1 INTRODUCTION

The high cost of healthcare has been known to pose a significant financial burden on individuals and households, particularly those residing in low- and middle-income countries [1, 2]. Individuals with HIV and AIDS are not exempted due to their lifelong medication and treatment requirements, making healthcare costs even more challenging to bear. In many regions, healthcare costs create a barrier to accessing treatment, thereby preventing people living with HIV/AIDS from receiving the necessary care. For instance, as much as 70% of Nigerians rely on out-of-pocket (OOP) expenditures to finance their healthcare [1, 2]. These OOP payments become catastrophic when households sacrifice their basic needs to pay for healthcare expenses, leading to financial hardships [1].

The World Health Organization (WHO) has recently recommended that health expenditures should not exceed 10% of total household consumption or 25% of income [3]. However, over 150 million individuals are incurring catastrophic health expenditure (CHE), with more than 100 million sliding into poverty due to OOP payments for healthcare [3]. Interestingly, the focus on financial protection can help prevent households from experiencing financial hardships from healthcare expenses. In 2005, the Nigerian Federal Government launched the National Health Insurance Scheme to provide financial risk protection for Nigerians seeking healthcare, and in 2022, the National Health Insurance Authority Act, 2022 was signed into law to provide an oversight and regulatory function for Health Insurance Schemes in Nigeria [4, 5]. However, only a small percentage of Nigerians are health insured, with most being Federal Government workers [4]. HIV/AIDS is a global epidemic affecting over 84.2 million individuals, with approximately 40.1 million deaths recorded, and has been found to impose financial hardship on clients [6]. As of 2021, about 38.4 million individuals were living with HIV worldwide [6], with two-thirds residing in sub-Saharan Africa with Nigeria ranking fourth globally in terms of HIV burden [7, 8]. According to the Nigeria AIDS Indicator and Impact Survey, the prevalence of HIV in Nigeria is 1.4% (NAIIS 2022). Of the 1.4% infected with HIV, Akwa-Ibom state (in the South-south zone) has the highest prevalence of 5.6%, while Katsina state (in the North-west zone) has the lowest prevalence of 0.3% with Lagos sitting with the highest prevalence in the South-west with a prevalence of 1.3% [9].

Poverty and HIV/AIDS are interrelated, with poverty being a significant factor in HIV and AIDS transmission [10, 11]. HIV and AIDS can lead to poverty and may worsen existing poverty.

Developing countries like Nigeria have little or no social security systems for the poor and vulnerable individuals, making the financial impact of HIV more severe in Nigeria than in developed countries. The primary sources of finance for the health sector in Nigeria are the three tiers of government, public general revenue from various forms of taxation, health insurance institutions, the private sector, and donors, with out-of-pocket payments also contributing significantly. Studies show that households affected by HIV/AIDS have lower income levels than those without the disease, with increased health expenditures, loss of productivity, and asset sales associated with HIV-affected households [11-13]. It has been proven that OOP expenses, comorbidities, low socioeconomic status, and transportation costs are significant contributors to CHE among HIV patients in Nigeria [14].

In light of the above-identified findings combined with the existing studies on the economic burden of HIV and AIDS on households in some states in Nigeria, there is still a paucity of knowledge as regards the extent of financial hardship vis-a-vis. catastrophic health expenditure and the specific contributory factors to it among people living with HIV (PLHIV) in Lagos, hence the contribution of this study. It aimed to determine the CHE among PLHIV in Lagos and identify factors associated with CHE amongst them. Through this research, we aimed to deepen our understanding of the challenges faced by PLHIV and AIDS and to inform policy and practice in the provision of healthcare services.

2 METHODOLOGY

3 RESULTS

About 30.5% of respondents were less than 30 years old, 59% were females at birth, and close to 61% were females after birth. More than half (52.9%) were either unskilled workers or unemployed, and nearly 6% were sex workers. About 83% reported that they had excellent or very good health status, while approximately 35% earned ₦30,000 ($42.6) or less as personal monthly income, and the majority (92%) reported that they had no household monthly income. About 10% were homosexual, and a majority (70.2%) did not belong to any of the groups (Table 1).

