3 December 2018

Nigeria: HIV Treatment - User Fees, Not Virus Killing Nigerians - Ibrahim Umoru

On the 2018 World AIDS Day with the theme: "Know Your Status", Chioma Obinna spoke to a member of Peer Review Forum, Mr. Ibrahim Umoru, on the major challenges of HIV treatment, control and prevention efforts in the country.

Umoru, who has lived with HIV for almost 20 years, asserts that except the government removes user fee and States devote 0.5 -1 percent of their budget to HIV response, ending the epidemic by 2030 will remain a mirage. Excerpts:

The Nigeria AIDS response has greatly been shouldered by donors. We have about 1.1 million people on treatment over 870 of them are supported by the US government. Then, over 200 are supported by Global Fund while the Nigerian government only supports less than 100. That is how bad it is.

In 2010, the Nigerian government signed a PEPFAR partnership framework where the government was to support the AIDS response by 50 per cent but they never delivered. By 2015, the Federal government has not gone up to 15 per cent. So by 2015, the PEPFAR team which funds most of our treatment said they don't have enough fund but they are going to reduce their support.

So what they did was to reduce funding support for laboratory investigations. When somebody is on antiretroviral, there are basic fundamental laboratory tests the person must undergo.

That is what we call the baseline tests which are done every three months and six months. And this includes chemistry and haematology tests. So when the US government stopped funding these tests, the facilities, in turn, say they don't have reagents, so they used that idea to start collecting money to do all these tests.

What US government was expecting was that as they were removing that the federal government will take it up but they didn't. That is the genesis of the problem. Trust our people, Nigerians have abused it.

When you now go to those facilities which used to be Global Fund sites they will tell you that the Federal government is not supporting them so you must pay. It is so bad that some of the facilities in Lagos will ask you to come and pick up your drugs and they charge you up to N3, 000 just to pick your drugs.

Introduction of user fees

In a particular hospital in Lagos for you to see a doctor and do a consultation with a doctor, they charge you N7, 000. It used to be a global fund site. The government has refused to take up the responsibility so they now throw it for people to pay this money from consultation, drug pickups and lab investigations.

Since 2015 we have continued to demand the removal of all forms of user fees by treatment facilities. We have consistently shown how the institution of user fees negates the rights of individuals living with HIV to access treatment and care. Worse, in 2017, PEPFAR had discouraged the user fees because of its impact on reducing access of people living with HIV's access to treatment. Ambassador Birx threatened that the countries who continue to institute these fees will face flat funding of their response from PEPFAR.

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On the 26th of November 2018, Ambassador Birx noted in her public speech that she is done pleading and will start penalizing counties like Nigeria and will freeze its programme in the country to the current level.

For a country whose response is 85 per cent dependent on donor funding - mainly PEPFAR, this is a suicidal option. We are demanding the Federal government to address the challenges associated with the institution of this user fees; and fast track action on the use of health insurance coverage to support service provision for people living with HIV. We consider these fees illegal as there is no policy provision for the payment of any type of fees by people living with HIV in Nigeria in order to access life-saving treatment.

Impact of user fees on treatment access

I am privileged to be part of the team of Medicine Sans Frontiers, we did a survey during Former President Obasanjo era when people were paying N1,000 as subsidized rate. That study showed that even at N1000 people were not still able to come for treatment because they could not pay. You can imagine now asking people to pay N3000 or N7,000 to pick up drugs or see a doctor? All these things impede access to treatment and when you default, adherence goes down and the virus will have the chance of replicating and developing resistance and you will now have increased in morbidity and mortality. That is what user fees do. It impedes access and increases mortality and morbidity for those who are already on treatment.

What are the state governments doing?

Ideally, the Global Fund does not pay staff, but it provides these things. Unfortunately, in some states, where the government does not pay salaries, you find staff going on strike. What happens, people do not receive quality care. I give an example of a particular state, I must be frank, there is this facility in Osun state and this facility is among the top 45 high burden facilities on Global Fund.

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This facility has over 1,500 patients on treatment. As we speak, there was a time they were so constraints at the laboratory and you know Lab is the backbone of HIV management but they do not have enough staff. Global Fund has to bend backwards to employ volunteers to work there.

This is happening there right now. It got worse and the roof of the facility was blown off. Monkeys from the forest come to scare people away from the clinic because the clinic is close to a forest.

The state has never responded. In Global Fund, you have principal and sub-recipients. The principal recipients have just given approval for that roof to be repaired. So what if the funders are not here at all? So we cannot even maintain our own facilities and part of the agreement we had was that if you bring in this treatment we will provide infrastructure and human resources.

Human resources, a lot of them are failing. Infrastructure a lot of them are failing. Most states do not even have a budget for HIV/AIDS. So this is criminal, bad and grossly irresponsible. That is why recently some civil society in Nigeria under the platform of accountability forum held a summit in Abuja recently and there you could see the outcry and implication of user fee.

This was very hurting, annoying and very painful. This is why this cannot continue and this is why the civil society organizations are crying out and doing everything possible to get government working.

It is grossly irresponsible to have patients every day and you depend on donor funding to treat your patients. You can imagine in African settings that a man gets married and have children every time and now depend on another man to feed the children. Is it the right thing to do? The government should wake up.

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