Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria

Abstract

The transition to PEPFAR 2.0 with its focus on country ownership was accompanied by substantial funding cuts. We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria. We surveyed 30 comprehensive HIV treatment clinics to assess services supported before (October 2013-September 2014) and after (October 2014-September 2015) the PEPFAR funding policy change, the impact of these policy changes on service delivery areas, and response of clinics to the change. We compared differences in support for staffing, laboratory services, and clinical operations pre- and post-policy change using paired t-tests. We used framework analysis to assess answers to open ended questions describing responses to the policy change. Most sites (83%, n = 25) completed the survey. The majority were public (60%, n = 15) and secondary (68%, n = 17) facilities. Clinics had a median of 989 patients in care (IQR: 543–3326). All clinics continued to receive support for first and second line antiretrovirals and CD4 testing after the policy change, while no clinics received support for other routine drug monitoring labs. We found statistically significant reductions in support for viral load testing, staff employment, defaulter tracking, and prevention services (92% vs. 64%, p = 0.02; 80% vs. 20%, 100% vs. 44%, 84% vs. 16%, respectively, p<0.01 for all) after the policy change. Service delivery was hampered by interrupted laboratory services and reduced wages and staff positions leading to reduced provider morale, and compromised quality of care. Almost all sites (96%) introduced user fees to address funding shortages. Clinics in Nigeria are experiencing major challenges in providing routine HIV services as a result of PEPFAR’s policy changes. Funding cutbacks have been associated with compromised quality of care, staff shortages, and reliance on fee-based care for historically free services. Sustainable HIV services funding models are urgently needed.

The impact of user fees on uptake of HIV services and adherence to HIV treatment: Findings from a large HIV program in Nigeria

“…Some programs have instituted protections to limit the burden of out-of-pocket expenses imposed by charging user fees [36]. NIMR (our study site), for example, instituted fee exemptions for children, pregnant women, elderly and indigent patients.…”

“…Similar user fee-based strategies have been implemented in other countries the region, and particularly in Western Africa, to cover the cost of lab monitoring tests, hospital registration clinical consultations, as well as to compensate for low provider wages [40]. Mean yearly fees vary widely depending on context, average around $40 USD yearly, and range from as low as $4 USD to as much as $166 USD [36,40]. There is a global challenge to dramatically decrease the cost of ART care and data such as these can help drive the urgency of this challenge.…”

Opportunities and challenges to Integrating mental health into HIV programs in a Low- and Middle-Income Country: Insights from the Nigeria Implementation Science Alliance

“…al., reported on group psychotherapy for depression integrated into HIV treatment (38). Some of the structures identi ed in our study and those utilized in Malawi, Zimbabwe and Uganda are already connected to HIV services infrastructure, and are very widely spread across Nigeria both in rural and urban settings (39,40).…”

Opportunities and challenges to integrating mental health into HIV programs in a low- and middle-income country: insights from the Nigeria implementation science Alliance

“…In Zimbabwe, Duffy et al described a stepped-care model integrating mental health screening and referral to treatment [37] and in Uganda, Mpungu et al, reported on group psychotherapy for depression integrated into HIV treatment [38]. Some of the structures identified in our study and those utilized in Malawi, Zimbabwe and Uganda are already connected to HIV services infrastructure, and are very widely spread across Nigeria both in rural and urban settings [39,40]. Four themes were identified relating to challenges and barriers to integration; (the double burden of HIV and mental health stigma and the problems of early detection, existing health policy gaps and structural challenges, poor human resources for mental health care in Nigeria and dearth of research for data and action).…”