Implementing operational research to scale-up access to antiretroviral therapy for HIV infection: lessons learned from the Cameroonian experience.

PURPOSE OF REVIEW: Given the lack of evidence on how to best design and implement antiretroviral therapy (ART) scaling-up policies, operational research has seen a surge in interest. There is, however, little published information on the contribution of operational research in ART programs' implementation or in improvement of associated outcomes. The article focuses therefore on how operational research may contribute to such improvements and what the key enabling factors are for its integration into program frameworks. RECENT FINDINGS: One of the most systematic operational research linked to a national ART program on the African continent was conducted in Cameroon between 2006 and 2010. Along with operational research carried out elsewhere in Africa, it helped demonstrate that a strategy of decentralizing HIV care can increase treatment coverage and improve early access to care, while maintaining good clinical outcomes. Multipartnership between local researchers, national authorities, healthcare professionals and the civil society is the key enabling factor for the relevance of operational research and the translation of its results into policy and practice. SUMMARY: In spite of a dramatic increase in access to ART during recent years in low-income countries, the fight against HIV remains a failure in terms of the goal of breaking the pandemic dynamic. Operational research is needed more than ever to face this challenge.

Desire for a child among HIV-infected women receiving antiretroviral therapy in Cameroon: results from the national survey EVAL (ANRS 12-116).

The majority of HIV-infected people in sub-Saharan Africa are women, many of reproductive age. Cameroon is severely hit by the AIDS epidemic and has developed a large national program for improving access to antiretroviral treatment (ART). The reproductive intentions of women living with HIV/AIDS (WLHA) who obtain access to ART in this country remain poorly documented. Our study aimed at exploring factors associated with the desire to have a child among 1433 ART-treated fertile WLHA aged <50. Analyses were based on data collected during the national cross-sectional survey EVAL (ANRS 12-116), which was conducted between September 2006 and March 2007 in 27 HIV care centers in Cameroon. Logistic regression was used to explore factors associated with women's desire to have a child, defined as reporting the wish to have a/another child. A total of 791 women (55%) reported the desire to have a child. After adjusting for age, matrimonial status, number of biological children, and sexual activity, the main factors independently associated with this desire in a multivariate analysis were having a good physical health-related quality of life (1.02 [1.01-1.03] for a one-point increment on the 12-item Short-Form Health Survey scale) and a CD4 count at ART initiation <200 cells/mm(3) (1.7 [1.2-2.4]). As a conclusion, the desire to have a child is frequent among ART-treated WLHA in Cameroon. HIV care and family planning programs should be integrated more thoroughly in order to support WLHA's reproductive choices.

Prevalence of unsafe sex with one's steady partner either HIV-negative or of unknown HIV status and associated determinants in Cameroon (EVAL ANRS12-116 survey).

OBJECTIVE: Our study aimed at estimating the prevalence of inconsistent condom use and at identifying its determinants in steady partnerships among people living with HIV/AIDS (PLWHA) in Cameroon. METHODS: Analyses were based on data collected during the national cross-sectional multicentre survey EVAL (ANRS 12-116), which was conducted in Cameroon between September 2006 and March 2007 among 3151 adult PLWHA diagnosed HIV-positive for at least 3 months. The study population consisted of the 907 survey participants who reported sexual activity during the previous 3 months, with a steady partner either HIV-negative or of unknown HIV status. Logistic regression was used to identify factors associated with individuals' report of inconsistent condom use during the previous 3 months. RESULTS: Inconsistent condom use was reported by 35.3% of sexually active PLWHA. In a multivariate analysis adjusted for socio-demographic characteristics, not receiving antiretroviral therapy (OR (95% CI): 2.28 (1.64 to 3.18)) was independently associated with inconsistent condom use. CONCLUSIONS: The prevalence of unsafe sex remains high among sexually active PLWHA in Cameroon. Treatment with antiretroviral therapy is identified as a factor associated with safer sex, which further encourages the continuation of the national policy for increasing access to HIV treatment and care, and underlines the need to develop counselling strategies for all patients.

Scaling up access to antiretroviral treatment for HIV infection: the impact of decentralization of healthcare delivery in Cameroon.

