Decentralization of HIV care in Cameroon: Increased access to antiretroviral treatment and associated persistent barriers
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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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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ABSTRACT: Introduction Tuberculous meningitis (TBM) the most fatal presentation of tuberculosis (TB) especially in HIV-infected patients is a real diagnostic and therapeutic challenge worldwide. In Cameroon where HIV and TB are amongst the leading public health problems, the magnitude of TBM has not been defined. Therefore, the objective of this cross sectional study was to describe the presentation and in-hospital outcome of TBM among HIV patients in Douala as well as its diagnostic difficulties. Methods We did a clinical case note analysis of all HIV-1 infected patients treated for TBM in the Internal medicine unit of the Douala General Hospital, between January 1st 2004 and December 31st 2009. The diagnosis of TBM was made using clinical, laboratory [cerebrospinal fluid (CSF) analysis] and/or brain computerised tomographic (CT) scan features. Results During the study period, 8% (54/672) of HIV-infected patients had TBM. Their mean age was 40.3 ± 12.7 years. The main presenting complaint was headache in 74.1% (40/54) of patients. Their median CD4 cell count was 16 cells/mm3 (IQR: 10 – 34). CSF analysis showed median protein levels of 1.7 g/l (IQR: 1.3 – 2.2), median glucose level of 0.4 g/l (IQR: 0.3 – 0.5) and median white cell count (WCC) count of 21 cells/ml (IQR: 12 – 45) of which mononuclear cells were predominant in 74% of CSF. Acid fast bacilli were found in 1.9% (1/54) of CSF samples. On CT scan hydrocephalus was the main finding in 70.6% (24/34) of patients. In hospital case fatality was 79.6% (43/54). Conclusion TBM is a common complication in HIV-infected patients in Douala with high case fatality. Its presumptive diagnosis reposes mostly on CSF analysis, so clinicians caring for HIV patients should not hesitate to do lumbar taps in the presence of symptoms of central nervous system disease.AIDS Research and Therapy 06/2013; 10(1):16. DOI:10.1186/1742-6405-10-16 · 1.84 Impact Factor
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ABSTRACT: In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services.BMC Health Services Research 08/2014; 14(1):352. DOI:10.1186/1472-6963-14-352 · 1.66 Impact Factor