Background

Comprehensive services are essential for an effective response to the HIV/AIDS epidemic. For instance, community members should have comparable knowledge about HIV/AIDS and accepting attitudes towards people living with HIV/AIDS. They should also have access to HIV testing and antiretroviral therapy (ART) [1]. These services will help countries achieve the three 95s: 95% of people living with HIV know their status, 95% of those who know their status will be on ART, and 95% of those on ART will achieve viral load suppression. This will enable countries to end the HIV/AIDS epidemic by 2030 as part of the sustainable development goal 3.3 [2,3,4].

Several efforts have been implemented to address inequity and ensure no one is left behind in the HIV/AIDS services. For instance, the ‘President’s Emergency Plan for AIDS Relief’ is being implemented for marginalised and underserved populations in many African countries [5,6,7,8]. Similarly, the ‘Federal Care and Prevention Project in the United States of America’ (USA) [9] and the ‘Centres for Disease Control and Prevention’ [10] have suggested holistic interventions to close disparities in social and living conditions. These interventions are supported by strategic collaborations between nations, non-governmental partners, the private and public sectors, effective leadership, global funds, and evidence-based practices based on disparities in social classes [11,12,13,14,15].

However, inequities and inequalities in HIV/AIDS services hinder the progress of the HIV/AIDS responses and universal health coverage (UHC) [16, 17]. HIV/AIDS-related morbidity, mortality, and disability-adjusted life years are higher in developing countries [18]. For instance, two-thirds of people living with HIV were in Africa in 2020 [19], where a few countries bore most of the burden [18]. The disparities largely affect individuals who have a lower probability of accessing services [20, 21]. In 2020, 19.3 million women and 16.7 million men were living with HIV worldwide [22]. Moreover, individuals under poor socioeconomic status and multiple disadvantageous identities had lower chance for accessing HIV/AIDS-related services [23,24,25,26,27,28]. Disadvantaged groups face inequalities because of their social category, which people form, transform, or maintain their identities. Due to its dynamic nature of being non-medical factors, they are influenced by the dynamic political situations [29,30,31], changing health policies [32], and emerging pandemic diseases [33,34,35,36,37]. Examples of groups and dynamics are racial and ethnic minorities, women, religious minorities, and other social groups, who influence their identities by their income. Multiple disadvantaged groups are those who cannot full-fill their health care needs due to their two or more disadvantaged classes [38]. In general, inequities in services are underscored in relation to social strata, which World Health Organization calls ‘social determinants of health’ [39].

Social determinants of health are the condition in which people are born, grow, work, and live and considered as non-medical factors that influence health outcomes. The ‘Commission on the Social Determinants of Health’ urged the marshalling of evidence on inequity for policy inputs [39]. This provides an understanding of disparities in the combined HIV/AIDS services to deliver tailored interventions [40]. Equity is a less investigated concept in the UHC period [41], and a priori systematic review focused on combination HIV prevention assessed empowerment, inclusion, and agency in low- and middle-income countries [42]. However, it did not address inequity in the HIV prevention services across social strata around the world. The current review aims to fill this gap.

This review aims to assess the inequities in knowledge about HIV/AIDS, attitudes towards people living with HIV or HIV-associated stigma, HIV testing practice, and ART coverage across different social classes. Specifically, it investigates which social strata demonstrates significant differences in knowledge, attitudes or stigma, and testing related to HIV/AIDS. Moreover, it explores how ART coverage varies among these social classes. Understanding the extent of these inequities is crucial for tailoring healthcare services based on social determinants of health. Additionally, this review will serve as a framework for future research by synthesising evidence from various sources, offering a comprehensive overview of existing knowledge. By examining global research on inequities, it sheds light on areas where equity-oriented research on HIV/AIDS services has been under investigated, particularly among specific social groups.

Methods and materials

Results reporting

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guideline (PRISMA checklist) [43]. It helps to present a systematic, transparent, and complete methods and findings of the review. The protocol is registered in PROSPERO database with a registration number CRD42024521247.

Eligibility criteria

Empirical articles published in English without a geographic limit were eligible. This systematic review was based on studies conducted in accordance with qualitative and quantitative methods approach. Those reported at least one of the selected outcome variables, including: knowledge about HIV/AIDS, accepting attitude towards people living with HIV, HIV associated stigma and discrimination, HIV testing, and ART coverage. Articles were included if they mentioned to assess the (in)equity, disparity, or (in)equality of those services based on one of the components of the PROGRESS Plus Framework, including multiple disadvantageous groups.

