Lagos, Nigeria: Is paying for HIV treatment bad

for you?

Comprehensive HIV-care in the General Hospital Lagos

MSF-Holland/Germany

ART Availability

• ARVs available in the country since 1990s

• Private sector provision, pay out of pocket

• 2002: public sector funded ART-program– 10 000 patients (user fee based)

• Nov 2003-Jan 2004-crisis:

Gov. Program out of stocks

Project description

• Start November 2003

• July 2004: first patient on ARV

• April 2006:

– Total Patients enrolled: 1862

– Patients on ART: 1275

– Mortality: 3.1 %

– Lost to Follow UP (2M): 7.8%

– WHO-stage 3/4: 78 %

– ARV-Experienced patients: 13 %

Why do Experienced patients come to MSF-clinic ?

• Questionnaire to assess:– Treatment background

• Which drugs , how long

• ART interruptions

– ART expenses in the user fee based system

WHAT ARE OUR FINDINGS SO FAR

Income of HIV+ patients in the Lagos General Hospital

0%

10%

20%

30%

40%

50%

60%

0-36 36-71

71-107

107-178

178-249

249-355

355-533

533-710

over710

% o

f pa

tient

s

USD

What do patients pay for ART in non-MSF-sites ?

3036

40

0

10

20

30

40

USD

70 % of Nigerians 50 % HIV+ in GHL ART costs

income versus ART costs per month

122 experienced patients interviewed : Average costs = 40 USD

88

34

NUMBER OF PATIENTS WITHTREATMENT INTERRUPTION

NUMBER OF PATIENTS WITHOUT TREATMENT INTERRUPTION

27.8 %72.1 %

72% of all ARV experienced interviewed people had ART interruption average cumulative interruption time: 6 month 8 % shared the ARVs with their partners

ART Interruption in Patients with ARV Experience

n= 122

Reasons why ART was stopped

61%14%

6%

17%

1%1%

0%

FINANCE

out ofgovt.stock

SIDEEFFECTS

SOCIAL

HEALTH OK

FAILUREIMPROVE

OTHER

Results of ARV-Questionnaire (n= 88)

Sources of financing ART

39%

18%25%

12%

6%

Borrow/begging

Sell property

Support fromfriends and family

Using personalsavings

Others

Have you ever experienced a financial crisis due to expenses for

ART ?

83%

8%4% 3% 2%

YES Severe

YES Medium

YES Light

Could not qualify

Pat. Answered withNO

N=114

Comparing ARV Naive and ARV Experienced patients at baseline

Parameter Experienced (n=113), 13.8 %

Naive (n=703)

CD4 (cell/microl) 313 138

Weight(kg) 62 57

former time on ART( Mo)

13

(IQR:7,24)

0

regimens AZT-3TC-NVP (49%)

D4T-3TC-NVP (30%)

AZT-3TC (15 %)

---------------

naive and experienced patients after 3-6mo

CD4 drop

29

8

0

5

10

15

20

25

30

35

exp.Pat naive Pat

% o

f p

at.

wit

h C

D4

dro

p

weight drop

27

17

0

5

10

15

20

25

30

exp.Pat naive Pat%

of

pat

. wit

h w

eig

ht

dro

p

P<0.001 P=.0023

%

%%

%

N= 237 N= 807

Virological outcomes after 6-12 months of ART (n=158)

ART experienced

(% of patients)

ART

naïve (% of patients)

< 1000 copies/ml

63 72

1000-10,000 15 23

> 10,000 * 22 5

* OR 6.0, 95% CI 1.8-20.2 , p=0.004

Pill Counts November 2005Lagos Project

 

88

6 51

0

10

20

30

40

50

60

70

80

90

% of patients

>95 % adherence, 0-5 % pills missed

95- 90 % adherence, 5-10% pills missed

90-80 % adherence, 10-20% pills missed

< 80 % adherence, >20% pills missed

Adherence estimated by pill counts, n=329

Failing ARV-exp.Patients

genotyping:

77 %resistance

n=13

NRTI NNRTI Protease Inhibitors

ResistantReduced

ResponseResistant

Reduced Response

ResistantReduced

Response

1 No Resistance No Resistance No Resistance

2 No Resistance No Resistance Protease not seq

3 No Resistance No Resistance Unable sequence

4 No ResistanceNevirapine Efavirenz

No Resistance

5Emtricitabine Lamivudine

Abacavir Didanosine

Nevirapine Efavirenz

Unable sequence

6Emtricitabine Lamivudine

Zidovudine Nevirapine Efavirenz

Nelfinavir Saquinavir

7Emtricitabine Lamivudine

Nevirapine Efavirenz

Protease not seq

8Emtricitabine Lamivudine

Didanosine Zidovudine

Nevirapine Efavirenz

No Resistance

9Emtricitabine Lamivudine

Nevirapine Efavirenz

Nelfinavir Amprenavir

10Emtricitabine Lamivudine

Abacavir

Zidovudine Didanosine Tenofovir

Nevirapine Efavirenz

No Resistance

11Emtricitabine Lamivudine

Nevirapine Efavirenz

No Resistance

12Emtricitabine Lamivudine

Zidovudine Didanosine

Nevirapine Efavirenz

Amprenavir Nelfinavir

13

Emtricitabine Lamivudine

Abacavir Tenofovir

Zidovudine Stavudine

Didanosine

Nevirapine Efavirenz

Ritonavir Nelfinavir

Saquinavir

Amprenavir Indinavir

Saquinavir / r

Conclusions

• User fees for HIV care are unaffordable for PLWHA and contribute to impoverishment

• Financial constraints are the most common reason for treatment interruptions in fee-paying patients

• Outcomes of treatment among experienced patients on 1st line therapy appear worse than among naives, probably due to ARV resistance

Acknowledgements:Daniel O`brien (AMS)Kamalini (AMS)Tom Ellman (London)

Wilma (Medco)Francois( HoM)Kai Braker, Berlin

Bernadette Olomo

Els St.-Bothawhole team in Lagos

Philomina Orji

Team at BCCfEin Vancouver,David Tu