and equitable access to treatment and care, including combination antiretroviral therapy. Les financements de l’accès des patients vivant avec le virus d’immunodéficience humaine/syndrome d’immunodéficience acquise (VIH/SIDA) aux antirétroviraux dans les pays en développement constituent plus que jamais un problème de santé publique majeur. L’objectif de cet article est de proposer une synthèse des modalités de ces financements au niveau microéconomique et d’analyser leur portée et leurs limites. Une revue thématique de la littérature publiée, entre 1990 et 2008, en anglais et en français, principalement à p