Monitoring HIV Drug Resistance Early Warning Indicators in Cameroon: A Study Following the Revised World Health Organization Recommendations

Abstract

BackgroundThe 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.MethodsA 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.ResultsOnly 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.ConclusionsDelayed 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.

Predictors of poor retention on antiretroviral therapy as a major HIV drug resistance early warning indicator in Cameroon: results from a nationwide systematic random sampling

“…In terms of programmatic perspectives, an accurate mastering of patients in care provide a better accountability and planning for ARV drug procurement, thereby reducing events of discontinuous drug supply as previously reported [7–9]. Of note, drug shortage suggests ART interruption, which is a direct indicator of suboptimal ARV adherence and higher risks of HIVDR emergence in a context where low-genetic barrier drugs (i.e.…”

“…Our experience in assessing these factors locally, using early warning indicators (EWI) of HIV drug resistance (HIVDR), consistently reveals pharmacy stock-outs and delayed pill pick-up as major factors favoring HIVDR emergence; while prescribing/dispensing practices remain appropriate, indicators of retention in care and lost to follow-up are fluctuating, making it challenging to design and implement reasonable public health interventions nationwide [7–9], especially with the changing paradigms in ART [5]. …”

“…As this indicator remains with uncertainty [7–9], it became crucial for the national AIDS programme to delineate the country performance in patient retention on ART as well as related determinants. Such investigation would provide a reliable representativeness of Cameroon’s capacity in retaining patients on ART and prompt real time corrective measures while transitioning to current treatment strategies [3, 4].…”

“…Moreover, retention on ART varied significantly between urban and rural settings in Cameroon [9], thereby stressing the necessity of in-depth understanding of disparities surrounding this key indicator of patient adherence to ART program [5, 6]. …”

“…To minimize lost to follow-up and its associated risks of HIVDR, the WHO recommends to evaluate “ retention in care at 12 months of ART ” as part of five simplified EWIs ( on- time pill pick-up ; retention in care at 12 months ; pharmacy stock-outs; dispensing practices; and virological suppression ) [4, 5, 9]. Following the WHO sampling strategy, we earlier evaluated EWIs on selected ART clinics based on predefined criteria [4–9].…”