BACKGROUND: HIV epidemic control in West Africa has been suboptimal. Although this challenge is multifactorial, the region has some of the world's highest out-of-pocket (OOP) health expenditures, and user fees are common in the public sector. In Côte d'Ivoire (CI), the government provides free antiretroviral therapy (ART) but charged user fees for HIV treatment until early 2019.
METHODS: From March-May 2019, we used an interviewer-administered survey to evaluate OOP spending in a convenience sample of 400 adults receiving HIV treatment at 10 public health facilities in urban and rural CI. Eligibility criteria included being on ART for '¥ 1 year and missing '¥ 1 appointment in the past year. Data were analyzed using descriptive statistics, simple linear regressions, and bootstrapped confidence intervals.
RESULTS: 365/400 participants (91%) reported HIV-related OOP expenditures. 136 (34%) reported direct costs (median $2 USD/year [IQR: 1-41]), such as payments for medication, tests, hospitalization and/or supplies. No participants reported paying user fees. 349 (87%) reported indirect costs (median $17 USD/year [IQR 7-41]), primarily payment for transportation and lost wages. Excluding hospitalization costs, the median total cost (direct + indirect) was $14 USD (IQR: 5-43) per year. 15% of participants reported that they spent > 10% of their household income on HIV services.
Participants reported a median of two missed appointments in the past year (IQR: 2-3). Total OOP expenditure was not associated with the number of missed HIV appointments in a simple linear regression (95% CI -0.0004 to 0.0043). The most commonly reported reasons for missing appointments were that participants were travelling or away from home (35%); unable to leave work, school or home (26%); forgot their appointment (21%); or had transportation issues (13%). Only 7% cited OOP expenditures as a reason for missed appointments and only 5% cited costs as their primary reason for missing an appointment.
CONCLUSIONS: Almost all respondents reported OOP spending for HIV services and most of these costs were indirect; transportation was the most common expense. Although OOP spending has been associated with loss to follow up in other studies, it was not associated with missed appointments in this sample of adults retained in ART care.