Limited user fees for adult HIV diagnosis and routine laboratory monitoring in the global IeDEA consortium: analysis in 42 countries.

Introduction: While HIV services have scaled up dramatically under universal treatment recommendations, availability of routine laboratory services for HIV diagnosis and management, and the extent to which user fees are charged for these services, are not well documented. We described site-level availability and user fees for adult HIV laboratory testing among 238 sites in 42 countries of the International epidemiology Databases to Evaluate AIDS (IeDEA) global consortium, and contextualized practices by site- and country-level characteristics, including country income level and receipt of Global Fund or PEPFAR support. Methods: Availability of HIV-related laboratory services and charging of user fees, were examined via an IeDEA site assessment survey conducted September 2020-March 2021, with responses reflecting practices in 2019. Laboratory services examined included: HIV-1/HIV-2 antigen/antibody immunoassay test (HIV-1/2 Ag/Ab), HIV-1 p24 antigen test (p24), supplemental HIV-1/HIV-2 antibody differentiation immunoassay (HIV-1/2 Ab suppl), quantitative PCR for HIV viral load (VL), HIV-1 genotypic drug resistance testing (genotyping), and CD4 count testing (CD4). Availability was defined as provided on-site in the HIV clinic or within the same health facility. User fees were fees other than insurance co-pays paid for a given test, conditional on their on-site availability. We reported frequencies and percentages of site-level availability and user fees, overall and by site- and country-level characteristics. Results: Most sites (88%) reported HIV-1/HIV-2 Ag/Ab availability on-site, while fewer than half of sites reported having p24 and HIV-1/2 Ab suppl available. Approximately half of sites reported VL and CD4 testing availability, while less than one-third of sites (28%) reported genotyping availability. The percentage of sites reporting user fees ranged from 6.5% (HIV-1/2 Ag/Ab) to 10.5% (CD4). A higher percentage of sites reporting user fees were from upper-middle income countries, countries receiving any Global Fund or any PEPFAR country support, and the Asia-Pacific region. Conclusions: While most HIV care sites participating in IeDEA did not charge user fees for HIV-related laboratory tests in 2019, on-site availability of such tests was limited. Continued action to identify and address constraints in the routine provision of these laboratory services is critical for appropriate management of HIV.