Articles on (in)equity that did not report HIV/AIDS services based on at least one component of PROGRESS plus, systematic reviews, meta-analyses, scoping review, any other types of review, conference abstracts, brief communications, letters to the editor, commentary, erratum, and retracted articles were excluded.

Information sources

PubMed, Web of Science, Excerpta Medical Database (EMBASE), Scopus, and Google Scholar were searched. Reference lists of retrieved articles were also screened for additional article inquiry. Database search was conducted from the date of the first publication on the topic to September 15, 2022, and the search was updated on May 29, 2023. By the date of the first publication, we mean the earliest date when a relevant study on the topic was published. This means that we did not exclude any studies based on the year of publication. For example, according to the search strategy that we used in PubMed, the first study on the topic was published in 1984. Therefore, our systematic review process considered studies published from 1984 to the last search date (May 29, 2023).

Search strategy

Search terms were knowledge, attitude, stigma, discrimination, test*, “HIV test”, “highly active antiretroviral therapy”, ART, HAART, antiretroviral, anti-retroviral, antiviral, therapy, “acquired immunodeficiency syndrome”, aids, hiv, “human immunodeficiency virus”, “HIV infections”, HIV/AIDS, “human immunodeficiency virus/acquired immunodeficiency syndrome”, equit*, inequit*, equalit*, equal, inequalit*, inequalit*, unequal, disparit*, and differenc*. The search strategy was constructed based on Boolean and truncation operators (AND, OR, *). An example search strategy used in EMBASE is (‘attitude’/exp OR ‘attitude’ OR ‘knowledge’/exp OR ‘knowledge’ OR ‘stigma’/exp OR ‘stigma’ OR ‘discrimination’/exp OR ‘discrimination’ OR ‘highly active antiretroviral therapy’/exp OR ‘highly active antiretroviral therapy’ OR ‘antiretroviral therapy’/exp OR ‘antiretroviral therapy’ OR ‘antiretrovirus agent’/exp OR ‘antiretrovirus agent’ OR ‘test’/exp OR test) AND (‘human immunodeficiency virus infection’/exp OR ‘human immunodeficiency virus’/exp OR ‘acquired immune deficiency syndrome’/exp OR ‘hiv aids’/exp) AND (‘equity’/exp OR ‘health disparity’/exp OR ‘diversity, equity and inclusion’/exp OR ‘inequality’/exp OR ‘disparity’/exp) AND [english]/lim. The full search strategy is found in the supplementary file (sT1).

Selection process

One reviewer (AE) conducted a database search and screened based on their title and abstract. Subsequently, two reviewers (AE and WSS) discussed the eligibility criteria to ensure a shared understanding. Independently, they performed full-text screening. Afterward, they cross-checked the screened articles. Finally, through discussion, they resolved discrepancies between the two authors (AE and WSS).

Data collection process

Qualitative and quantitative data were extracted and imported into Microsoft Excel©. Data included author(s)/year of publication, data collection period, country of publication, study design, statistical analysis, HIV/AIDS service category, study population, sample size, statistical analysis, and main findings. Main findings focus on differences between social classes. This include PROGRESS-plus refers to the place of residence, race/ethnicity/culture/language, occupation or employment status, gender/sex, religion, education, socioeconomic status, and social capital; ‘plus’ refers to personal characteristics (age) [44]. Intersectionality (multiple social identities) was also considered in this review [45]. Data from the quantitative studies were extracted based the significant level by evaluating the reported p-values and confidence intervals. If the required variables were reported as significantly associated social classes with no mentions of p-value or confidence intervals, we included them into the data set as per the report from the included studies. Regrading qualitative data, we reviewed the main findings content wise and extracted the reported findings to add into the data set.

Data items

Mintzker et al. suggested PECO to establish research question for observational studies [46]. Accordingly, all people with no restriction were the population (P) for knowledge about HIV/AIDS, attitudes towards people living with HIV, and HIV testing, while people living with HIV is for stigma or discrimination and ART. Exposure (E) denotes variables in the PROGRESS-plus framework. Comparison (C) was the disadvantageous group in social classes (e.g., the rural category if urban is considered as exposure). The outcome (O) was inequality, inequity, or disparity in knowledge, attitude or stigma and discrimination, HIV testing, and ART coverage.

