Article

Decentralization of HIV care in Cameroon: Increased access to antiretroviral treatment and associated persistent barriers

INSERM, U912 (SE4S), Marseille, France.
Health Policy (Impact Factor: 1.73). 05/2009; 92(2-3):165-73. DOI: 10.1016/j.healthpol.2009.03.006
Source: PubMed

ABSTRACT The national antiretroviral treatment (ART) program in Cameroon has reached one of the highest rate of coverage in Western and Central Africa (58% of the estimated eligible HIV-infected population in June 2008).
To assess the extent to which decentralized delivery of HIV care at the district level has contributed to increased access to ART.
Comparison of ART-treated and non-ART-treated in the sub-sample of medically eligible HIV-positive patients (n=2566) in the cross-sectional ANRS-EVAL survey was carried out among patients seeking HIV care in 14 hospitals at central level (Yaoundé, Douala and capitals of 8 provinces) and 13 at district levels. Logistic regressions and multivariate analysis were carried out to identify factors related to non-access to ART at both levels of care.
Only 7% of eligible patients did not have access to ART. After adjustment for time since initial HIV diagnosis and CD4 counts (at initiation of treatment for those ART-treated and at time of survey for those who were not), younger and male patients, as well as those who only had a primary level education were less likely to be ART-treated at central but not at district level, whereas those who were unemployed were less likely to be treated at both levels. Patients were less likely to be treated in central hospitals with higher workload per medical staff member and absence of task shifting policy, and in district hospitals with non-availability of equipment for CD4 counts and larger size (150 beds or more).
Main persisting barriers in access to ART in Cameroon are rather due to insufficient access to HIV testing and difficulties in patients' referral to ART delivery centers after HIV diagnosis, since the overwhelming majority of eligible patients already seeking HIV care had effective access. However, health systems strengthening (HSS) is still needed to overcome some remaining barriers in access to ART and to guarantee its long-term sustainability.

