66% decline in new HIV patients following introduction of user fees in Nigeria

Following the introduction of user fees in a Nigerian clinic, the number of people enrolling in HIV care fell by 66% in one year, finds a study published in PLOS One this month.

This decline was also accompanied by a four-fold (75%) decrease in the cumulative number of antiretroviral treatment (ART) doses that were dispensed over one year.

While it’s not a new concern, the findings add further evidence to the negative impact of health clinic user fees on HIV prevention and treatment services in resource-limited settings.

In 2014, Nigerian clinics introduced user fees to bridge the gap between government contributions and diminished international funding for HIV programmes. Important donors such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) had wanted countries to begin funding their own HIV programmes as part of a more sustainable approach. While Nigeria committed to increasing its contribution from 7% in 2008 to 50% by 2015 – they have fallen far short due to fiscal challenges and a lack of political will.

In a retrospective analysis of patients enrolled in care before and after the introduction of user fees in one Nigerian clinic, researchers sought to understand the impact of fee introductions. They looked at patient characteristics and enrolment trends pre- and post-user fee, as well as rates of care interruption, loss to follow-up and treatment adherence.

The study was conducted at the Nigerian Institute for Medical Research (NIMR), a PEPFAR-supported clinic located in Lagos, Nigeria which has 7,351 patients enrolled in care. In this clinic, user fees began in October 2014, with children and pregnant women exempt from charges. The fees ranged from 3 USD for HIV testing to 45 USD for new patient labs. In total, yearly user fees at NIMR are 166 USD, but 82% of Nigerians live on less than 2 USD per day.

In the years following fee introduction, the number of people tested for HIV dropped from a high of 7,360 in 2013, to 2,801 in 2015 following the first year of user fees and 2,265 in 2016. Between 2014 and 2015, there was a 66% decline in new patient enrolment each year. The demographics of the patients remained the same proportionately, with the exception of a significant increase in new patients who had secondary or tertiary education, with a greater absolute difference seen in the ‘high earner’ category of patients pre- vs. post-user fee. This indicates that the fees may have been a barrier to some accessing care for the first time.  

The analysis also looked at retention in care in the post-user-fee era. Patients who had to pay for care had a 45% reduction in the risk of interrupting care, and a 23% reduction in the risk of being lost to follow-up, compared to patients in the pre-user fee cohort. They were also more likely to have started treatment at all. The findings of improved retention and care utilisation in the post-fee era may highlight an association between personal financial investment in care and clinic attendance.

However, despite these positive health-seeking behaviours, patients who paid for ART were less likely to have optimal medication adherence, as assessed by medication pick-up from the pharmacy in the year after starting ART.

The reasons for this are not entirely clear. In their discussion, the authors hypothesised that the cumulative out-of-pocket expenses may have made treatment that little bit too expensive. These include transport costs, needing to miss work to collect their treatment or being inconvenienced by waiting times at the pharmacy.  One study from Nigeria conducted when HIV care was free to patients found that out-of-pocket expenses for HIV care accounted for 40% of healthcare expenses. Options to overcome these barriers include less intensive monitoring of stable patients, or making user-fee exemptions for children, pregnant women, elderly and patients in the lowest economic thresholds – which this clinic did.

The findings show that without investments into the quality of services provided, which aim to keep people adhering to their treatment, then the gains in care utilisation will be lost. The authors call for "creative, sustainable financing options that eliminate user fees and instead leverage mechanisms for pre-payment and risk-pooling, to support HIV care in Nigeria and other resource-limited settings.”