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.
Highlights
The US President’s Emergency Plan for AIDS Relief (PEPFAR) is one of the largest commitments to date to combat a single disease globally.[1]
We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria
The PEPFAR program has facilitated a rapid scale up of life-saving antiretroviral therapy (ART) over the past decade, expanding treatment to nearly 11.5 million people living with HIV in sub-Saharan Africa, compared to only 50,000 when PEPFAR was established in 2003.[1]. This investment led to a 39% decline in HIV/AIDS mortality over the same period.[3]
Summary
The US President’s Emergency Plan for AIDS Relief (PEPFAR) is one of the largest commitments to date to combat a single disease globally.[1]. PEPFAR 2.0 has provided a framework for the gradual transfer of ownership of the HIV response from PEPFAR to the national governments of recipient countries.[5, 6] PEPFAR, in the course of this transition, gradually reduced its involvement in direct service delivery.[7, 8] sub-Saharan Africa, home of the largest HIV epidemic worldwide, has experienced funding decreases exceeding 80 million USD since 2011.[9]
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