Cost of drugs and lack of resources mean irregular HIV care from routine providers in Cameroon

The cost of HIV care and lack of resources including specialist HIV doctors and pharmacists, mean that routine HIV care provided at both public and private healthcare facilities in Douala in Cameroon is irregular with many patients interrupting treatment, according to a study published in the July 1^st edition of Clinical Infectious Diseases (now available on-line).

Most data on the provision of HIV treatment and care in Africa comes from UNAIDS, research institutes, or international non-governmental organisations. For the most part, there is a lack of data on the delivery of HIV treatment and care by routine public and private healthcare facilities. Such information is, however, needed to facilitate the design of antiretroviral treatment programmes able to reach large numbers of patients.

Investigators from France and Cameroon examined the effectiveness of antiretroviral treatment in a large cohort of patients treated at 19 public and private clinics in Douala, the economic capital of Cameroon. These clinics were included in the DARVIR (Douala antiretroviral) initiative. Healthcare providers involved in the DARVIR initiative included major district public hospitals, private medical centres, private company medical officers, and non-governmental organsiations. HIV care was standardised across the participating institutions, with clinic visits and routine blood tests scheduled on the 15^th day of anti-HIV treatment, then after one month, three months, and three-monthly thereafter. CD4 and viral load were scheduled every six months.

Few physicians were involved in the management of antiretroviral treatment, at most one or two at each clinic, and this often led to the postponement of appointments because doctors were overwhelmed or absent. In addition, antiretroviral therapy was only dispensed by the main hospital pharmacy, which was only open three days a week.

Patients had to pay for their treatment and care. The cost of drugs varied between $23 - $100 a month, tests cost between $58 and $84 for a viral load assay and $23 - $30 for a CD4 cell count, and clinic visits cost between $1.50 and $15.00. Most patients were not reimbursed for their costs.

An intent-to-treat analysis was performed. Investigators estimated the probability of continuing to receive treatment.

A chart review of all adult HIV-positive patients receiving care between October 2000 and October 2003 was conducted. A total of 788 individuals were included in the investigators’ analysis, providing 941 person-years of follow-up.

Median age was 39 years, median baseline CD4 cell count was 123 cells/mm³ and median baseline viral load was 94,000 copies/ml. Most patients had symptoms of HIV infection, with a third having a previous AIDS diagnosis. Antiretroviral therapy had been used by 15% of individuals in the past, and at baseline all but one patient were provided with a three drug antiretroviral regimen, the remaining patient receiving a two drug combination.

Individuals were followed for a median of 13 months. The median number of visits was nine, but the median number of clinical visits was only two. No clinic visits were recorded for 135 (17%) patients, even though they were observed for a median of seven months. A quarter of individuals were considered lost to follow-up. A total of 52 deaths were reported (7% mortality, 5.5 deaths per 100 person-years). The probability of continuing treatment was 0.76 at twelve months and 0.62 at 24 months.

Only 22% of the expected number of viral load measurements were made, and only 37% of patients had a viral load test. In addition, only 37% of the anticipated CD4 cell counts were undertaken, with 50% of patients having a CD4 cell count.

Amongst patients who did have their viral load or CD4 cell the investigators found a good response to antiretroviral therapy. After twelve months of treatment 59% of these patients had a viral load below 50 copies/ml, with 47% undetectable at 24 months. The median increase in CD4 cell count at twelve months was 113 cells/mm³ and 143 cells/mm³ at month 24.

“We found that clinical follow-up visits, biological follow-up visits, and drug supply were irregular and that many patients interrupted treatment”, write the investigators. In particular, the investigators note that “patient management was hindered by organisational constraints”, including a lack of trained physicians and limited pharmacy facilities.