Lagos, Nigeria: Is paying for HIV treatment bad for you

1. Lagos, Nigeria: Is paying for HIV treatment bad for you? Comprehensive HIV-care in the General Hospital Lagos MSF-Holland/Germany

14. population: approx. 17 Million, most populated city in Africa prevalence: 7 % , 1.2 Mill approx. 200000 in need for ARVs only 8500 ( 4.3 %) have access in MOH, MSF, PEPFAR population: approx. 17 Million, most populated city in Africa prevalence: 7 % , 1.2 Mill approx. 200000 in need for ARVs only 8500 ( 4.3 %) have access in MOH, MSF, PEPFAR

15. 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

16. 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 % further we seen a lot of exp. Pat reporting a former drug history , also during in gov. program in the beginning not allowed to get ART if experienced, i.e. stigmatization, slowely people came forward not less 13 % comparing with international figures Malawi And rural urban Malawi 1.5 % dec. Cameroun, 4.0 % further we seen a lot of exp. Pat reporting a former drug history , also during in gov. program in the beginning not allowed to get ART if experienced, i.e. stigmatization, slowely people came forward not less 13 % comparing with international figures Malawi And rural urban Malawi 1.5 % dec. Cameroun, 4.0 %

17. 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 We found it a high number of exp., knowing thee are noot many ARV providers Where are they coming from , why are they coming to MSF and most especially what is their exact treatment background More then that sporadic observations, that some of the experienced dont respond as good on the ARVs as naive Genral feeling: More problems, OI s different , CD4 response delayed We found it a high number of exp., knowing thee are noot many ARV providers Where are they coming from , why are they coming to MSF and most especially what is their exact treatment background More then that sporadic observations, that some of the experienced dont respond as good on the ARVs as naive Genral feeling: More problems, OI s different , CD4 response delayed

18. WHAT ARE OUR FINDINGS SO FAR

19. Income of HIV+ patients in the Lagos General Hospital Questionnaire more then 100 HIV pos of our patients asked N=89 Might be biased by those who cant remember, low education what they earned or some dont earn any money life on what is givin to them Questionnaire more then 100 HIV pos of our patients asked N=89 Might be biased by those who cant remember, low education what they earned or some dont earn any money life on what is givin to them

20. What do patients pay for ART in non-MSF-sites ? In fact some people paid more then 100 USD per month at a timeIn fact some people paid more then 100 USD per month at a time

21. ART Interruption in Patients with ARV Experience

22. Reasons why ART was stopped

23. Sources of financing ART financingfinancing

24. Have you ever experienced a financial crisis due to expenses for ART ?

25. Comparing ARV Naive and ARV Experienced patients at baseline

26. naive and experienced patients after 3-6mo

27. Virological outcomes after 6-12 months of ART (n=158) Explain that; Analysis of slightly more recent data: ie cohort of all patients with VL done between 6-12 months 2. Preliminary univariate analysis Need to do multivariate logistic regression at a later date.Explain that; Analysis of slightly more recent data: ie cohort of all patients with VL done between 6-12 months 2. Preliminary univariate analysis Need to do multivariate logistic regression at a later date.

29. We have been using self report this past year As you can see from our newly introduced pill count data, this cross sectional study shows 87% of patients have adherence levels 95% and above.We have been using self report this past year As you can see from our newly introduced pill count data, this cross sectional study shows 87% of patients have adherence levels 95% and above.

30. Failing ARV-exp.Patientsgenotyping:77 %resistancen=13 Patients criteria : at least 3 month on ART, 6 mo VL >1500, mst over 10 000 Genotyping means basically to seqeunce two regions of the virsal genom and to search for mutations which render the virus resistant against a drug the virus was exposed to. Independent from CD4 Genotype Red manifest resistance Yellow reduced response White wild-no resitance Question when to switch virologically failing patientsPatients criteria : at least 3 month on ART, 6 mo VL >1500, mst over 10 000 Genotyping means basically to seqeunce two regions of the virsal genom and to search for mutations which render the virus resistant against a drug the virus was exposed to. Independent from CD4 Genotype Red manifest resistance Yellow reduced response White wild-no resitance Question when to switch virologically failing patients

31. 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 All this data together are not a proof yet for anything but What they suggest is mainly: And we think this mainly due to viral resistance in the experienced ppatientsAll this data together are not a proof yet for anything but What they suggest is mainly: And we think this mainly due to viral resistance in the experienced ppatients