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    • "These changes were instituted to improve access to HIV care. Consequently, an increased number of patients are receiving ART [16,17] but the outcomes of these patients before and after these interventions are not known in terms of morbidity and mortality. "
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    ABSTRACT: Access to Human Immunodeficiency Virus (HIV) care has been rolled out in Cameroon in the last decade through decentralised delivery of care and timely initiation of free antiretroviral drugs. We sought to describe the evolution of mortality and loss to follow up (LTFU) and their patient-related determinants at an HIV clinic which is facing significant challenges. A retrospective review of point of care data from HIV patients was conducted in June 2012 at Nkongsamba Regional Hospital in Cameroon to establish mortality and LTFU rates. Univariable and multivariable Cox regression models were used to screen for factors associated with the outcomes. Telephone calls were made to trace patients LTFU. Between June 2005 and December 2010, 2388 HIV infected patients were admitted. Of these, 1858 were aged 15 and above and were included in our analysis. Their median age was 36 years (IQR: 30-44) and they were followed up over a total risk period of 3647.3 person-years (pyrs). The overall mortality rate was 34.6 deaths per 1000 pyrs (95%CI: 29.0-41.1) while the overall LTFU rate was 94.6 per 1000 pyrs (95%CI: 85.1-105.1).The mortality rates steadily rose to a peak of 69.6 deaths per 1000 pyrs in 2009 and then fell drastically to 20.6 per 1000 pyrs in 2010. The LTFU rate increased sharply from 29.7 in 2006 to 138.2 in 2007 and remained virtually stable until 2010. The factors associated with mortality were: being male (aHR = 2.25, 95%CI: 1.58-3.19), clinical disease progression (aHR = 2.0, 95%CI: 1.58-2.53), CD4 count <200 cells/mul (aHR = 3.14, 95%CI: 1.27-7.73), haemoglobin level <10 g/dl (aHR = 2.50, 95%CI: 1.69-3.69). Major factors associated with high LTFU rate were: distance to clinic of over 5 km (aHR = 1.25, 95%CI: 1.00-1.55), being single, having partners with unknown HIV status or taking no treatment and with CD4 count >500 cells/mul. Two- thirds (66.7%) of traced LTFU patients were dead. Mortality and LTFU rates in our cohort were high but there is evidence that patients' outcomes are improving. Interventions to address factors associated with high mortality and LTFU should be implemented for optimal results in patient care.
    BMC Research Notes 12/2013; 6(1):512. DOI:10.1186/1756-0500-6-512
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    • "[16]. In this setting where HAART coverage is low [17] and HIV patients still present with severe immune deficiency, TE might be a major cause of morbidity and mortality whose real picture is still unclear. This therefore calls for systematic primary anti-toxoplasma prophylaxis for patients with low CD4 counts. "
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    ABSTRACT: Background It is estimated that about a third of the world’s population is chronically infected with Toxoplasma gondii. Toxoplasma encephalitis (TE), which occurs as a reactivation of quiescent chronic infection, is one of the leading causes of central nervous system (CNS) infection in AIDS. Its diagnosis in most centres still remains difficult. We opted to describe the clinical and radiological features of TE as well as in-hospital outcome and its associated factors. Methods We carried out a cross sectional study on the clinical case notes of adult patients admitted and treated for TE at the Douala General Hospital, Cameroon between January 1st 2004 to December 31st 2009. Results Of 672 patients admitted during the study period, 14.4% (97/672) had TE. The mean age was 36.9 ± 14.1 years and the median CD4 cell count was 68/mm3 (IQR): 43 – 103). Headache and fever were the most common presenting symptoms in 92.8% (90/97) and 87.6% (85/97) of patients. Annular contrast enhanced lesions were the most common brain scan finding in 81.4% (79/97) of patients. In-hospital mortality was 29.9% (29/97). Altered sensorium, presence of focal signs, neck stiffness and low CD4 cell count were factors associated with mortality. Adjusting for low CD4 count, altered sensorium remained strongly associated with fatality, adjusted odd ratio (AOR) 3.5 (95% CI 1.2 – 10.5). Conclusion Toxoplasma encephalitis is common among AIDS patients in Douala. Its high case fatality warrants adequate and compliant prophylactic therapy in severely immune depressed patients as well as early initiation of antiretroviral therapy in HIV-infected patients.
    BMC Research Notes 04/2013; 6(1):146. DOI:10.1186/1756-0500-6-146
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    • "In addition, resource limited settings lack adequate diagnostic and therapeutic tools for HIV-associated CNS disease. In Cameroon where HIV prevalence among adults is estimated at 5.3% [1], and HAART coverage is low [14], the magnitude of HIV-associated CNS disease has been sparingly elucidated [15] [16]. We therefore decided to carry out a hospital-based retrospective clinical chart review of patients admitted with HIV-associated CNS disease in order to describe their clinical presentations and identify the different aetiologies, in hospital outcome and their associated factors. "
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    ABSTRACT: Background. Studies on HIV-associated central nervous system (CNS) diseases in Cameroon are rare. The aim of this study was to describe the clinical presentation, identify aetiological factors, and determine predictors of mortality in HIV patients with CNS disease. Methods. From January 1, 2004 and December 31, 2009, we did at the Douala General Hospital a clinical case note review of 672 admitted adult (age ≥ 18 years) HIV-1 patients, and 44.6% (300/672) of whom were diagnosed and treated for HIV-associated CNS disease. Results. The mean age of the study population was years, and median CD4 count was 49 cells/mm3 (interquartile range (QR): 17–90). The most common clinical presentations were headache (83%), focal signs (40.6%), and fever (37.7%). Toxoplasma encephalitis and cryptococcal meningitis were the leading aetiologies of HIV-associated CNS disease in 32.3% and 25% of patients, respectively. Overall mortality was 49%. Primary central nervous system lymphoma (PCNSL) and bacterial meningitis had the highest case fatality rates of 100% followed by tuberculous meningitis (79.8%). Low CD4 count was an independent predictor of fatality (AOR: 3.2, 95%CI: 2.0–5.2). Conclusions. HIV-associated CNS disease is common in Douala. CNS symptoms in HIV patients need urgent investigation because of their association with diseases of high case fatality.
    AIDS research and treatment 02/2013; 2013. DOI:10.1155/2013/709810
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