Financial burdens of HIV and chronic disease on people living with HIV in Côte d'Ivoire: A cross-sectional out-of-pocket expenditure study.

BACKGROUND: Although people living with HIV in Côte d'Ivoire receive antiretroviral therapy (ART) at no cost, other out-of-pocket (OOP) spending related to health can still create a barrier to care. METHODS: A convenience sample of 400 adults living with HIV for at least 1 year in Côte d'Ivoire completed a survey on their health spending for HIV and chronic non-communicable diseases (NCDs). In addition to descriptive statistics, we performed simple linear regression analyses with bootstrapped 95% confidence intervals. FINDINGS: 365 participants (91%) reported OOP spending for HIV care, with a median of $16/year (IQR 5-48). 34% of participants reported direct costs with a median of $2/year (IQR 1-41). No participants reported user fees for HIV services. 87% of participants reported indirect costs, with a median of $17/year (IQR 7-41). 102 participants (26%) reported at least 1 NCD. Of these, 80 (78%) reported OOP spending for NCD care, with a median of $50/year (IQR 6-107). 76 participants (95%) with both HIV and NCDs reported direct costs, and 48% reported paying user fees for NCD services. Participants had missed a median of 2 HIV appointments in the past year (IQR 2-3). Higher OOP costs were not associated with the number of HIV appointments missed. 21% of participants reported spending over 10% of household income on HIV and/or NCD care. DISCUSSION AND CONCLUSIONS: Despite the availability of free ART, most participants reported OOP spending. OOP costs were much higher for participants with co-morbid NCDs.

Results from a rapid national assessment of services for the prevention of mother-to-child transmission of HIV in Côte d'Ivoire.

INTRODUCTION: Loss-to-follow-up (LTFU) in the prevention of mother-to-child HIV transmission (PMTCT) programmes can occur at multiple stages of antenatal and follow-up care. This paper presents findings from a national assessment aimed at identifying major bottlenecks in Côte d'Ivoire's PMTCT cascade, and to distinguish characteristics of high- and low-performing health facilities. METHODS: This cross-sectional study, based on a nationally representative sample of 30 health facilities in Côte d'Ivoire used multiple data sources (registries, patient charts, patient booklets, interviews) to determine the magnitude of LTFU in PMTCT services. A composite measure of retention - based on child prophylaxis, maternal treatment and infant testing - was used to identify high- and low-performing sites and determine significant differences using Student's t-tests. RESULTS: Among 1,741 pregnant women newly recorded as HIV-positive between June 2011 and May 2012, 43% had a CD4 count taken, 77% received appropriate prophylaxis and 70% received prophylaxis intended for their infant. During that time, 1,054 first infant HIV tests were recorded. A conservative rate of adherence to antiretroviral therapy was estimated at 50% (n=219 patient charts). Significant differences between high- and low-performing sites included: duration of time elapsed between HIV testing and CD4 results (29.5 versus 56.3 days, p=0.001); and density (number per 100 first antenatal care visits) of full-time physicians (6.7 versus 1.7, p=0.04), laboratory technicians (2.3 versus 0.7, p=0.046), staff trained in PMTCT (10.7 versus 4.7, p=0.01), and staff performing patient follow-up activities (7.9 versus 2.5, p=0.02). Key informants highlighted staff presence and training, the availability of medical supplies and equipment (i.e., on-site CD4 machine), and the adequacy of infrastructure (i.e., space and ventilation) as perceived key factors positively and negatively impacting retention in care. CONCLUSIONS: Patient LTFU occurred throughout the PMTCT cascade from maternal to infant testing, with retention scores ranging from 0.10 to 0.83. Sites that scored higher had more dedicated and trained frontline health workers, and emphasised patient follow-up through outreach and the reduction of delays in care. Strategies to improve patient retention and decrease transmission should emphasise patient tracking systems that utilise critical human resources to both improve data quality and increase direct patient follow-up.