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

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 %

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

18. WHAT ARE OUR FINDINGS SO FAR

19. Income of HIV+ patients in the Lagos General Hospital USD

20. What do patients pay for ART in non- MSF-sites ? 122 experienced patients interviewed : Average costs = 40 USD

21. 88 34 NUMBER OF PATIENTS WITH TREATMENT INTERRUPTION NUMBER OF PATIENTS WITHOUT TREATMENT INTERRUPTION 27.8 % 72.1 %  72% of all ARV experienced interviewed people had ART interruption  average cumulative interruption time: 6 month  8 % shared the ARVs with their partners ART Interruption in Patients with ARV Experience n= 122

22. Reasons why ART was stopped 61% 14% 6% 17% 1% 0% FINANCE out of govt.stock SIDE EFFECTS SOCIAL HEALTH OK FAILURE IMPROVE OTHER  Results of ARV-Questionnaire (n= 88)

23. Sources of financing ART

24. Have you ever experienced a financial crisis due to expenses for ART ? 83% 8% 4% 3% 2% YES Severe YES Medium YES Light Could not qualify Pat. Answered with NO N=114

25. Comparing ARV Naive and ARV Experienced patients at baseline ParameterExperienced (n=113), 13.8 % Naive (n=703) CD4 (cell/microl) 313 138 Weigh t (kg) 62 57 former time on ART( Mo) 13 (IQR:7,24) 0 regimens AZT-3TC-NVP (49%) D4T-3TC-NVP (30%) AZT-3TC (15 %) ---------------

26. naive and experienced patients after 3-6mo P<0.001 P=.0023 % % % % N= 237N= 807

27. Virological outcomes after 6-12 months of ART (n=158) ART experienced (% of patients) ART naïve (% of patients) < 1000 copies/ml 6372 1000-10,0001523 > 10,000 *225 * OR 6.0, 95% CI 1.8-20.2, p=0.004

29. Pill Counts November 2005 Lagos Project 88 6 5 1 0 10 20 30 40 50 60 70 80 90 % of patients >95 % adherence, 0-5 % pills missed 95- 90 % adherence, 5-10% pills missed 90-80 % adherence, 10-20% pills missed < 80 % adherence, >20% pills missed Adherence estimated by pill counts, n=329

30. Failing ARV-exp. Patients genotyping: 77 % resistance n=13

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 1 st line therapy appear worse than among naives, probably due to ARV resistance

33. Acknowledgements: Daniel O`brien (AMS) Kamalini (AMS) Tom Ellman (London) Wilma (Medco) Francois( HoM) Kai Braker, Berlin Bernadette Olomo Els St.-Botha whole team in Lagos Philomina Orji Team at BCCfE in Vancouver, David Tu