Abstract:
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 feebased care for historically free services. Sustainable HIV services funding models are
urgently needed.
