title: Monitoring HIV Drug Resistance Early Warning Indicators in Cameroon: A Study Following the Revised World Health Organization Recommendations.
abstract: BACKGROUND
  The majority (>95%) of new HIV infection occurs in resource-limited settings, and Cameroon is still experiencing a generalized epidemic with ~122,638 patients receiving antiretroviral therapy (ART). A detrimental outcome in scaling-up ART is the emergence HIV drug resistance (HIVDR), suggesting the need for pragmatic approaches in sustaining a successful ART performance.
  
  
  METHODS
  A survey was conducted in 15 ART sites of the Centre and Littoral regions of Cameroon in 2013 (10 urban versus 05 rural settings; 8 at tertiary/secondary versus 7 at primary healthcare levels), evaluating HIVDR-early warning indicators (EWIs) as-per the 2012 revised World Health Organization's guidelines: EWI1 (on-time pill pick-up), EWI2 (retention in care), EWI3 (no pharmacy stock-outs), EWI4 (dispensing practices), EWI5 (virological suppression). Poor performance was interpreted as potential HIVDR.
  
  
  RESULTS
  Only 33.3% (4/12) of sites reached the desirable performance for "on-time pill pick-up" (57.1% urban versus 0% rural; p<0.0001) besides 25% (3/12) with fair performance. 69.2% (9/13) reached the desirable performance for "retention in care" (77.8% urban versus 50% rural; p=0.01) beside 7.7% (1/13) with fair performance. Only 14.4% (2/13) reached the desirable performance of "no pharmacy stock-outs" (11.1% urban versus 25% rural; p=0.02). All 15 sites reached the desirable performance of 0% "dispensing mono- or dual-therapy". Data were unavailable to evaluate "virological suppression" due to limited access to viral load testing (min-max: <1%-15%). Potential HIVDR was higher in rural (57.9%) compared to urban (27.8%) settings, p=0.02; and at primary (57.9%) compared to secondary/tertiary (33.3%) healthcare levels, p=0.09.
  
  
  CONCLUSIONS
  Delayed pill pick-up and pharmacy stock-outs are major factors favoring HIVDR emergence, with higher risks in rural settings and at primary healthcare. Retention in care appears acceptable in general while ART dispensing practices are standard. There is need to support patient-adherence to pharmacy appointments while reinforcing the national drug supply system.
authors.affiliation: Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé, Cameroon; University of Rome Tor Vergata, Department of Experimental Medicine and Surgery, Rome, Italy; National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon.
authors.forename: Joseph
authors.initials: J
authors.lastname: Fokam
authors.affiliation: National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon; National AIDS Control Committee, Ministry of Public Health, Yaoundé, Cameroon.
authors.forename: Jean-Bosco N
authors.initials: JB
authors.lastname: Elat
authors.affiliation: Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé, Cameroon; National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon; National AIDS Control Committee, Ministry of Public Health, Yaoundé, Cameroon.
authors.forename: Serge C
authors.initials: SC
authors.lastname: Billong
authors.affiliation: National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon; World Health Organization (WHO), Afro, Country Office, Yaoundé, Cameroon.
authors.forename: Etienne
authors.initials: E
authors.lastname: Kembou
authors.affiliation: Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé, Cameroon; National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon; Division of Operational Health Research, Ministry of Public Health, Yaoundé, Cameroon.
authors.forename: Armand S
authors.initials: AS
authors.lastname: Nkwescheu
authors.affiliation: National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon; Division of Operational Health Research, Ministry of Public Health, Yaoundé, Cameroon.
authors.forename: Nicolas M
authors.initials: NM
authors.lastname: Obam
authors.affiliation: Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé, Cameroon; National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon.
authors.forename: André
authors.initials: A
authors.lastname: Essiane
authors.affiliation: Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé, Cameroon; National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon.
authors.forename: Judith N
authors.initials: JN
authors.lastname: Torimiro
authors.affiliation: United Nations program on HIV/AIDS (UNAIDS), Yaoundé, Cameroon.
authors.forename: Gatien K
authors.initials: GK
authors.lastname: Ekanmian
authors.affiliation: Chantal BIYA International Reference Centre for research on HIV/AIDS prevention and management (CIRCB), Yaoundé, Cameroon; Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé, Cameroon.
authors.forename: Alexis
authors.initials: A
authors.lastname: Ndjolo
authors.affiliation: Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé, Cameroon; General Secretariat, Ministry of Public Health, Yaoundé, Cameroon; Agence National de Recherche sur le SIDA et les hépatites virales (ANRS), Yaoundé, Cameroon.
authors.forename: Koulla S
authors.initials: KS
authors.lastname: Shiro
authors.affiliation: Faculty of Medicine and Biomedical Sciences (FMBS), University of Yaoundé I, Yaoundé, Cameroon; National HIV Drug Resistance Surveillance and Prevention Working Group, Ministry of Public Health, Yaoundé, Cameroon; Division of Operational Health Research, Ministry of Public Health, Yaoundé, Cameroon.
authors.forename: Anne C Z-K
authors.initials: AC
authors.lastname: Bissek
mesh_terms: D019380:Anti-HIV Agents / Q000494:pharmacology* / Q000627:therapeutic use; D002163:Cameroon; D003695:Delivery of Health Care / Q000706:statistics & numerical data; D016903:Drug Monitoring; D024882:Drug Resistance, Viral; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D017410:Practice Guidelines as Topic; D015397:Program Evaluation; D012189:Retrospective Studies; D012424:Rural Population / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013997:Time Factors; D014505:Urban Population / Q000706:statistics & numerical data; D014944:World Health Organization
chemical_list: D019380:Anti-HIV Agents