Abstract
BackgroundThe impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described.MethodsWe evaluated ART-eligible patients and patients starting ART at a prototypical scale up ART clinic in Mbarara, Uganda between April 1, 2009 and May 14, 2010 where four stakeholders sponsor treatment – two PEPFAR implementing organizations, the Ugandan Ministry of Health – Global Fund (MOH-GF) and a private foundation named the Family Treatment Fund (FTF). We assessed temporal trends in the number of eligible patients, the number starting ART and tabulated the distribution of the stakeholders supporting ART initiation by month and quartile of time during this interval. We used survival analyses to assess changes in the rate of ART initiation over calendar time.FindingsA total of 1309 patients who were eligible for ART made visits over the 14 month period of the study and of these 819 started ART. The median number of ART eligible patients each month was 88 (IQR: 74 to 115). By quartile of calendar time, PEPFAR and MOH sponsored 290, 192, 180, and 49 ART initiations whereas the FTF started 1, 2, 1 and 104 patients respectively. By May of 2010 (the last calendar month of observation) FTF sponsored 88% of all ART initiations. Becoming eligible for ART in the 3rd (HR = 0.58, 95% 0.45–0.74) and 4th quartiles (HR = 0.49, 95% CI: 0.36–0.65) was associated with delay in ART initiation compared to the first quartile in multivariable analyses.InterpretationDuring a period of flat line funding from multinational donors for ART programs, reductions in the number of ART initiations by public programs (i.e., PEPFAR and MOH-GF) and delays in ART initiation became apparent at the a large prototypical scale-up ART clinic in Uganda.
Highlights
Multinational HIV/AIDS treatment programs have been one of greatest public health successes this century, diminishing resource commitments by major donors have raised uncertainty about the future of access to antiretroviral therapy (ART) and the goal of universal access
We found diminishing ARV supply for new ART initiation by large President’s Emergency Plan for AIDS Relief (PEPFAR) sources and an increasing reliance on Family Treatment Fund (FTF) at a prototypical HIV clinic in southwestern Uganda during a period when ART-eligible patients continued to present to care
We found a nearly 50% decline in the rate of ART initiation for patients who presented in the final quartile of calendar time as compared to the first quartile (April to mid-June, 2009) that translates into a decrease in the 90 day cumulative incidence of ART initiation from 71% to 47% or an absolute difference of 24%
Summary
Multinational HIV/AIDS treatment programs have been one of greatest public health successes this century, diminishing resource commitments by major donors have raised uncertainty about the future of access to antiretroviral therapy (ART) and the goal of universal access. Despite concerns about the feasibility of implementing life-long HIV therapy with limited health care infrastructure, the scale-up of ART has been accompanied by rates of medication adherence and viral suppression which exceeded expectations and in many cases surpassed precedents established in North America and Western Europe [2,3,4]. Despite the fact that early mortality [7] and losses to follow-up are high [8], the effectiveness of the global ART roll out is indisputable These successes notwithstanding, funding at the global level has been flat during 2009–2010 [9] and the United States President’s 2011 Budget Request to Congress contains 6.7 billion in total global HIV funding which represents a 2.2%. The impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described
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