Self-disclosure of HIV status, disclosure counseling, and retention in HIV care in Cameroon.

Poor retention in care is common among HIV-positive adults in sub-Saharan Africa settings and remains a key barrier to HIV management. We quantify the associations of disclosure of HIV status and referral to disclosure counseling with successful retention in care using data from three Cameroon clinics participating in the Phase 1 International epidemiologic Databases to Evaluate AIDS Central Africa cohort. Of 1646 patients newly initiating antiretroviral therapy between January 2008 and January 2011, 43% were retained in care following treatment initiation. Self-disclosure of HIV status to at least one person prior to treatment initiation was associated with a minimal increase in the likelihood of being retained in care (risk ratio [RR] = 1.14; 95% confidence interval (CI): 0.94, 1.38). However, referral to disclosure counseling was associated with a moderate increase in retention (RR = 1.37; 95% CI: 1.21, 1.55) and was not significantly modified by prior disclosure status (p = .3). Our results suggest that while self-disclosure may not significantly improve retention among patients receiving care at these Cameroon sites, counseling services may play an important role regardless of prior disclosure status.

HIV infection among children and adolescents in Burundi, Cameroon, and the Democratic Republic of Congo.

Evidence demonstrates a substantial HIV epidemic among children and adolescents in countries with long-standing generalized HIV epidemics, where availability of prevention of mother-to-child transmission services has historically been limited. The objective of this research was to explore factors associated with antiretroviral therapy (ART) initiation and morbidity among HIV-infected surviving children 2-17 years of age attending HIV programs in Central Africa. Programmatic data from 404 children attending HIV programs in Burundi, Cameroon, and the Democratic Republic of Congo (DRC) were included in our evaluation. Children were followed prospectively from 2008 to 2011 according to each clinic's standard of care. Diagnosis at a reference hospital was significantly associated with not having initiated ART (adjusted odds ratio, AOR = 0.40; 95% confidence interval, CI, 0.24-0.67). Being seen at a clinic in Cameroon (AOR = 0.45; 95%CI = 0.24-0.85) and being in school were associated with decreased risk (AOR = 0.55; 95%CI = 0.31-0.96). Being ART-naïve (AOR = 1.88; 95%CI = 1.20-2.94) and being diagnosed at a reference hospital (AOR = 2.39; 95%CI = 1.29-4.41) or other testing facility (AOR = 2.86; 95%CI = 1.32-6.18) were associated with increased risk of having a morbid event at the initial visit. In longitudinal analysis of incident morbidity, we found a decreased risk associated with attending clinics in Cameroon (adjusted hazard ratio, AHR = 0.23; 95%CI = 0.11-0.46) and the DRC (AHR = 0.46; 95%CI = 0.29-0.74), and an increased risk associated with being ART-naïve (AHR = 1.83; 95%CI = 1.12-2.97). We found a high burden of HIV-related health problems among children receiving care in this setting. Children face significant barriers to accessing HIV services, and the HIV epidemic among surviving children in the Central African region has not been adequately evaluated nor addressed.

Characteristics of antiretroviral therapy-naïve patients lost-to-care in HIV clinics in Democratic Republic of Congo, Cameroon, and Burundi.

Antiretroviral therapy (ART)-naïve patients are vulnerable to becoming lost-to-care (LTC) because they are not monitored as often as patients on treatment. We examined data from 19,461 HIV positive adults at 10 HIV clinics in Democratic Republic of Congo (DRC), Cameroon, and Burundi participating in the Phase 1 International epidemiologic Databases to Evaluate AIDS Central Africa (IeDEA-CA) study. Patients were LTC if they were ART-naïve and did not return within 7 months of the end of data collection. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs) for risk factors associated with LTC. Of 5353 ART-naïve patients, 4420 (83%) were LTC and 933 (17%) were in-care. The odds of being LTC were greatest among patients from DRC (OR = 2.16, CI: 1.64-2.84, p < .0001), males (OR = 1.39, CI: 1.15-1.69, p = .0009), and ages 18-49 (OR = 1.45, CI: 1.16-1.82, p = .001). The odds of being LTC were least among patients with a WHO Clinical Stage of 1 or 2 (OR = 0.65, CI: 0.55-0.77, p < .0001) and in a perceived concordant relationship (OR = 0.61, CI: 0.43-0.87, p < .0001). LTC patients were more likely to have characteristics associated with higher risk for HIV transmission and progression. Many entered care at advanced stages and were less likely to know their partner's serostatus. Greater efforts to retain ART-naïve patients may increase earlier initiation of ART.

HIV/AIDS-related stigma felt by people living with HIV from Buea, Cameroon.

The universal access to treatment and care for people living with HIV (PLWHIV) is a major problem especially in Sub-Saharan Africa, where the majority of HIV infected people live. However, equally important is the fact that HIV/AIDS-related stigma is recognized to be a major obstacle to successfully control the spread of this disease. In this study we measured the HIV/AIDS-related stigma felt by PLWHIV in Cameroon using "The people living with HIV stigma index" questionnaire developed by UNAIDS, International Planned Parenthood Federation and Global Network of PLWHIV/AIDS among others. A total of 200 questionnaires were anonymously administered to PLWHIV in the HIV/AIDS treatment center of the Regional Hospital Annex Buea in the South West Region of Cameroon by trained academics who were themselves PLWHIV. In this setting the major problems faced by the PLWHIV with regard to stigmatization and discrimination were gossiping and verbal insults, which was felt by about half of the interviewees. Equally important was internal stigma, half of the PLWHIV felt ashamed and guilty to be HIV infected. This is the first report of this kind in Cameroon. These results will help to better understand HIV/AIDS-related stigma in this setting and in turn will improve the quality of life of PLWHIV by promoting their acceptance by the community.

