An AIDS-free world through the full decentralisation of HIV services: a proof-of-concept study

Abstract

BackgroundNigeria has the third largest global burden of HIV/AIDS, with an epidemic that is described as stable. HIV/AIDS management in Nigeria has been run as a vertical programme since 2004, which has fuelled stigma and discrimination because facilities have designated AIDS doctors, treatment days, and specialist clinics. This situation has hindered access for patients, and catalysed inefficiency and ineffectiveness in the system with mass refusal of care by HIV-infected individuals. The objective of this proof-of-concept study was to explore the potential effect of full service decentralisation and commonisation. This study involved assessment of the benefits of integrating comprehensive HIV services into core daily health services, involving the training and empowerment of all health-care workers in HIV diagnosis, treatment, and care, thus ensuring the management of HIV-infected individuals as normal patients in selected health-care facilities in Nigeria. MethodsWith funding from the US Government, Excellence & Friends Management Consult (EFMC) developed an innovative HIV programming matrix that fully integrates comprehensive HIV services into the core health services of supported facilities. This new model was piloted in three states of Nigeria across 121 public and private health-care facilities. In selected sites, HIV-designated vertical services were dismantled because the new model did not require a specialist task-force on HIV, nor specialist clinics, laboratories, or personnel. As a replacement, HIV-related services were provided together with other clinical services on all days of the week in an integrated manner. Additionally, HIV drugs were stored in the central pharmacy, HIV laboratory equipment was installed in the central hospital laboratory, and counselling and testing was done at all relevant units of the facilities. Supported facilities signed an agreement with EFMC that allowed EFMC to provide financial and technical assistance. Findings121 facilities, consisting of ten secondary health centres, 99 primary health centres, and 12 private medical vendors in three states participated in this process over 18 months (October, 2011, to March, 2013). Newly activated (or HIV naive) sites adapted to the new programming pattern faster than did sites where HIV services were already in place. In all sites, the cost of programming reduced by an average of 45%, with most sites able to sustain full HIV care at half or less of their projected budgets. Training and mentoring of all health-care workers in supported facilities and their involvement in the programme improved efficiency, because previously disfranchised health workers had access to HIV knowledge. Weekly enrolment improved by more than 200%, quality of care was reported to be better by both internal and external assessors, and reports of work done were submitted on time. InterpretationAn AIDS-free generation is possible through commonisation of HIV services. For this to happen, HIV services must be fully decentralised and integrated into the fabric of the health system. Every health worker within a facility should be equipped with knowledge and skills to provide HIV services. This training can begin from pre-services undergraduate education and will enhance effectiveness, improve quality, and minimise or eradicate stigma and discrimination in all supported sites. FundingFunding was provided through US Centers for Disease Control (PEPFAR; through grant number 1U2GGH000197-01) and as sub-grant from the Institute of Human Virology Nigeria (IHVN) and Center for Clinical Care and Research Nigeria (CCCRN).