Individual and healthcare supply-related barriers to treatment initiation in HIV-positive patients enrolled in the Cameroonian antiretroviral treatment access programme

Abstract

Increasing demand for antiretroviral treatment (ART) together with a reduction in international funding during the last decade may jeopardize access to ART. Using data from a cross-sectional survey conducted in 2014 in 19 HIV services in the Centre and Littoral regions in Cameroon, we investigated the role of healthcare supply-related factors in time to ART initiation in HIV-positive patients eligible for ART at HIV diagnosis. HIV service profiles were built using cluster analysis. Factors associated with time to ART initiation were identified using a multilevel Cox model. The study population included 847 HIV-positive patients (women 72%, median age: 39 years). Median (interquartile range) time to ART initiation was 1.6 (0.5–4.3) months. Four HIV service profiles were identified: (1) small services with a limited staff practising partial task-shifting (n = 4); (2) experienced and well-equipped services practising task-shifting and involving HIV community-based organizations (n = 5); (3) small services with limited resources and activities (n = 6); (4) small services providing a large range of activities using task-shifting and involving HIV community-based organizations (n = 4). The multivariable model showed that HIV-positive patients over 39 years old [hazard ratio: 1.26 (95% confidence interval) (1.09–1.45), P = 0.002], those with disease symptoms [1.21 (1.04–1.41), P = 0.015] and those with hepatitis B co-infection [2.31 (1.15–4.66), P = 0.019] were all more likely to initiate ART early. However, patients in the first profile were less likely to initiate ART early [0.80 (0.65–0.99), P = 0.049] than those in the second profile, as were patients in the third profile [association only significant at the 10% level; 0.86 (0.72–1.02), P = 0.090]. Our findings provide a better understanding of the role played by healthcare supply-related factors in ART initiation. In HIV services with limited capacity, task-shifting and support from community-based organizations may improve treatment access. Additional funding is required to relieve healthcare supply-related barriers and achieve the goal of universal ART access.

Individual and healthcare supply-related HIV transmission factors in HIV-positive patients enrolled in the antiretroviral treatment access program in the Centre and Littoral regions in Cameroon (ANRS-12288 EVOLCam survey)

“…Finally, detailed data on the characteristics of the participating 19 HIV services were collected through interviews with hospital staff, in situ observations, and cross-validation with data recorded in HIV service activity reports. Specifically, the information obtained included: i) hospital’s general characteristics (location, opening date, legal status, number of beds), ii) human resources working in the HIV service (number and qualifications), iii) activity (number of ART-treated patients and available services including educational, nutritional and financial support, HIV community-based organization involvement), iv) HIV service organization (separate ARV storage, stock management and task-shifting for clinical consultations of ART-treated patients and/or ARV prescription renewals), v) technical resources (functional medical imaging equipment, CD4 count machine, ARV stock-outs for at least one of the three most prescribed ART regimens [ 28 ].…”

“…The above healthcare supply-related characteristics (see subsection ‘Study design and data collection’) were used to build an HIV service profile variable using a multiple correspondence analysis (MCA) combined with a hierarchical cluster analysis [ 28 ]. More specifically, the MCA allowed us to combine healthcare supply-related correlated variables to create continuous factors, which were then used in a classification procedure to identify service profiles (clusters), hereafter called ‘HIV-service profiles’ (HSP) (see S1 – S3 Figs for more details) [ 40 , 41 ].…”

“…More specifically, the MCA allowed us to combine healthcare supply-related correlated variables to create continuous factors, which were then used in a classification procedure to identify service profiles (clusters), hereafter called ‘HIV-service profiles’ (HSP) (see S1 – S3 Figs for more details) [ 40 , 41 ]. The method used is fully described elsewhere [ 28 ].…”

“…The few studies to date exploring the role of healthcare supply-related factors [ 24 , 26 , 27 ] only assessed a limited number of HIV service characteristics and did not consider the more complex nature of the organization of these services (e.g., dimensions such as the working process, available resources and management of ARV). In a previous study conducted in Cameroon, we showed that HIV service profiles, built using a cluster analysis of a wide range of healthcare supply-related characteristics, had different performances in terms of time to ART initiation [ 28 ]. In the present study, we used a similar approach to provide a better understanding of the role of supply-related factors, beside individual factors, on achieving the third UNAIDS target in Cameroon.…”

Living conditions, HIV and gender affirmation care pathways of transgender people living with HIV in France: a nationwide, comprehensive, cross-sectional, community-based research protocol (ANRS Trans&HIV)

“…HIV care units with similar characteristics will be grouped together (eg, large urban centres vs small centres in large cities vs small centres in small cities). 46 After this, we will perform multilevel analyses to disentangle individual barriers to care access and retention from their structural counterparts.…”