APIN Public Health Initiatives (APIN), Abuja, Nigeria.
Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.
PLoS One. 2019 Sep 25;14(9):e0221809. doi: 10.1371/journal.pone.0221809. eCollection 2019.
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.
PEPFAR 2.0 模式强调国家自主权，伴随而来的是大幅削减资金。我们描述了这一转变对尼日利亚一个大型艾滋病毒诊所网络中艾滋病毒护理的影响。我们调查了 30 家综合艾滋病毒治疗诊所，以评估在 PEPFAR 资金政策变化之前（2013 年 10 月至 2014 年 9 月）和之后（2014 年 10 月至 2015 年 9 月）提供的服务，这些政策变化对服务提供领域的影响，以及诊所对这些变化的反应。我们使用配对 t 检验比较了政策变化前后人员配备、实验室服务和临床运营方面的支持差异。我们使用框架分析评估了对描述对政策变化的反应的开放式问题的回答。大多数（83%，n=25）站点完成了调查。大多数是公立（60%，n=15）和二级（68%，n=17）机构。诊所平均有 989 名患者在接受治疗（IQR：543-3326）。所有诊所继续获得一线和二线抗逆转录病毒药物和 CD4 检测的支持，而没有诊所获得其他常规药物监测实验室的支持。我们发现，政策变化后，病毒载量检测、员工就业、失访者追踪和预防服务的支持显著减少（92%对 64%，p=0.02；80%对 20%，100%对 44%，84%对 16%，所有均 p<0.01）。政策变化后，实验室服务中断、工资和员工岗位减少导致提供者士气低落，护理质量受损，服务提供受到阻碍。几乎所有（96%）站点都引入了用户收费来解决资金短缺问题。由于 PEPFAR 的政策变化，尼日利亚的诊所正在经历提供常规艾滋病毒服务的重大挑战。资金削减与护理质量下降、人员短缺以及历史上免费服务依赖收费服务有关。迫切需要可持续的艾滋病毒服务供资模式。