Study risk of bias assessment

Hoy et al’s quality assessment criteria with a 10-point checklist was used to assess cross-sectional studies [47]. This checklist includes (1) target population representativeness, (2) true sampling frame, (3) random selection or census, (4) non-response bias handling, (5) data collected directly from the subjects, (6) case definition, (7) tool validity and reliability, (8) same mode of selection for all participants, (9) adequate length of study, and (10) appropriateness of numerator and denominator. The Joanna Brigg Institute’s (JBI) quality appraisal checklist was used for qualitative studies was used [48]. The JBI checklist includes (1) philosophical perspective and the research methodology congruity; (2) research methodology and the research question congruity; (3) congruity between the research methodology and the methods used to collect data; (4) research methodology and the representation and analysis of data congruity; (5) congruity between the research methodology and the interpretation of results; (6) a statement locating the researcher culturally or theoretically; (7) addressing researcher’s influence on the research and vice- versa; (8) participants, and their voices adequately represented; (9) evidence of ethical approval by an appropriate body; and (10) conclusions drawn in the research report flow from the analysis, or interpretation of the data. Two reviewers (AE and WSS) independently assessed the quality of the articles. Two reviewers solved disagreements raised during scoring articles for quality status by discussion.

Synthesis methods

We used mixed-method analysis, including descriptive analysis (e.g., frequency of articles based on country) and qualitative content analysis for the main findings. The findings did not invite meta-analysis due to various analysis method and interest of outcome. Only a systematic review without meta-analysis was conducted. Both quantitative and qualitative findings were described as per the PROGRESS elements. Choropleth maps were generated by using Microsoft Excel to show available article distribution across the countries. The main findings were synthesised, framed, and interpreted based on the PROGRESS plus elements (place of residence, race/ethnicity/culture/language, occupation or employment status, gender/sex, religion, education status, socioeconomic status, and social capital, age [44] and intersectional identities (multiple social groups) [45].

Results

Study selection

A total of 6,029 articles were identified and screened. Following the removal of duplicates as well as screening by reading title and abstract, 107 articles were selected for full-text review. Finally, 72 articles met the inclusion criteria and were included in the systematic review (Fig. 1).

Fig. 1
figure 1

Article selection process

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Study characteristics

HIV/AIDS service inequality was observed in low, lower-middle, upper-middle- and high-income countries. Based on study settings, 31 articles were from North America (28 articles from the USA [28, 49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75] and 3 articles from Canada [76,77,78]); 20 articles were from Africa (Ethiopia, Mozambique, Uganda, Ghana, Kenya, South Africa, Malawi, Nigeria, East Africa, sub-Saharan African countries) [26, 79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97], seven articles were from south east Asia (Nepal, Vietnam, Thailand, India, Indonesia, Bangladesh) [98,99,100,101,102,103,104], five articles were from the European region (France, UK, Turkey, Kazakhstan, 35 European countries) [105,106,107,108,109], three articles were from China [110,111,112], one article each from Latin America and Caribbean countries [113], low-and middle-income countries [114], Eastern Mediterranean (Iran) [115], African, Caribbean and southeast Asia countries [116], 49 countries [117], and Brazil [118]. Based on the frequency of publication by year, four articles were published before 2000, six articles were published between 2000 and 2005, six articles were published between 2006 and 2010, twenty articles were published between 2011 and 2015, twenty-three articles were published between 2016 and 2020, and thirteen articles were published after 2020 (Table 1). Figure 2 displays article distribution according to each country. To illustrate, 31 articles from North America are displayed on the map after classified to corresponding country, namely, 28 articles for the USA and 3 articles for Canada (Fig. 2).

Table 1 Characteristics of included articles
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Fig. 2
figure 2

Available articles distribution across countries

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Risk of bias in studies

Out of 72 articles assessed for risk of bias, 67 were quantitative and 5 were qualitative articles. Of 67 quantitative articles, 48 articles were found low and 19 have moderate risk for bias (Fig. 3).

