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

Autoři: Bolanle Banigbe aff001;  Carolyn M. Audet aff002;  Prosper Okonkwo aff001;  Olujide O. Arije aff005;  Elizabeth Bassi aff001;  Kate Clouse aff002;  Melynda Simmons aff002;  Muktar H. Aliyu aff002;  Kenneth A. Freedberg aff007;  Aima A. Ahonkhai aff002
Působiště autorů: APIN Public Health Initiatives (APIN), Abuja, Nigeria aff001;  Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America aff002;  Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America aff003;  Friends in Global Health, Maputo, Mozambique aff004;  Institute of Public Health, Obafemi Awolowo University, Ile-Ife, Nigeria aff005;  Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America aff006;  Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America aff007;  Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America aff008;  Harvard Medical School, Boston, Massachusetts, United States of America aff009;  Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America aff010;  Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America aff011
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: 10.1371/journal.pone.0221809


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.

Klíčová slova:

Government funding of science – Health care policy – HIV diagnosis and management – Nigeria – Clinical laboratories – Government laboratories


1. PEPFAR. PEPFAR 3.0-Controlling the epidemic: delivering on the promise of an aids-free generation. 2014.

2. PEPFAR. PEPFAR: About Us 2017 [cited 2017 July 20]. https://www.pepfar.gov/about/270968.htm#.

3. UNAIDS. UNAIDS GAP Report 2014 [cited 2017 June 28]. http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf.

4. PEPFAR. Sustainable HIV epidemic control, PEPFAR position paper. 2016.

5. Getahun H, Kittikraisak W, Heilig CM, Corbett EL, Ayles H, Cain KP, et al. Development of a Standardized Screening Rule for Tuberculosis in People Living with HIV in Resource-Constrained Settings: Individual Participant Data Meta-analysis of Observational Studies. PLoS Med. 2011;8(1):e1000391. Epub 2011/01/27. doi: 10.1371/journal.pmed.1000391 21267059.

6. PEPFAR. Summary of the HIV/AIDS Partnership Framework with the Government of Nigeria, 2010 [cited 2014 November 1]. http://www.pepfar.gov/countries/frameworks/nigeria/index.htm.

7. Médecins Sans Frontières. No time to quit: HIV/AIDS treatment gap widening in Africa. Médecins Sans Frontières analysis of the widening funding gap for HIV/AIDS treatment in sub-Saharan Africa 2010.

8. Kavanagh MM. The politics and epidemiology of transition: PEPFAR and AIDS in South Africa. J Acquir Immune Defic Syndr. 2014;65(3):247–50. Epub 2013/12/19. doi: 10.1097/QAI.0000000000000093 24346642.

9. Vallejo A, Ruiz-Mateos E, Molina-Pinelo S, Soriano-Sarabia N, de Felipe B, Gutierrez S, et al. Immunovirologic characteristics of human immunodeficiency virus-infected patients consisting mainly of injecting drug users on highly active antiretroviral treatment with prolonged virologic failure. Viral immunology. 2006;19(4):759–67. Epub 2007/01/05. doi: 10.1089/vim.2006.19.759 17201671.

10. Vogus A, Graff K. PEPFAR Transitions to Country Ownership: Review of Past Donor Transitions and Application of Lessons Learned to the Eastern Caribbean. Glob Health Sci Pract. 2015;3(2):274–86. Epub 2015/06/19. doi: 10.9745/GHSP-D-14-00227 26085023.

11. Katz IT, Bassett IV, Wright AA. PEPFAR in transition—implications for HIV care in South Africa. N Engl J Med. 2013;369(15):1385–7. Epub 2013/10/11. doi: 10.1056/NEJMp1310982 24106930.

12. Katz IT, Bogart LM, Cloete C, Crankshaw TL, Giddy J, Govender T, et al. Understanding HIV-infected patients’ experiences with PEPFAR-associated transitions at a Centre of Excellence in KwaZulu Natal, South Africa: a qualitative study. AIDS Care. 2015;27(10):1298–303. Epub 2015/08/25. doi: 10.1080/09540121.2015.1051502 26300297.

