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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
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