The respondents incurred a mean consultation cost of N662 ($1.2) for outpatient and inpatient services over the past 12 months. The 5th–95th percentile ranged from N0 to N8000. The mean monthly expenditure was N29,282 ($53.2) on food and N8364 ($15.2) on healthcare. The 5th–95th percentile for monthly food spending was N4350 ($8) to N95,500 ($174). For monthly healthcare spending, the range was N0–N30,000 ($55) (Table 2).

Close to 60% of respondents experienced catastrophic healthcare expenditures, while about 40% did not. Approximately 30% of respondents borrowed money to pay for some of their treatments. Almost all (96%) had no health insurance. About 30.3% said that sometimes the cost of transportation made it difficult for them to get to their health clinic (Table 3).

Gender at birth, gender after birth, and occupation were found to be statistically significantly associated with catastrophic health expenditure among the respondents. Approximately 61% of those who were female at birth (vs. 49% males) and close to two-thirds (63.7%) who were unskilled/unemployed respondents (vs. skilled [54%], professionals [50%]) experienced catastrophic healthcare expenditure, p < 0.05 (Table 4).

Respondents whose personal income was less than or equal to ₦30,000 ($42.6) experienced high (72%) catastrophic healthcare expenditure as compared to those who earned higher (₦31,000–60,000; 52%, >₦60,000; 27%). Respondents' group, perception of current health status, and the number of people in their households were significantly associated with catastrophic health expenditure p < 0.05 (Table 4).

PLHIV in the racial/ethnic minority/migrant group and those who earned less than ₦30,000 ($55) were statistically significantly associated with catastrophic healthcare expenditure at p < 0.001 with OR 28.7 and 3.15, respectively (Table 5).

4 DISCUSSION

The delivery of the healthcare system is being faced with a lot of inequalities, with CHE serving as a fundamental challenge to it. Evaluating the incidence and intensity of HIV-related CHE will help in providing insight into the UHC and also reflect the economic burden of HIV on patients and their families [17, 18].

There was a predominance of female respondents of 59.2% in this study, which is consistent with the outcome obtained from another study in Nigeria with 60% females. It was also found that the healthcare expenditure catastrophic was 57%, similar in percentage to what was reported in another study [17], but higher than what was observed in some other sub-Saharan countries [19-21]. This is also higher than the CHE in the general Nigerian population [22]. The high catastrophic health expenditure is potentially a consequence of health system reforms not being actualized, along with limited aid for accessing healthcare services [20, 23]. There is a pressing need in Nigeria for innovative social safety net programs to help households manage routine healthcare needs and emergencies. The increased risk and vulnerability to incurring CHE as seen in this study have important policy implications and have also been brought to the fore in prior studies [19, 20, 23].

Another key aspect is healthcare insurance enrollment, which was very low (4%) in this study. This low value was similar to what was observed in other low- to medium-income countries [17, 24]. This study found that health insurance status did not have a statistically significant association with catastrophic health expenditure among respondents, similar to the finding from a study in Iran [23]. This suggests that other factors, such as the cost of healthcare services, household income level, and higher expenses for transportation, food, and accommodation related to inpatient and outpatient care, may exert a greater influence on the risk of catastrophic spending on health. It is therefore critical that the government implement policies to minimize inequities in welfare provision across the nation.

