HIV/AIDS Service Provision Assessment 2008

HIV/AIDS continues to pose major challenges to the socioeconomic development of Nigeria. As of 2006, 2.9 million Nigerians from age 0-49 are living with HIV, and AIDS deaths have taken 220,000 lives. The government in collaboration with development partners has made tremendous progress in expanding services across the country. Much more work is needed to make sure that country has the capacity to expand and sustain services over time. Policy makers and program planners need empirical evidence on the availability of HIV/AIDS-related services in both public and private health facilities in order to effectively and efficiently increase access to care and treatment. Building on the preceding Human Resources for Health (Chankova et al. 2006) and ART Costing (Kombe et al. 2004) assessments, the Nigeria HIV/AIDS Service Provision Assessment provides evidence-based results on the infrastructure, type of services, and logistics required to support HIV/AIDS service delivery scale-up.

The objectives of the assessment were to:
• Measure the extent to which basic and advanced HIV/AIDS services are available in public and faith based facilities
• Examine facilities’ ability to provide auxiliary services
• Assess the quality of care being provided by facilities through infection control, training, reporting, and protocols
• Review facility management and administration practices

A representative national sample of 200 public and 100 faith-based facilities was selected for the survey. In January 2008, interviews following a structured questionnaire format were completed at 280 public and private faith-based facilities in all 36 states and the FCT. Data were collected on the availability of basic and advanced HIV/AIDS prevention, treatment, and care and support services, as well as laboratory and pharmacy support, staff training, and management and quality assurance practices. For almost all the key indicators analyzed, there are substantial disparities in service provision according to the level of facility, managing authority, and location. Higher-level and federally-managed facilities are the most likely to provide key services, while service provision at the primary level, in rural areas, and in LGA-managed facilities is substantially lower. Service availability at Faith-Based Organization-managed facilities matches (or slightly exceeds) that at LGA-managed facilities, but is frequently weaker than service availability at state-managed and federally-managed facilities.

The assessment examined HIV/AIDS services and HIV/AIDS related services including Counseling and Testing (CT), Prevention of Mother-to-Child Transmission (PMTCT) services, Antiretroviral Therapy (ART), Tuberculosis (TB) services, and Post-Exposure Prophylaxis (PEP) services. The study found that 77% of facilities offer HIV counseling and testing. Less than two-fifths of all facilities offer PMTCT services (39%), while less than one in six offer ART services (16%). A little under half of the facilities surveyed provide TB diagnosis and/or treatment (48%). Of significant concern is the limited availability of post-exposure prophylaxis for health workers (20%).

The availability of appropriate drugs and laboratory services is critical for the success ART programs. Despite providing the bulk of ART services, most secondary facilities (81%) did not have essential first line ARV drugs (such as AZT, EFV, 3TC, NVP, and D4T) in stock on the day of the survey. Similarly, less than one-third of all pharmacies had the first-line tuberculosis drugs – ethambutol, isoniazid, pyrazinamide, or rifampin – in stock on the day of the interview. The assessment found that approximately two-thirds of health facilities have laboratories; however, few have the capacity to measure CD4 counts (20%), viral load (2%), or conduct liver function tests (28%), and only 28% of laboratories have the necessary supplies and equipment to analyze sputum smears for diagnosis of tuberculosis.

Training on HIV counseling, testing, confidentiality practices, and prevention is available in more than half of all facilities. However, only 39% of facilities provide training on post-exposure prophylaxis. Half or fewer of all facilities have national protocols or guidelines for ART, PMTCT, and VCT available. Between 18% and 24% of facilities charge user fees for PMTCT, ART, or VCT services despite national policies that mandate free provision of these services.

The Nigeria HIV/AIDS SPA report identifies 10 conclusions based on the assessment findings. An important positive conclusion is that CT services are widely available across Nigeria; 77% of facilities sampled provided CT. However, this is not matched by secondary prevention and treatment services like PMTCT services, ART, and TB services that support individuals who have tested positive for HIV. Only 39%, 16%, and 48% of all facilities provide PMTCT, ART, and TB services, respectively.