13. HIV/AIDS Division Federal Ministry of Health. National Operational Plan for the Elimination of Mother to Child Transmission (eMTCT) of HIV in Nigeria 2015–2016. 2014.

14. Ayadi FS, Ayadi FO. The impact of external debt on economic growth: A comparative study of Nigeria and South Africa. Journal of Sustainable Development in Africa. 2008;10.3:234–64.

15. PEPFAR. Congressional budget justification supplement: Fiscal year 2017 [cited 2017 November 1]. https://www.pepfar.gov/documents/organization/259634.pdf.

16. Odekunle FF, Odekunle RO. The impact of the US president’s emergency plan for AIDS relief (PEPFAR) HIV and AIDS program on the Nigerian health system. Pan Afr Med J. 2016;25:143. Epub 2017/03/16. doi: 10.11604/pamj.2016.25.143.9987 28292105.

17. APIN Public Health Initiatives. About us- practice areas. 2018. https://apin.org.ng/practice-area/. Accessed on 31 October 2018.

18. Ghosn J, Wirden M, Ktorza N, Peytavin G, Ait-Mohand H, Schneider L, et al. No benefit of a structured treatment interruption based on genotypic resistance in heavily pretreated HIV-infected patients. AIDS. 2005;19(15):1643–7. Epub 2005/09/27. doi: 10.1097/01.aids.0000181322.17679.b2 16184034.

19. Ritchie J, Spencer L. Analysing qualitative data. In: Bryman A, Burgess RG, editors. Qualitative data analysis for applied policy research. London: Routledge; 1994. p. 173–94.

20. Cromer C, Pandit T, Robertson J, Niewikj A. The family planning graduation experience: lessons for the future. Executive summary. Washington DC: 2004.

21. UNAIDS. 90-90-90 An ambitious treatment target to help end the AIDS epidemic. 2014.

22. Ahonkhai AA, Bassett IV, Ferris TG, Freedberg KA. Improving HIV outcomes in resource-limited countries: the importance of quality indicators. BMC Health Serv Res. 2012;12:427. Epub 2012/11/28. doi: 10.1186/1472-6963-12-427 23176556.

23. Geng EH, Bangsberg DR, Musinguzi N, Emenyonu N, Bwana MB, Yiannoutsos CT, et al. Understanding reasons for and outcomes of patients lost to follow-up in antiretroviral therapy programs in Africa through a sampling-based approach. J Acquir Immune Defic Syndr. 2010;53(3):405–11. Epub 2009/09/12. doi: 10.1097/QAI.0b013e3181b843f0 19745753.

24. Lawn SD, Campbell L, Kaplan R, Little F, Morrow C, Wood R. Delays in starting antiretroviral therapy in patients with HIV-associated tuberculosis accessing non-integrated clinical services in a South African township. BMC Infect Dis. 2011;11:258. Epub 2011/10/01. doi: 10.1186/1471-2334-11-258 21957868.

25. Lawn SD, Harries AD, Wood R. Strategies to reduce early morbidity and mortality in adults receiving antiretroviral therapy in resource-limited settings. Current opinion in HIV and AIDS. 2010;5(1):18–26. Epub 2010/01/05. doi: 10.1097/COH.0b013e328333850f 20046144.

26. Rawizza HE, Chaplin B, Meloni ST, Eisen G, Rao T, Sankale JL, et al. Immunologic criteria are poor predictors of virologic outcome: implications for HIV treatment monitoring in resource-limited settings. Clin Infect Dis. 2011;53(12):1283–90. Epub 2011/11/15. doi: 10.1093/cid/cir729 22080121.

27. Mee P, Fielding KL, Charalambous S, Churchyard GJ, Grant AD. Evaluation of the WHO criteria for antiretroviral treatment failure among adults in South Africa. AIDS. 2008;22(15):1971–7. Epub 2008/09/12. doi: 10.1097/QAD.0b013e32830e4cd8 18784460.