Older Adults Accessing HIV Care and Treatment and Adherence in the IeDEA Central Africa Cohort.

Background. Very little is known about older adults accessing HIV care in sub-Saharan Africa. Materials and Methods. Data were obtained from 18,839 HIV-positive adults at 10 treatment programs in Burundi, Cameroon, and the Democratic Republic of Congo. We compared characteristics of those aged 50+ with those aged 18-49 using chi-square tests. Logistic regression was used to determine if age was associated with medication adherence. Results. 15% of adults were 50+ years. Those aged 50+ were more evenly distributed between women and men (56% versus 44%) as compared to those aged 18-49 (71% versus 29%) and were more likely to be hypertensive (8% versus 3%) (P < 0.05). Those aged 50+ were more likely to be adherent to their medications than those aged 18-49 (P < 0.001). Adults who were not heavy drinkers reported better adherence as compared to those who reported drinking three or more alcoholic beverages per day (P < 0.001). Conclusions. Older adults differed from their younger counterparts in terms of medication adherence, sociodemographic, behavioral, and clinical characteristics.

Adult HIV care resources, management practices and patient characteristics in the Phase 1 IeDEA Central Africa cohort.

INTRODUCTION: Despite recent advances in the management of HIV infection and increased access to treatment, prevention, care and support, the HIV/AIDS epidemic continues to be a major global health problem, with sub-Saharan Africa suffering by far the greatest humanitarian, demographic and socio-economic burden of the epidemic. Information on HIV/AIDS clinical care and established cohorts' characteristics in the Central Africa region are sparse. METHODS: A survey of clinical care resources, management practices and patient characteristics was undertaken among 12 adult HIV care sites in four countries of the International Epidemiologic Databases to Evaluate AIDS Central Africa (IeDEA-CA) Phase 1 regional network in October 2009. These facilities served predominantly urban populations and offered primary care in the Democratic Republic of Congo (DRC; six sites), secondary care in Rwanda (two sites) and tertiary care in Cameroon (three sites) and Burundi (one site). RESULTS: Despite some variation in facility characteristics, sites reported high levels of monitoring resources, including electronic databases, as well as linkages to prevention of mother-to-child HIV transmission programs. At the time of the survey, there were 21,599 HIV-positive adults (median age=37 years) enrolled in the clinical cohort. Though two-thirds were women, few adults (6.5%) entered HIV care through prevention of mother-to-child transmission services, whereas 55% of the cohort entered care through voluntary counselling and testing. Two-thirds of patients at sites in Cameroon and DRC were in WHO Stage III and IV at baseline, whereas nearly all patients in the Rwanda facilities with clinical stage information available were in Stage I and II. WHO criteria were used for antiretroviral therapy initiation. The most common treatment regimen was stavudine/lamivudine/nevirapine (64%), followed by zidovudine/lamivudine/nevirapine (19%). CONCLUSIONS: Our findings demonstrate the feasibility of establishing large clinical cohorts of HIV-positive individuals in a relatively short amount of time in spite of challenges experienced by clinics in resource-limited settings such as those in this region. Country differences in the cohort's site and patient characteristics were noted. This information sets the stage for the development of research initiatives and additional programs to enhance adult HIV care and treatment in Central Africa.

Retention in an antiretroviral therapy programme during an era of decreasing drug cost in Limbe, Cameroon.

BACKGROUND: In 2002, Cameroon initiated scale up of antiretroviral therapy (ART); on 1 October 2004, a substantial reduction in ART cost occurred. We assessed the impact of this event and other factors on enrolment and retention in care among HIV-infected patients initiating ART from February 2002 to December 2005 at the single ART clinic serving the Southwest Region in Limbe, Cameroon. METHODS: We retrospectively analyzed clinical and pharmacy payment records of HIV-infected patients initiating ART according to national guidelines. We compared two cohorts of patients, enrolled before and after 1 October 2004, to determine if price reduction was associated with enhanced enrolment. We assessed factors associated with retention and survival by Cox proportional hazards models. Retention in care implied patients who had contact with the healthcare system as of 31 December 2005 (including those who were transferred to continue care in other ART centres), although these patients may have interrupted therapy at some time. A patient who was not retained in care may have dropped out (lost to follow up) or died. RESULTS: Mean enrolment rates for 2920 patients who initiated ART before and after the price reduction were 46.5 and 95.5 persons/month, respectively (p < 0.001). The probabilities of remaining alive and in care were 0.66 (95% CI 0.64-0.68) at six months, 0.58 (95% CI 0.56-0.60) at one year, 0.47 (95% CI 0.45-0.49) at two years and 0.35 (95% CI 0.32-0.38) at three years; they were not significantly different between the two cohorts of patients enrolled before and after the price reduction over the first 15 months of comparable follow up (hazard ratio 1.1; 95% CI 0.9-1.2, p = 0.27). In multivariable analysis using multiple imputations to compensate for missing values, factors associated with dropping out of care or dying were male gender (HR 1.33 [1.18-1.50], p = 0.003), treatment paid by self, family or partly by other (HR 3.05 [1.99-4.67], p < 0.001), and, compared with residents of Limbe, living more than 150 km from Limbe (HR 1.41 [1.18-1.69], p < 0.001), or being residents of Douala (HR 1.51 [1.16-1.98], p < 0.001). CONCLUSIONS: Reducing the cost of ART increased enrolment of clients in the programme, but did not change retention in care. In a system where most clients pay for ART, an accessible clinic location may be more important than the cost of medication for retention in care. Decentralizing ART clinics might improve retention and survival among patients on ART.