Second, there is a great deal of heterogeneity in service availability by level, management and location of facilities. Primary-level facilities are consistently less likely to provide CT, PMTCT, ART, TB, or PEP services than secondary or tertiary facilities. This heterogeneity is also mirrored in differences by managing authority, since most primary care facilities are LGA-managed. Rural facilities also have lower service availability than urban facilities. In particular, rural facilities are 75% less likely to provide ART and half as likely to provide PMTCT as urban facilities- this is a concern since most of the Nigerian population lives in rural areas.

Third, HIV/AIDS-related service availability at Faith-Based Organization (FBO)-managed facilities slightly exceeds that at LGA-managed facilities, but is usually weaker than service availability at state-managed and federally-managed facilities. This suggests both opportunities and challenges with expanding the role of FBO-managed facilities in HIV/AIDS service delivery through public-private partnerships.

Fourth, PEP services are available in only 20% of all facilities, with especially low availability in primary level, LGA-managed, and rural facilities. Staff training on PEP is provided in almost two-fifths of facilities, but this training is not translated into PEP service availability.

Fifth, limited laboratory capacity is a critical concern in primary-level, LGA-managed and rural facilities. Among facilities that provide laboratory services, only small proportions have the equipment and supplies to perform critical tests like CD4, viral load and liver function tests. Close to three-fourths of FBO-managed facilities have laboratories, which suggests potential for public-private partnerships to expand laboratory services at lower levels of the health system.

Sixth, the availability of HIV drugs (in terms of stocks on the day of the survey) is very low, especially at primary care and LGA-managed facilities. Tertiary care facilities had widespread availability of first line ARV drugs: lamivudine, nevirapine, zidovudine, efavirenz and stavudine. However, fewer than half of all
tertiary facilities had second line drugs in stock.

Seventh, less than one-third of surveyed facilities with pharmacies had each of the key TB drugs in stock on the day of the interview. This is of great concern given increasing TB prevalence rates and HIV/TB co-infections. For diagnosis of TB, most facilities use sputum smears alone or sputum smears in combination with X-rays, although 4% of facilities that provide TB services rely only on X-rays or clinical symptoms for diagnosis.

Eighth, counseling HIV-positive mothers on infant feeding and provision of breast milk substitutes is limited at primary care facilities. As well, at the primary level there is a substantial gap between provision of ARV prophylaxis to mothers (36%) and newborns (10%) indicating an important missed opportunity for prevention.

Ninth, quality assurance, monitoring and evaluation (M&E), and surveillance are areas that require attention. A very limited proportion of facilities implement routine quality assurance activities. This is a problem in all types of facilities except federally-managed and tertiary care facilities. The limited availability of HIV/AIDS or TB protocols in facilities is potentially also indicative of the problem, as is the small proportion of facilities that provide training on monitoring and surveillance.

Tenth, user fees are charged at three-quarters of all facilities in Nigeria, though more than half of facilities that charge fees report providing exemptions to some groups. Despite a national policy that CT, ART, and PMTCT services should be provided free of charge, 18 to 24% of all facilities charge user fees for these services.

Key recommendations that emerge include the following:

1. Expand the provision of ART, PMTCT, and TB services, especially in primary-level and LGA managedfacilities that are more accessible to rural populations.
2. Ensure that PEP services are available in all facilities to protect health workers from the risk of occupational exposure.
3. Ensure the consistent availability of HIV/AIDS and TB drugs at health facilities.
4. Institutionalize quality assurance programs and M&E at health facilities, especially at secondary and primary-level facilities.
5. Explore public-private partnerships with FBOs to expand service availability to underserved populations.
6. Increase access to laboratory services, especially at the primary level.
7. Expand access to ARV prophylaxis for newborns and pregnant women, especially at the primary level and through outreach-based methods.