Survival and Adherence to ART in an Era of Decreasing Drug Cost in Limbe, Cameroon
Jembia J Mosoko*1, W Akam2, P Weidle3, J Brooks3, A Aweh1, M Ebad2, T Kinge2, C Vitek3, and P Raghunathan1
1CDC Camerooon; 2Provincial Hosp, Ministry of Publ Hlth, Limbe, Cameroon; and 3Natl Ctr for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA, US
Since 2002, Cameroon has undertaken an
initiative to scale-up access to ART, and in October 2004 including a
substantial reduction of ART cost. We assessed enrollment
and retention in care among HIV-infected patients initiating ART from February
2002 to December 2005 at the only ART clinic serving the Southwest
Province in Limbe, Cameroon.
Methods: We retrospectively analyzed clinical and
pharmacy payment records of HIV-infected patients who were newly enrolled in
ART according to national guidelines. We
compared 2 cohorts of patients—cohort 1 enrolled before October 2004, and
cohort 2 since October 2004—to determine by Wilcoxon
Rank-Sum test whether the price reduction was associated with enhanced enrollment. We assessed retention and survival by Cox
proportional hazards models. Access to the clinic was considered good for those
who lived within 40 km of it or on a main road as far away as 80 km in the
nearby city of Douala; and poor for those who lived >40 km away and
not on a main road.
Results: A total of 2920 patients (62% female, median
age 35 years, CD4 cell count 107 cells/mL) initiated ART (median follow-up time, 6.2
months). Access to the clinic was good for 1561 (55.7%) and poor for 1242
(44.3%); 2241 (96.3%) paid for ART through family or self-support, while 87
(3.7%) received ART through a funding program or employer. Mean enrollment for cohort 1 was 46.5 persons/month and for cohort
2 was 95.5 persons/month (p <0.001).
The probabilities of remaining alive and in care were 0.66 (95% CI 0.64-0.68)
at 6 months, 0.58 (95% CI 0.56-0.60) at 1 year, 0.47 (95%CI 0.45 to 0.49) at 2
years and 0.35 (95%CI 0.32 to 0.38) at 3 years, and were not significantly
different between the 2 cohorts over the first 15 months of comparable
follow-up (HR 1.1, 95%CI 1.0 to 1.2). Retention in care was associated with
female gender (HR 1.2, 1.1 to 1.3; p =
0.003), good access to the clinic (HR1.5, 1.3 to 1.8; p <0.001), and treatment paid by a funding program or
employer (HR 3.6, 2.2 to 6.0; p <0.001).
Multivariable analysis reproduced these findings.
An ART price reduction led to increased
enrollment of clients in the program, but was not associated with improved
retention in care. In a system where most clients pay for ART, an accessible
clinic location may be more important than the cost of medication for retention
in care. Decentralizing ART clinics may be one way to improve retention and
survival among patients on ART.