28. Bisson GP, Frank I, Gross R, Lo Re V 3rd, Strom JB, Wang X, et al. Out-of-pocket costs of HAART limit HIV treatment responses in Botswana’s private sector. AIDS. 2006;20(9):1333–6. Epub 2006/07/04. doi: 10.1097/01.aids.0000232245.36039.2b 16816566.

29. Brinkhof MW, Dabis F, Myer L, Bangsberg DR, Boulle A, Nash D, et al. Early loss of HIV-infected patients on potent antiretroviral therapy programmes in lower-income countries. Bull World Health Organ. 2008;86(7):559–67. Epub 2008/08/02. doi: 10.2471/BLT.07.044248 18670668.

30. Mosoko JJ, Akam W, Weidle PJ, Brooks JT, Aweh AJ, Kinge TN, et al. Retention in an antiretroviral therapy programme during an era of decreasing drug cost in Limbe, Cameroon. J Int AIDS Soc. 2011;14:32. Epub 2011/06/18. doi: 10.1186/1758-2652-14-32 21679416.

31. Mahal A, Canning D, Odumosu K, Okonkwo P. Assessing the economic impact of HIV/AIDS on Nigerian households: a propensity score matching approach. AIDS. 2008;22 Suppl 1:S95–101. Epub 2008/08/02. doi: 10.1097/01.aids.0000327629.62350.59 18664961.

32. Ivers LC, Kendrick D, Doucette K. Efficacy of antiretroviral therapy programs in resource-poor settings: a meta-analysis of the published literature. Clin Infect Dis. 2005;41(2):217–24. Epub 2005/06/29. doi: 10.1086/431199 15983918.

33. El-Sadr WM, Donnell D, Beauchamp G, Hall HI, Torian LV, Zingman B, et al. Financial Incentives for Linkage to Care and Viral Suppression Among HIV-Positive Patients: A Randomized Clinical Trial (HPTN 065). JAMA Intern Med. 2017;177(8):1083–92. Epub 2017/06/20. doi: 10.1001/jamainternmed.2017.2158 28628702.

34. Clouse K, Mongwenyana C, Musina M, Bokaba D, Long L, Maskew M, et al. Acceptability and feasibility of a financial incentive intervention to improve retention in HIV care among pregnant women in Johannesburg, South Africa. AIDS Care. 2017:1–8. Epub 2017/10/27. doi: 10.1080/09540121.2017.1394436 29067861.

35. Bassett IV, Wilson D, Taaffe J, Freedberg KA. Financial incentives to improve progression through the HIV treatment cascade. Current opinion in HIV and AIDS. 2015;10(6):451–63. Epub 2015/09/16. doi: 10.1097/COH.0000000000000196 26371461.

36. Cailhol J, Craveiro I, Madede T, Makoa E, Mathole T, Parsons AN, et al. Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM and PEPFAR-funded HIV-activities. Globalization and health. 2013;9:52. Epub 2013/10/29. doi: 10.1186/1744-8603-9-52 24160182.

37. Vermund SH, Sidat M, Weil LF, Tique JA, Moon TD, Ciampa PJ. Transitioning HIV care and treatment programs in southern Africa to full local management. AIDS. 2012;26(10):1303–10. Epub 2012/06/19. doi: 10.1097/QAD.0b013e3283552185 22706012.

38. Souteyrand YP, Collard V, Moatti JP, Grubb I, Guerma T. Free care at the point of service delivery: a key component for reaching universal access to HIV/AIDS treatment in developing countries. AIDS. 2008;22 Suppl 1:S161–8. Epub 2008/08/02. doi: 10.1097/01.aids.0000327637.59672.02 18664948.

39. Atun R, Silva S, Ncube M, Vassall A. Innovative financing for HIV response in sub-Saharan Africa. J Glob Health. 2016;6(1):010407. Epub 2016/05/28. doi: 10.7189/jogh.06.010407 27231543.

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