Thirteen Years of Trade-Offs: How poverty affects medication non-adherence

Editors note on our Health & Development series:

The correlation between access to first-rate healthcare and least developed countries is striking.  That correlation is more than superficial.  Causality runs in both directions: poor health leads to poverty by constraining the ability to work while simultaneously requiring expensive treatment.  But poverty limits access to expensive care and therefore leads to poor health.  All of this is exacerbated in countries without strong healthcare institutions.  As a result, fighting poverty is as much about providing healthcare opportunities as it is about providing economic opportunities.  Our ongoing series on Health & Development this year will focus on how the world is dealing with these interactions.


Part two of a series on HIV/AIDS in South Africa:

Out of the 35 million people worldwide currently living with HIV/AIDS, 24.7 million of them reside in Africa. That’s more than 70% of the people living with HIV worldwide. Of this giant fraction, 6.3 million call South Africa home. An economic, social, and scientific leader of its region, South Africa serves as a model for other sub-Saharan countries grappling with HIV/AIDS. How the global community stems the tide of the AIDS epidemic may indeed depend heavily on how South Africa handles its share.  

In the previous blog post of this series, I pointed out the dangerously low antiretroviral therapy (ART) adherence levels in South Africa (50-77%), yet did not provide any explanation for why patients elect to not take free, life-saving medications. The issue of non-adherence is certainly a complex, multifactorial one – it encompasses stigma, mental illness, drug abuse, homelessness, gender inequality, and more. Yet I believe that each of these challenging factors can be connected and understood in the context of one clear overarching determinant: poverty.

Of the entire South African population, a tremendous 65.7% live in poverty as of 2011. Breaking down this statistic shows that 20.2% of the entire population, or 10.2 million people, live in “extreme poverty” – i.e., they are unable to purchase enough food for an adequate diet. Another 32.3%, or 16.3 million people, live in “less extreme poverty,” which means they can afford an adequate diet but would have to sacrifice food to purchase non-food items.

The monetary trade-off that people living with HIV (PLHIV) face regarding antiretroviral therapy is not so obvious to the casual observer – after all, ART has been provided free of charge since 2004 by the South African government. The face value of the pill itself, however, is a far cry from the actual costs of treatment. As public health researcher Sera Young of Cornell University details:

Even when clinic consultations are ‘‘free,’’ clinical care is not without costs. These include opportunity costs, such as income foregone while traveling far distances to clinics or waiting in long lines for care, as well as expenditures required to receive care, such as payment for transportation to health care facilities. In many settings PLHIV struggle to simultaneously afford food, household expenses (e.g. rent, school tuition), [other] medications, healthcare fees, and transportation costs to the clinic.

An average clinic visit in South Africa consumes a full working day, oftentimes even longer because patients tend to attend clinics far away from their homes so as to minimize the likelihood of being identified by community members. For those who can afford to lose a day’s paycheck and can also afford the transportation costs (which present a larger burden for those who live in rural areas compared to urban areas), it is often hard to negotiate time off from work to get prescriptions, mainly because they do not want to disclose their HIV status to employers out of fear of discrimination. With soaring unemployment rates (24% as of 2014) and widespread food insecurity, few patients are willing to risk their jobs, especially when only one in five households in the country currently meets its dietary energy needs.

But the relationship between food and medication extends even further beyond the income argument. Some classes of antiretroviral drugs (such as Saquinvair and Nelfinavir) actually cause adverse side effects when taken without food, such as nausea, vomiting, and stomach pain. On the other hand, other classes of drugs (such as Didanosine and Indinavir) cause side effects when taken with food, such as increased appetite. For patients living in poverty, reducing these negative side effects naturally become priorities in the context of scarce food and income. In this case, non-adherence seems more convenient and advantageous to the patient.

Meanwhile, those who are non-adherent progress faster towards the debilitating Acquired Immunodeficiency Syndrome (AIDS) and other opportunistic infections, which further deteriorate their ability to generate income. The lack of income leads to even poorer food access, and so this perpetuates a “devastating cycle in which food insecurity is both a cause and consequence of deleterious health outcomes.”

In order to break this cycle, the root cause – poverty – must be targeted. The good news is that the South African government is attempting to do just that. Nearly 60% of government spending is allocated to the “social wage,” which is primarily composed of old age grants, child support grants, and disability grants. In the HIV context, the latter is the most relevant; the government provides disability grants for patients in the public health system whose CD4 counts fall below 200 cells per microliter (μL)for a period of six months. CD4 cells are white blood cells that HIV attacks, and when CD4 levels are low enough, a patient is officially diagnosed with AIDS.

Unfortunately, this well-intentioned social welfare provision spawns some unintended consequences. The availability of temporary disability grants actually works as a disincentive for AIDS patients to maintain medication adherence. The whole point of antiretroviral therapy is to raise CD4 counts and lower viral loads. Patients with CD4 counts lower than 350 cells/μL should theoretically start ART without delay. Unfortunately, unemployed patients may choose to sacrifice wellbeing in order to be eligible for the disability grant, which can be a main source of income. According to the Global AIDS Response Progress Report, by the end of April 2011, 989,446 South Africans were on permanent disability grants and 210,985 were on temporary disability grants.

This trend of forgoing treatment in order to receive monetary compensation is not necessarily myopic. When one’s life expectancy at birth is 56 years (as it was in South Africa in 2012), the short term tends to become much more valuable than the long term. In a perverse way, the natural progression of HIV/AIDS makes this temporal trade-off easier than one might expect: it typically takes ten years (with mild to acute flu-like symptoms) for an untreated patient infected with HIV to develop AIDS. From there, it is another three years to death.

This thirteen-year span, though often marked or shortened by other infectious diseases and opportunistic infections, still represents a significant amount of time. HIV/AIDS thus lends itself to high non-adherence rates by virtue of its slow progression. When symptoms are bearable, having enough money to eat for the week becomes the ultimate priority. Extending longevity for a distant future is often more difficult to justify. Put in this context, the choice to be non-adherent is not so irrational; in fact, forgoing strict adherence appears to be a tactic of survival.

In the third and final installment of this series, I will explore the role of the HIV/AIDS epidemic in South Africa’s pursuit of sustainable development.

Image credit by John Hill via Wikimedia Commons depicting an HIV/AIDS clinic in India. 


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