AIDS and Behavior

, Volume 18, Issue 7, pp 1199–1223 | Cite as

Impact of Geographic and Transportation-Related Barriers on HIV Outcomes in Sub-Saharan Africa: A Systematic Review

  • Alexander J. LankowskiEmail author
  • Mark J. Siedner
  • David R. Bangsberg
  • Alexander C. Tsai
Substantive Review


Difficulty obtaining reliable transportation to clinic is frequently cited as a barrier to HIV care in sub-Saharan Africa (SSA). Numerous studies have sought to characterize the impact of geographic and transportation-related barriers on HIV outcomes in SSA, but to date there has been no systematic attempt to summarize these findings. In this systematic review, we summarized this body of literature. We searched for studies conducted in SSA examining the following outcomes in the HIV care continuum: (1) voluntary counseling and testing, (2) pre-antiretroviral therapy (ART) linkage to care, (3) loss to follow-up and mortality, and (4) ART adherence and/or viral suppression. We identified 34 studies containing 52 unique estimates of association between a geographic or transportation-related barrier and an HIV outcome. There was an inverse effect in 23 estimates (44 %), a null association in 26 (50 %), and a paradoxical beneficial impact in 3 (6 %). We conclude that geographic and transportation-related barriers are associated with poor outcomes across the continuum of HIV care.


Transportation barriers Linkage to care Retention in care Adherence Sub-Saharan Africa 


Las dificultades para obtener un transporte confiable a la clínica son frecuentemente citadas como una barrera para la atención del VIH en el África subsahariana; sin embargo, la magnitud de este efecto es desconocido. En esta reseña sistemática, resumimos la literatura sobre el impacto de las barreras geográficas y de transporte en los resultados relacionados con el VIH en el África subsahariana. Se buscaron estudios realizados en el África subsahariana examinando los siguientes resultados en el continuo de la atención del VIH: 1) asesoramiento y pruebas voluntarias, 2) vinculo a los servicios antes de empezar el tratamiento antirretroviral (ART), 3) pérdida en el seguimiento y la mortalidad, y 4) adherencia al ART y/o la supresión viral. Se identificaron 34 estudios que contienen 52 estimaciones únicas de asociación entre una barrera geográfica o relacionados al transporte y el resultado de VIH. Se produjo un efecto adverso en 23 estimaciones (44 %), una asociación nula en 26 (50 %), y un impacto paradójico beneficioso en 3 (6 %). Se concluyó que las barreras geográficas y relacionadas con el transporte están asociadas con resultados pobres de todo el continuo de la atención del VIH.



This work was supported by the Doris Duke Charitable Foundation International Clinical Research Fellowship at Harvard Medical School; the American Medical Association Foundation Seed Grant Research Program; and the U.S. National Institutes of Health R24TW007988, K23MH099916, K24MH087227, and K23MH096620. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We declare no conflicts of interest.


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Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Alexander J. Lankowski
    • 1
    • 2
    Email author
  • Mark J. Siedner
    • 2
  • David R. Bangsberg
    • 2
    • 3
    • 4
  • Alexander C. Tsai
    • 2
    • 4
    • 5
  1. 1.Departments of Internal Medicine and PediatricsUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Center for Global HealthMassachusetts General HospitalBostonUSA
  3. 3.Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of TechnologyHarvard Medical SchoolCambridgeUSA
  4. 4.Mbarara University of Science and TechnologyMbararaUganda
  5. 5.Chester M. Pierce Division of Global Psychiatry, Department of PsychiatryMassachusetts General HospitalBostonUSA

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