Background:  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. 

Conclusions:  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.