BACKGROUND: The independent evaluation of the Cameroonian antiretroviral therapy (ART) Programme, which reached one of the highest coverage in the eligible HIV-infected population (58%) in Sub-Saharan Africa, offered the opportunity to assess ART outcomes in the context of the decentralization of HIV care delivery. MATERIALS AND METHODS: A cross-sectional survey (EVAL, ANRS 12-116, 2007) was carried out in a random sample of 3151 HIV-positive patients (response rate 90%) attending 27 treatment centres at the different level of the healthcare delivery (central, provincial and district), as well as in the exhaustive sample of doctors in charge of HIV care in these centres (response rate 92%, n = 97). Multivariate two-level analyses were conducted to assess the impact of the level of healthcare delivery on CD4 cell gains since initiation of treatment and adherence to treatment in the subsample of patients who were ART-treated for 6 months or more (n = 1985). RESULTS: District treatment centres were characterized by more limited technical and human resources but a lower workload. ART-treated patients followed up in these centres had significantly lower socioeconomic status. After adjustment for other explanatory factors, immunological improvement was similar in patients followed up at the central and district level, whereas adherence to ART was better both at provincial and district levels. CONCLUSION: Success in scaling-up access to ART in Cameroon has been facilitated by decentralization of the healthcare system. Long-term sustainability urgently implies better integration of this HIV-targeted programme in the global healthcare reform of financing mechanisms, management of human resources and drug procurement systems.

Delayed first consultation after diagnosis of HIV infection in Cameroon.

OBJECTIVES: To study the impact of both decentralization of HIV care and individual factors on delayed first consultation (> or =6 months) after HIV diagnosis in Cameroon, in the context of the national antiretroviral treatment scale-up program. DESIGN: The national cross-sectional multicenter survey EVAL (ANRS 12-116) was conducted from September 2006 to March 2007 in 27 HIV centers in Cameroon. METHODS: : Logistic regression was used to characterize patients with delayed first consultation among 3151 HIV-infected adults. RESULTS: Fifteen percent of patients reported a delay of at least 6 months before their first consultation after HIV diagnosis. In the multivariate analysis adjusted for the frequency of visits to the HIV center, independent correlates of reporting a delay of at least 6 months before consulting included the characteristics of the HIV centers (created before 2005 and located in small or medium-size hospitals) and the following individual patient characteristics: sex and matrimonial status (women living in a couple), the circumstances of the HIV diagnosis (test not performed in the hospital providing HIV care, test performed during a voluntary screening campaign) and patient's negative perception of antiretroviral treatment toxicity. CONCLUSION: Delays before first consultation for HIV care in Cameroon have been reduced, thanks to the full implementation of the national program of decentralization. Results underline the importance of coordinating diagnosis with treatment activities and the need to develop counseling actions, focusing on the balance between antiretroviral treatment effectiveness and its potential side effects. Counseling should also be part of patients' follow-up after diagnosis during voluntary screening campaigns.

Determinants of unplanned antiretroviral treatment interruptions among people living with HIV in Yaoundé, Cameroon (EVAL survey, ANRS 12-116).

OBJECTIVE: To identify correlates of self-reported antiretroviral therapies (ART) interruptions among people living with HIV and AIDS (PLWHA) in Cameroon. METHODS: Analyses were based on data collected in the national survey EVAL (ANRS 12-116) among 533 ART-treated PLWHA in Yaoundé, the capital city of Cameroon, and its neighbourhood. Logistic regression models were used to identify factors associated with self-reported ART interruptions longer than two consecutive days during the previous 4 weeks. RESULTS: ART interruptions were reported by 68 patients (12.8%). After adjustment for gender, education and household income, characteristics independently associated with interruptions were pharmacy stock shortages [OR (95%CI):3.25 (1.78-5.90)], binge drinking [2.87 (1.39-5.91)] and the number of self-reported slimming symptoms [1.23 (1.02-1.48)]. CONCLUSION: In poor-resource settings where access to second and third-line regimens is still limited, food supply programs and interventions to minimise ART shortage may reduce the risk of ART interruptions.