The treatment access riddle: Which comes first-the chicken or the egg?

A little over a month ago, we posted a article talking about the 2011 United Nations Political Declaration on HIV/AIDS and Australia’s response to those commitments in the Melbourne Declaration.

One of the action areas identified in the Melbourne Declaration is the uptake and access to treatment for PLHIV. The action area identified three goals necessary to improve treatment uptake and access:

  1. Enhance the scope for people with HIV and their doctors to initiate antiretroviral treatment, including the removal of the PBS indication limiting antiretroviral drug prescribing above CD4 counts of 500;
  2. Remove financial barriers to treatment uptake arising from patient dispensing fees for HIV antiretroviral medications in all jurisdictions and broaden HIV dispensing arrangements beyond hospital-based pharmacies; and
  3. Establish programs to provide antiretroviral treatment to people with HIV not eligible for Medicare cover.

The good news: Australia has successfully completed the first goal, with the PBS barrier being lifted.  Read more here.

The not-so-good news: There is still more work to do in removing financial barriers and establishing access for Medicare ineligible PLHIV.

The cost of HIV medication is one of the most significant barriers to treatment access for PLHIV.  The costs, even with a co-payment can be debilitating. POZ Action has written a position paper on the case for waiving for co-payment for HIV medication.

The take-home message is that greater uptake of treatment requires treatment to be accessible, which means that it must be:

  • affordable; and
  • easily obtained.

Too often, we fail to look at treatment in the bigger picture, and the connection between access and uptake.

We cannot advocate for greater access without using the urgency of our push for treatment uptake because of the benefits of early treatment. Likewise, we cannot have a meaningful push or campaign for greater treatment uptake if we do not acknowledge and address the barriers to treatment access due to the social determinants of health. These barriers may not only include the prohibitive cost of medication but also the dispensing of medication.

When it comes to ARV dispensing practices, there are variations across every State. For instance, NSW have trialled the Enhanced Medication Access (EMA) scheme which allows eligible PLHIV to have up to 4 months supply of ARVs dispensed and delivered without the requirement of going to a hospital pharmacy. The option of having more efficient and tailored ARV dispensing is just one strategy to help alleviate access issues.

Further, access and uptake issues are exacerbated for those who are Medicare ineligible. The options of paying full cost for ARV or obtaining generics online through a wholesale company often means Medicare ineligibles cannot access medication, or do so at such a cost that it places the individual at risk to live below the poverty line.

When looking at treatment access and uptake, the age old riddle of: ‘which came first, the chicken or the egg?’ springs to mind. We could easily ask the same of our treatment riddle. So, which comes first: greater access to medication or uptake of treatment?

I believe the answer is neither-both need to happen at the same time.

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