Monday, October 7, the Petrie-Flom Center is co-sponsoring “15+ Years of PEPFAR: How U.S. Action on HIV/AIDS Has Changed Global Health,” from 8:30 AM to 6:00 PM. The event is free and open to the public, but registration is required. This event is cosponsored by the Harvard Global Health Institute, the Harvard University Center for AIDS Research, the Center for Health Law Policy and Innovation at Harvard Law School, and the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School.
By Prosper Okonkwo
HIV diagnosis in Sub Saharan Africa in the nineties and early 2000s was literally a death sentence. This was either due to one or a combination of ignorance, denial, and weak health systems.
A few focusing events and the return to democratic rule in 1999, acted as fillip, jump-starting the national response, albeit modestly. In 2001, 10,000 adults and 5,000 children were placed on antiretrovirals (ARVs) at the cost of $7 a month. This was at a time when sourcing these drugs privately cost about $350 monthly in a country with a GDP per capita of less than $750, less than 5% health insurance coverage, and with about 80% of health expenditure paid out of pocket.
With commencement of PEPFAR in 2004, these 15,000 patients were rolled over to the program, which was more robust with better monitoring opportunities. Those awaiting treatment, who had been hoping that the few patients accommodated in the program dropped off (usually by dying), so they could possibly get slotted in, were now being enrolled into the treatment program.
From about only 25 sites in Nigeria in 2001, the number of antiretroviral treatment (ART) sites have increased to more than 1000, and prevention of mother-to-child transmission
(PMTCT) sites have increased to more than 6,500. The majority of these sites are PEPFAR funded sites. Currently, AIDS Prevention Initiative Nigeria (APIN) is supporting 664 sites (ART sites=339; PMTCT sites 325) through PEPFAR/CDC in eight states in Nigeria.
The number of people on treatment continues to increase to more than 1.1 million currently, with PEPFAR accounting for about 75% of these numbers. This number represents more than 150-fold increase since inception in 2004. APIN supports about 28% of the people living with HIV (PLHIV) in the PEPFAR program in Nigeria.
The proportion of infected individuals in Nigeria has dropped from 5.1% when PEPFAR started to 1.4% in 2018, though there are wide geographical differences, an indication of micro epidemics with diverse enablers within the larger national epidemic. This has necessitated focused, targeted, and epidemiologic data driven interventions.
The PEPFAR program has positively impacted the health systems in Nigeria, which were moribund at the inception of the program.
On the leadership and governance fronts, state actors are better able to coordinate and manage community-based efforts. Indigenous non-state actors are now well positioned to apply for and manage grants, particularly providing fiduciary oversight and so ensuring transparency and accountability.
The program also supported the entrenchment and unification of nationally robust commodity logistics management systems, resulting in the integration of supply chains for HIV, TB, malaria, and family planning commodities with attendant improved efficiencies.
Great revolution was witnessed in data management, with paper based, poorly organized medical record systems now being either a hybrid of electronic and manual, or in most cases, fully electronic. Quality and accountability are enhanced as the national data repository allows real time assessment of clinical experiences and outcomes. The patient biometric system (PBS) is helping to avoid patients’ duplication and misidentification. APIN is leading in PBS deployment in Nigeria, with 100% site deployment and about 85% of the clients under its care already captured. With inbuilt consenting processes and functional IRBs, the data from these programs had supported many completed and ongoing research grants and postgraduate dissertations. With availability of good quality data, most program decisions are now evidence driven.
Health workforce development and continuous improvement remains a prime focus of the PEPFAR programs, and like other systems issues, these gains transcend the entire health sector and not just HIV/AIDS. After our health systems support at a district hospital, the physician who used to drive more than 40 kilometers to send emails at cybercafés in the city, could now do so at the center, leveraging the IT systems installed for data management. More surgeries were now possible, since the power generating sets for the lab and data management also powered the theater which did not have regular power previously.
The transformation of laboratory systems had ensured that dilapidated labs — and in some cases, just empty spaces like carpenter sheds — had been converted to state of the art laboratories, with capacities ranging from basic serology to resistance testing for patients.
Part of the unfinished agenda includes maintaining the gains of PEPFAR by increased demonstrated government ownership of the programs, through increasing support, which presently stands at about 20%. As the PEPFAR program undergoes realignment toward sustainability, the patients are struggling to pay out of pocket for some service elements, while government fully articulates its plans. This is impeding access and leading to patient attrition. With better quality data from the recently concluded population-based HIV surveys, the national response is now better focused towards epidemic control.
Many lessons learnt are being ploughed back into planning and implementations of other programs to avoid some unintended negative consequences of the PEPFAR program, which overall has been truly transformative of the Nigerian health system.
Prosper Okonkwo is a Research Associate in the Department of Immunology and Infectious Diseases at the Harvard T.H. Chan School of Public Health.