Decentralization of HIV care in Cameroon: increased access to antiretroviral treatment and associated persistent barriers.
BACKGROUND
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).


OBJECTIVE
To assess the extent to which decentralized delivery of HIV care at the district level has contributed to increased access to ART.


METHODS
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.


RESULTS
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).


CONCLUSIONS
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.
Loubiere
Sandrine
S
INSERM, U912 (SE4S), Marseille, France. sandrine.loubiere@inserm.fr
Boyer
Sylvie
S
Protopopescu
Camélia
C
Bonono
Cécile Renée
CR
Abega
Séverin-Cécile
SC
Spire
Bruno
B
Moatti
Jean-Paul
JP
D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D002163:Cameroon; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000628:therapy; D006297:Health Services Accessibility / Q000458:organization & administration*; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D012923:Social Class; D011795:Surveys and Questionnaires
D044966:Anti-Retroviral Agents