Facility-Level Structural Drivers of HIV Treatment Outcomes: A Multi-Level Analysis of 27,288 Patients from a Nigerian HIV Programme and Implications for PEPFAR and Global Fund Programming
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Objective
To identify facility-level characteristics — including care level, ownership type, and funding model — associated with poor HIV treatment outcomes, and quantify their independent contributions after adjustment for patient-level clinical factors.
Design
Retrospective cross-sectional analysis using multivariable logistic regression with HC3 cluster-robust standard errors to account for facility-level clustering.
Setting
HIV care facilities in the Nigerian national HIV programme, spanning primary health centres, secondary health facilities, and tertiary hospitals.
Participants
27,288 HIV-positive patients enrolled on ART, from a publicly available de-identified Quality of Care dataset.
Main outcome measures
Composite poor outcome (poor ART adherence, treatment interruption, or mortality); individual outcomes including poor adherence rate, mortality, ART interruption, and diagnosis-to-ART delay exceeding 90 days.
Results
Primary health centres had 15.4% composite poor outcome versus 10.2% at tertiary hospitals. After adjustment for patient age, sex, WHO stage, and CD4 count, primary health centre patients had 95% higher odds of poor outcome (OR=1.95; 95%CI 1.45-2.61; p<0.001). NGO-funded facilities had 24% higher odds (OR=1.24; 95%CI 1.10-1.39; p<0.001) and federally funded facilities 25% higher odds (OR=1.25; 95%CI 1.06-1.48; p=0.008). Female sex was independently protective (OR=0.87; 95%CI 0.79-0.96; p=0.003). Diagnosis-to-ART delays exceeded 90 days in 47.3% of patients, with significant variation by facility level (chi-squared=49.4, p<0.001).
Conclusions
Facility level and funding model independently predict HIV treatment outcomes after patient-level adjustment. Primary health centres and NGO/federally funded facilities may require targeted quality improvement support. These findings have direct implications for PEPFAR, the Global Fund, and national HIV programme managers.
Summary Box
What is already known on this topic
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HIV treatment outcomes vary across health system levels in sub-Saharan Africa, with primary facilities generally underperforming tertiary institutions.
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Funding source and ownership type have been hypothesised as quality drivers, but confounding by patient clinical severity has rarely been controlled for in large observational studies.
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The independent contribution of facility-level structural characteristics to HIV outcomes remains poorly quantified.
What this study adds
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Primary health centres have 95% higher adjusted odds of composite poor HIV outcome versus tertiary hospitals (OR=1.95, p<0.001), independent of patient clinical severity.
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NGO and federal government funding are independently associated with worse outcomes — a counterintuitive finding that may reflect higher case complexity or structural resource constraints.
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These findings provide evidence-based targets for facility-level quality improvement investment in PEPFAR and Global Fund-supported programmes, starting with the Nigerian context and pending external validation in other settings.