Furthermore, this study revealed that nonmedical-related costs like transportation fares, which are invariably greater for the poor living far from health facilities, food-related costs, nonroutine tests, and inadequate care in primary health care facilities largely influence CHE, consistent with findings from other studies [20, 25]. Adherence to ART medications was again affected by the need for frequent visits, which led to CHE from increased transportation costs. Likewise, the higher use of patients' savings (37.7%) for healthcare in HIV services in this study was in agreement with what was found in a study where being a patient and a payer for medical bills increased susceptibility to the CHE. People with poor household incomes face more burdens of CHE, which is a hindrance to the attainment of UHC as more households of poor status are further pushed into poverty [26-29]. Poverty is both a cause and a consequence of HIV/AIDS. Poverty increases vulnerability to HIV infection, while HIV/AIDS can lead to or exacerbate poverty. These findings highlighted the urgent need to recommend that policymakers increase public healthcare funding and implement social health protection programs to completely replace OOP health payments, especially among PLHIV. Such actions would provide financial risk protection, which is currently lacking for many households in Nigeria [27]. This study also observed that there was a statistically significant association between respondents' occupation, perception of health status, household size, income, and incurring CHE. The occupation of the household members may impact their access to health insurance and healthcare services. Furthermore, respondents who perceived their health status to be poor may face an increased risk of catastrophic health expenditure since their greater healthcare needs and expenses lead to higher healthcare costs. The size of the household may also affect the risk of catastrophic health expenditures, as larger households may have more healthcare expenses to cover. Moreover, the total salary earned by households can impact their capacity to pay for healthcare expenses, since higher incomes may offer greater financial flexibility and the ability to allocate resources.

Overall, these findings suggest that multiple factors can influence the risk of catastrophic health expenditure and that policies and interventions aimed at reducing this risk may need to consider a range of economic and social factors beyond health insurance coverage alone.

The study focused only on a specific geographic region (South Western Nigeria) and a specific population (people living with HIV/AIDS), which may limit the generalizability of the findings to other regions or populations. The study used a cross-sectional design, which means that it was conducted at a single point in time and cannot establish causality or examine changes over time.

5 CONCLUSION

This study found that a significant proportion of PLHIV in South West Nigeria incurs CHE, which can have severe consequences for their health and well-being. Also, households with lower economic status, poorer perception of current health status, larger household sizes, and lower salaries were at higher risk of experiencing CHE. Also, we found a very low health insurance uptake among respondents, even though their health insurance status did not have a statistically significant effect on the likelihood of experiencing CHE.

Our recommendations include expanding access to responsive health insurance, extending funding for HIV support programs, especially for transportation, feeding, and accommodation during the clinic visits of PLHIV, improving economic opportunities for households, increasing public awareness of HIV/AIDS and its treatment, and conducting further research to better understand the drivers of CHE among PLHIV.

AUTHOR CONTRIBUTIONS

Adeyinka Adeniran: Conceptualization (lead); Data curation (equal); Formal analysis (equal); Investigation (equal); Methodology (lead); Project administration (lead); Supervision (equal); Validation (lead); Writing—original draft (equal); Writing—review & editing (equal). Omobola Y. Ojo: Methodology (equal); Writing—original draft (equal); Writing—review & editing (equal). Florence C. Chieme: Data curation (equal); Formal analysis (lead); Visualization (equal); Writing—review & editing (equal). Yeside Shogbamimu: Conceptualization (equal); Investigation (lead); Methodology (equal); Project administration (equal); Resources (equal); Supervision (lead); Writing—review & editing (equal). Helen O. Olowofeso: Conceptualization (equal); Funding acquisition (lead); Investigation (equal); Methodology (equal); Project administration (lead); Resources (lead); Supervision (lead); Writing—review & editing (equal). Imane Sidibé: Conceptualization (equal); Funding acquisition (lead); Investigation (equal); Resources (lead); Writing—review & editing (equal). Oladipupo Fisher: Funding acquisition (equal); Investigation (equal); Resources (equal); Writing—review & editing (equal). Monsurat Adeleke: Funding acquisition (equal); Investigation (equal); Project administration (equal); Resources (equal); Supervision (equal).

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

ETHICS STATEMENT

The study protocol was approved by the Health Research Ethics Committee of the Lagos State University Teaching Hospital Ikeja with approval number LREC/06/10/1390.

INFORMED CONSENT

An electronic/paper-based written consent was obtained from each respondent with the assurance of confidentiality of the information and their right to withdraw from the study at any point in time.