Fig. 3
figure 3

Percentage distribution of articles quality per quality indicators

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Five qualitative studies were assessed using the JBI’s quality appraisal criteria for qualitative studies. Four have scored 8 out of 10 because they missed a statement ‘locating the research culturally or theoretically’ and ‘addressing the researcher’s influence on the research and vice versa’. One article has scored 9 out of 10 because it missed a statement ‘locating the research culturally or theoretically’. The detailed quality appraisal checklist with articles is available in the supplementary file (sT2).

Results of synthesis

Knowledge about HIV/AIDS

Rural resident [100, 110, 114], unemployed [100], women [108, 110, 119], traditional religious followers [83], lower education status [52, 65, 83, 100, 110, 114, 120], lower income status [23, 26, 82, 83, 86, 100, 114], and non-US born people compared to US-born people [66] had lower knowledge about HIV/AIDS. One, in the United States [28], assessed intersectionality inequity (being monolingual and Latino) concluded that monolingual Latina women had a lower level of HIV/AIDS knowledge than their counterparts. Whites than Blacks or Latinos [68, 120], high-caste group than low-caste group in Nepal [99], and English speakers than Spanish speakers in the USA [67] were more knowlegeable about HIV/AIDS. Regarding age category, there were two studies with contradictory findings [53, 83]. One study each reported that there was no ethnic-based disparity in knowledge about HIV/AIDS among opioid users [64], and there was no gender based disparity in Democratic Republic of the Congo [89] and Malawi [91].

Attitude towards people living with HIV

One study revealed that a rural resident among female youths had exhibited a better attitude towards people living with HIV [98]. However, others, non-US born people [66], Asian men compared to an ethnic majority group in UK [121], individuals with lower education status [52] and lower income status [86], had showed a lower accepting attitude towards people living with HIV. In contrast, one study reported that individuals with middle-to-richest group had lower accepting attitude towards people living with HIV compared to the poorest [98].

HIV associated stigma

Compared to their counterparts, northern and rural regions of Ontario [76], black women and Asian/Latin American/unspecified men [111], women [79, 81, 84, 90, 101], and younger [118] were more likely to experience HIV-associated stigma. Similarly, individuals with multiple disadvantaged identities, such as immigrants, females, and drug users [122], African Caribbean and black men [78], sexual orientation, race/ethnicity, income, social class, and injection [73], and non-white Latinos [75] also faced a higher rate of HIV-associated stigma and discrimination. This phenomenon is known as intersectional inequity, which means that different social identities and systems of oppression interact and create unique experiences of marginalization.

HIV testing

Compared to their counterparts, rural residents [102], non-US born people [66], Whites compared to Blacks or Latinos [54], people from ethnic groups [102], lower education status [93, 102], and lower income status [23, 26, 80, 86, 93, 94, 103, 117, 123] had less access to HIV testing. However, one study revealed that pregnant women with lower income status had more access to HIV testing in South Africa [97]. Similarly, younger [102], women in the USA and sub-Saharan African countries [62, 123], employed [62], remote villages on the Maroni compared to Coastal areas in France [107] had more access to HIV testing. Bisexual women and gay men had a higher lifetime HIV testing rate than their heterosexual counterparts [72]. Finally, a study in the USA showed that there was no ethnic-based disparity in HIV testing among men who performed sex with men [51].

ART coverage

Rural residents [88], transgender women compared to females [118], lower education status [118], lower income status [96, 118], younger [49, 57, 77, 88], Black/ Hispanic/ Latino/ non-white people [50, 57,58,59,60,61, 69, 70, 77, 118, 124, 125], southern Europe than western Europe [109] had a lower access to ART compared to their counterparts. However, regarding gender, there was contradiction: six studies reported that women had less access to ART [55, 57, 59, 61, 87, 125], while one study reported that women in ten African countries, Haiti and Vietnam [116] had more access to ART. Additionally, employed individual had better access to ART [88]. On the other hand, multiple disadvantaged groups, such as HIV-infected or a sex worker and a lack of gender affirmation (e.g., misgendering) [104] had less access to ART. One study each reported that there was no racial- [71] and gender-based [126] difference in ART coverage. Undocumented participants linked their immigration status to their ability to get work, which then affected their HIV care [74].

