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

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:
– Patients on ART:
– Mortality:
– Lost to Follow UP (2M):
– WHO-stage 3/4:
– ARV-Experienced patients:
1862
1275
3.1 %
7.8%
78 %
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
% of patients
60%
50%
40%
30%
20%
10%
0%
0-36
3671
71107
107178
178- 249249 355
355- 533533 710
over
710
USD
What do patients pay for ART in nonMSF-sites ?
122 experienced patients interviewed : Average costs = 40 USD
income versus ART costs per month
40
36
40
30
30
USD 20
10
0
70 % of Nigerians 50 % HIV+ in GHL
ART costs
ART Interruption in Patients
with ARV Experience
NUMBER OF PATIENTS WITH
TREATMENT INTERRUPTION
NUMBER OF PATIENTS WITHOUT
TREATMENT INTERRUPTION
34
27.8 %
72.1 %
n= 122
88
 72% of all ARV experienced interviewed people had ART interruption
 average cumulative interruption time: 6 month
 8 % shared the ARVs with their partners
Reasons why ART was stopped
FINANCE
out of
govt.stock
17%
0%
1%
1%
6%
SIDE
EFFECTS
SOCIAL
HEALTH
OK
14%
61%
FAILURE
IMPROVE
OTHER
 Results of ARV-Questionnaire (n= 88)
Sources of financing ART
Borrow/begging
6%
39%
12%
25%
Sell property
Support from
friends and family
18%
Using personal
savings
Others
Have you ever experienced a
financial crisis due to expenses for
ART ?
8%
4%
3% 2%
YES Severe
YES Medium
83%
N=114
YES Light
Could not qualify
Pat. Answered with
NO
Comparing ARV Naive and ARV Experienced
patients at baseline
Parameter
CD4 (cell/microl)
Weight(kg)
former time on
ART( Mo)
regimens
Experienced
Naive (n=703)
(n=113), 13.8 %
313
138
62
57
13
(IQR:7,24)
0
AZT-3TC-NVP (49%)
D4T-3TC-NVP (30%)
AZT-3TC (15 %)
---------------
naive and experienced patients
after 3-6mo
35
30
weight drop
30
29 %
25
20
15
8 %
10
5
0
% of pat. with weight drop
% of pat. with CD4 drop
CD4 drop
27 %
25
17 %
20
15
10
5
0
exp.Pat
naive Pat
exp.Pat
N= 237
N= 807
P<0.001
P=.0023
naive Pat
Virological outcomes after 6-12
months of ART (n=158)
ART
experienced
ART
naïve
(% of patients)
(% of patients)
< 1000
copies/ml
1000-10,000
63
72
15
23
> 10,000 *
22
5
* OR 6.0, 95% CI 1.8-20.2 , p=0.004
Pill Counts November 2005
Lagos Project
Adherence estimated by pill counts, n=329
88
90
80
70
60
% of patients 50
40
30
20
10
0
6
5
>95 % adherence, 95- 90 % adherence, 90-80 % adherence,
0-5 % pills missed 5-10% pills missed 10-20% pills missed
1
< 80
% adherence,
>20% pills missed
Failing
ARV-exp.
Patients
genotyping:
77 %
resistance
n=13
NRTI
Resistant
Reduced
Response
NNRTI
Resistant
Reduced
Response
Protease Inhibitors
Resistant
Reduced
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 Resistance
Nevirapine
Efavirenz
No Resistance
Unable sequence
5
Emtricitabine
Abacavir
Lamivudine Didanosine
Nevirapine
Efavirenz
6
Emtricitabine
Lamivudine
Nevirapine
Efavirenz
7
Emtricitabine
Lamivudine
Nevirapine
Efavirenz
8
Emtricitabine
Lamivudine
Didanosine Nevirapine
Zidovudine
Efavirenz
9
Emtricitabine
Lamivudine
Nevirapine
Efavirenz
10
Emtricitabine Zidovudine
Lamivudine Didanosine
Abacavir
Tenofovir
Nevirapine
Efavirenz
No Resistance
11
Emtricitabine
Lamivudine
Nevirapine
Efavirenz
No Resistance
12
Emtricitabine Zidovudine
Lamivudine Didanosine
Nevirapine
Efavirenz
13
Emtricitabine
Zidovudine
Lamivudine
Stavudine
Abacavir
Didanosine
Tenofovir
Nevirapine
Efavirenz
Zidovudine
Nelfinavir
Saquinavir
Protease not seq
No Resistance
Nelfinavir
Amprenavir
Amprenavir
Nelfinavir
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
Team at BCCfE
in Vancouver,
David Tu
Acknowledgements:
Daniel O`brien (AMS)
Kamalini (AMS)
Tom Ellman (London)
Els St.-Botha
whole team in Lagos
Wilma (Medco)
Francois( HoM)
Kai Braker, Berlin
Philomina Orji
Bernadette Olomo