HIV patient access to healthcare services in post-austerity era in Greece

Our study suggests that a critical proportion of HIV patients in Greece face significant barriers to receiving optimal HIV care, according to diagnostic and clinical guidelines. Financial and social insurance status are the main variables that impact on access, despite the comprehensive and universal NHS coverage of antiretroviral treatment and HIV monitoring. Reforming and integrating NHS service provision together with addressing social barriers and discrimination are critical to ensuring care is offered as per standards to all people living with HIV in Greece.


Background
The ten-year economic crisis and the ensuing fiscal adjustment that Greece experienced between 2009 and 2018 has had a major impact on patient access to healthcare services and resulted in an increase in unmet population health needs. The present study assesses the impact of economic crisis and ensuing austerity on HIV patient access to healthcare services.

Methods
A cross-sectional study was carried out between February and April 2019 to assess barriers in access to HIV care faced by people living with HIV. 329 HIV-positive individuals participated in the study. An online, self-reporting questionnaire was developed on the basis of the HOPE studies tool (2,3,9,10) and adapted to the specific clinical and societal characteristics of HIV.
Results 94.2% of respondents were male and 67.80% lived in Athens. Most of them were diagnosed with HIV 1 to 10 years ago. 37,40% of respondents reported obstacles in accessing HIV care over the past year, such as shortages in antiretroviral medicine, restricted opening hours of pharmacies and delays in booking an appointment with physicians. 24,30% reported they were not tested for viral load in the last six months and received a result. Individuals, who self-evaluate their financial status as very bad or bad, were more likely to be unaware of their viral load (55.60%) compared to individuals with better financial status (33,5%) (P<0.01). Only 33.3% of uninsured participants were aware of their viral load, and this figure rose to 63.30% (P <0.01) amongst insured participants.

Conclusion
Our study suggests that a critical proportion of HIV patients in Greece face significant barriers to receiving optimal HIV care, according to diagnostic and clinical guidelines. Financial and social insurance status are the main variables that impact on access, despite the comprehensive and universal NHS coverage of antiretroviral treatment and HIV monitoring. Reforming and integrating NHS service provision together with addressing social barriers and discrimination are critical to ensuring care is offered as per standards to all people living with HIV in Greece. This study assesses barriers to access to optimal care of people living with HIV in Greece after a decade of austerity and the variables that impact on such access.

Methods
A cross-sectional study was carried out between February and April 2019 to assess barriers in access to HIV care faced by people living with HIV. An online, self-reporting questionnaire was developed on the basis of the HOPE I, II, III and IV (6,7,8,9)  Results 94.2% of respondents were male and 4.3% female. Almost half of participants were aged 36 to 50, and 27.1% were 26 to 36 years old. 67.80% lived in Athens. About 40% were university graduates, with an additional 23% holding a master's degree or PhD. 50,80% of respondents reported their economic status as good or very good.

Discussion
The fiscal crisis in Europe had a great impact on health services in a variety of ways (10). Healthcare systems were mainly affected by public budget cuts and a lack of financial and human resources (11,12,13). On the other hand, cost sharing has shifted to households and has hampered access, especially for patients with low incomes and high frequency of healthcare services utilization (6). Previous studies have highlighted the negative impact of austerity on the quality of healthcare services in Greece. These consequences were highlighted with regards to self-assessment of health status (14), quality of services (15), increasing inequalities in access to care (5,16), deterioration of physical and mental health indicators (14) and cuts in public health programs (17).
HIV has been traditionally considered a public health priority (18), and its management safeguarded through comprehensive monitoring and universal access to care. HIV antiretroviral treatment suppresses virus replication in blood and limits its copies to undetectable levels. The viral load test confirms the success of the process and is the most crucial indicator for the health status of people living with HIV and their response to antiretroviral therapy (19). The international, European (19) and Greek guidelines (20) for the management of HIV recommend viral load monitoring at least every 6 months. However, and as this study confirms, Greece has been facing increasing barriers in recent years, regarding patient access to viral load tests, primarily due to shortages of reagents in public laboratories and the inability of the state to address these through contracting services from the private sector, in a fully anonymized manner. Such a situation is expected to impact not only on personal but also on public health, as HIV-positive people with undetectable viral load cannot transmit the virus to their sexual partners (21). 44,40% of respondents in the study reported they have not confirmed in vitro whether they have an undetectable viral load in the last six months. This is critical for treating physicians as they cannot assess the effectiveness of antiretroviral medication and adjust treatment options accordingly. This figure is higher amongst the most vulnerable groups, such as persons with Additionally, the study confirmed that when people living with HIV face barriers in accessing care in the health system in Greece, these are likely to stem from more than lack of resources. Limited testing services due to bureaucratic inability to conduct international tenders for supplying reagents, shortages of antiretroviral medicines due to lack of a global hospital budget for HIV, restricted hospital pharmacy opening hours due to inefficient allocation of human resources and delays in booking an appointment due to lack of a fully operational scheduling system, all contest to the need for extensive administrative and operation reforms within the NHS and beyond (15,24), if to deliver on universal and comprehensive access to quality services. Such system shortcomings have been confirmed elsewhere before. In the HOPE studies, patients with rheumatoid arthritis, cancer or multiple sclerosis and drug users with hepatitis C in Greece reported critical difficulties in accessing medicines, physical distance from providers and long waiting times for a medical appointment (6,7,8,9).
These difficulties contest to a persisting need for structural work within the NHS. Unlike other countries such as Iceland and Finland in the early 2010s (25), where access to care was safeguarded against economic collapses through integrated administrative, health and social measures, out study confirms the negative impact the fiscal crisis has had on the operability and responsiveness to need of the NHS, amongst a group of patients, people living with HIV, that have been traditionally optimally managed.
Among these patients, addressing such barriers is a critical first step. And it is not the only one to be taken in the direction of effectively managing HIV. Any future HIV care policy needs to allow for the social dimension of the condition and contribute to reducing stigma and discrimination against people living with HIV, critically men who have sex with men, injecting drug users, sex workers, refugees and migrants, so that they are not only supported when overcoming barriers but also actively encouraged to seek the care they need.

Conclusion
Our study suggests that a critical proportion of HIV patients in Greece face significant barriers to receiving optimal HIV care, according to diagnostic and clinical guidelines, thus challenging not only personal but also public health. Financial and social insurance status are the main variables that impact on access, despite the comprehensive and universal NHS coverage of antiretroviral treatment and HIV monitoring. Reforming and integrating NHS service provision together with addressing social barriers and discrimination are critical to ensuring care is offered as per standards to all people living with HIV in Greece.
Ethics approval and consent to participate The study was approved by the Institutional Review Board of Positive Voice and was in line with the ethical standards set by the Declaration of Helsinki. Participation was voluntary, anonymized and informed consent for participation was requested and obtained from all participants.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.