Discussion

Evidence shows that HIV/AIDS service coverage varies according to place of residence, race or ethnicity, employment status or occupation, gender, religion, education, and socioeconomic status because of disparities in living and working conditions. These disparities can influence people’s knowledge, attitudes, and behaviours related to HIV/AIDS, as well as their uptake of HIV/AIDS services [127]. In settings characterised by significant resource scarcity, low-income nations, low gross domestic product, conflict areas, high corruption, and high gender inequality, there may be significant disparities in HIV/AIDS services and related to knowledge, attitude, stigma, and discrimination [128]. While most studies report that poorer people and women have lower access, some studies have found contradictions, indicating that poorer people and women actually had greater access to certain services, such as HIV testing [97]. There are discrepancies among the included studies because of study period, population, sample size, analysis, and context. This may indicate the application of different approaches and research in public health across different study periods.

Community engagement, inclusiveness, and collaborative response have become the priority strategies in health policy and care delivery. These strategies aim to address the social determinants of health and reduce health inequities. To provide comprehensive action on determinants, primary health care needs multisectoral action and policy, public and clinical care, and community engagement [129]. Legal and structural priorities are also frequently emphasised in cross-cutting social and environmental contexts [130]. The behavioural-based interventional and implementational research aims to narrow the gap of the social determinants-based inequality in HIV/AIDS services, using evidence from previous studies that show how factors such as income, education, and gender affect access to prevention, testing, and treatment [131, 132]. These types of studies need to accommodate evidence that shows different patterns of disparity in HIV/AIDS services among age groups [53, 83, 102, 118]. On the other hand, there has been historical, social, cultural, and economic consistency in ramping up gender-based inequity in HIV/AIDS services: as evidenced by higher HIV-associated stigma [79, 81, 84, 90, 101], lower knowledge about HIV/AIDS [108, 110, 119] and lower ART coverage [55, 57, 59, 61, 87, 125] among women. It is important to note that HIV/AIDS services are interconnected. Therefore, higher stigma among women affects their health-seeking behaviour and their access to other HIV/AIDS services [133]. It is thus true that the UN approved the need for global calls for gender equality, which enacted measures to engage women in political positions, empower them in the community, provide better opportunities for education, implement affirmative action in employment, and increase the number of female health workers in health sectors [134]. These strategies may close gender inequity in a country where women have fewer opportunities to learn and earn a living or a high gender pay gap [135, 136]. However, more research is needed to evaluate their effectiveness and impact on HIV/AIDS outcomes.

Studies reported that rural residents had lower knowledge about HIV/AIDS [100, 110, 114], HIV testing [102], and ART coverage [88]. This evidence supports the necessity of global and national strategies to reach marginalised and hard-to-reach populations, which usually reside in rural settings [137]. Primary health care, one of the long-term strategies to reach the rural population, aims to expand walk-in health clinics [138]. This will help in distributing health resources and infrastructure to rural areas so that they can have equal access to health information, advice, and education. Thus, the vicious cycle of HIV/AIDS services might be maintained in rural settings. The vicious cycle of HIV/AIDS services refers to the phenomenon that people who have more knowledge about HIV/AIDS are more likely to access prevention, testing, and treatment services, while those who have less knowledge are more likely to miss out on these services and remain at risk of infection or poor health outcomes [139]. However, the reverse may be true in that people who are tested for HIV or linked to an ART clinic may develop comprehensive knowledge about HIV/AIDS even though they have no prior information [140]. Moreover, even though rural residents have lower knowledge about HIV/AIDS, one study discovered female youths in rural areas had a better accepting attitude towards people living with HIV [98]. Therefore, community health workers could have a positive impact on narrowing the gap between urban and rural areas, aiming to maximise service coverage in rural areas and maintain the optimum level in urban areas [141].

Disparities in HIV/AIDS services are observed between ethnic groups; lower ART coverage [50, 57,58,59,60,61, 69, 70, 77, 118, 124, 125], knowledge about HIV/AIDS [54, 68, 99, 120], attitudes towards people living with HIV [111, 121], and HIV test coverage [102] were among ethnic minority groups. As most studies report, there is greater inequity between ethnic minority and majority groups. However, minority groups are inaccessible to many healthcare services because lower education and economic conditions have seriously affected them [142]. It is imperative to consider a further breakdown of social classes beyond ethnicity. For instance, the migrant populations face several challenges in accessing HIV/AIDS-related services, including individual- and organizational-level barriers [143]. Therefore, ‘culturally-tailored’ [144], ‘eHealth and mHealth’ [145], and ‘community-coalition-driven’ [146] interventions brought important change to health knowledge and self-management, psychosocial outcomes among ethnic minority and historically underserved populations.

Inequality in HIV/AIDS services is also apparent between household wealth rank, or income, occupation, and education status. Most studies reported that people with lower income had lower knowledge about HIV/AIDS [23, 26, 82, 83, 86, 100, 114] and HIV test coverage [23, 26, 80, 86, 93, 94, 103, 117, 123]. Similarly, people with lower education status had lower access to HIV/AIDS services [52, 65, 83, 93, 100, 102, 110, 112, 114, 118, 120]. Unless care consideration made for non-illitrate, literacy had been identified as one of the root causes of disparity, including in developed nations [147]. There is a good opportunity that, gradually, the number of literate people is increasing over time, including in developing countries [148]. This may create a suitable environment to prepare, conduct, and disseminate health literacy. Moreover, there should be an emphasis on quality education to close the gap between educated and uneducated people in knowledge about HIV/AIDS, attitude towards people living with HIV or HIV associated stigma and discrimination, and HIV service uptake.

Interventions for narrowing the gap in education-based disparity through increasing the education status of people with lower education status will have a positive impact on socioeconomic inequality. This will happen because differences in education status result in socioeconomic inequality in HIV testing [80, 94, 103] and knowledge about HIV/AIDS [82]. However, in most cases, individuals with a lower household wealth index had less knowledge about HIV/AIDS [23, 26, 83, 86, 100, 114] and accepting attitude towards people living with HIV [86], and less access to HIV testing [23, 26, 80, 86, 93, 94, 103, 117, 123] and ART [118]. Therefore, ongoing interventions are required to economically empower the poorest and groups of the population living in poverty that increase health-seeking behaviour and the ability to pay for health care expenditure, which can support people in multiple disadvantages identity [149].

Multiple disadvantages identity is called intersectional identities, which were a determinant of HIV/AIDS-related services, similar to other health care practises [150, 151]. Different axes of intersectionality prevent women from accessing HIV care [152]. Effective strategies are needed to address them. For example, implementation study in Ghana revealed that peer support reduced intersectional stigma [153].

Overall, the included studies were varied in year of study, contexts, study population, methodology, and outcome of interest. Rare studies have investigated patterns of inequity based on religion, social capital, disability, and language, and more research is needed on these social determinants. The contributors to socioeconomic inequalities and the extent of inequality among multiple disadvantageous groups over time were not well explored. The World Health Organisation launched the building blocks of the health system, which play a great role on equity [154]. Therefore, assessing inequities from this perspective would make it practical to address identified barriers comprehensively.

Strength and limitations

This is the first systematic review to assess inequities in knowledge of HIV/AIDS, attitude towards people living with HIV or HIV associated stigma, HIV testing, and ART coverage. Despite this, it has some limitations. First, this review included only articles published in English, and there may be other non-English articles with supporting or contradicting evidence. Second, this review included research with wide variability in methods, making it difficult to quantify inequity using meta-analysis. Third, this review included prior research if it aimed to or mentioned (in)equity or (in)equality, which in some instances may be social determinants assessed differently but are not part of this review.

Conclusions

To conclude, younger, uneducated, individuals with poor household income, the unemployed, rural residents, and ethnic minorities seem to have benefited from HIV/AIDS services less than their counterparts. HIV/AIDS service inequality was unlimited based on a lower or higher HIV prevalence rate. It means there was inequality in HIV/AIDS services in both countries, with lower and higher HIV burdens. Individuals who live under two or more socially disadvantaged conditions were deprived of HIV-associated knowledge and other services in developing countries that underscored more evidence is needed on intersectionality in developing countries. Ending service disparity and thus the global threat of HIV/AIDS demands multifaceted tailored interventions. Additionally, inequality-aimed research on HIV/AIDS services was more researched in developed countries where a relatively lower HIV prevalence than in high HIV burden countries. There is also a need to understand the deep-rooted causes of inequity and the challenges that an equity-oriented system faces over time.