Programme quality indicators of HIV drug resistance among adolescents in urban versus rural settings of the centre region of Cameroon

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Abstract

Background

The high rate of mortality among HIV-vertically infected adolescents might be favoured by HIV drug resistance (HIVDR) emergence, which calls for timeous actions in this underserved population. We thus sought to evaluate program quality indicators (PQIs) of HIVDR among HIV-vertically infected adolescents on antiretroviral therapy (ART).

Methods

A study was conducted in the Centre region of Cameroon among adolescents (10–19 years) receiving ART in two urban (The Mother–Child Centre of the Chantal BIYA Foundation, the National Social Welfare Hospital) and three rural (Mfou District Hospital, Mbalmayo District Hospital and Nkomo Medical Center) health facilities. Following an exhaustive sampling from ART registers, patient medical files and pharmacy records, data was abstracted for seven PQIs: on- time drug pick- up; retention in care; pharmacy stock outs; dispensing practices; viral load coverage; viral suppression and adequate switch to second- line. Performance in PQIs was interpreted following the WHO-recommended thresholds (desirable, fair and/or poor); with p < 0.05 considered significant.

Results

Among 967 adolescents (888 urban versus 79 rural) registered in the study sites, validated data was available for 633 (554 in urban and 79 in rural). Performance in the urban vs. rural settings was respectively: on- time drug pick- up was significantly poorer in rural (79% vs. 46%, p = 0.00000006); retention in care was fair in urban (80% vs. 72%, p = 0.17); pharmacy stock outs was significantly higher in urban settings (92% vs. 50%, p = 0.004); dispensing practices was desirable (100% vs. 100%, p = 1.000); viral load coverage was desirable only in urban sites (84% vs. 37%, p < 0.0001); viral suppression was poor (33% vs. 53%, p = 0.08); adequate switch to second- line varied (38.1% vs. 100%, p = 0.384).

Conclusion

Among adolescents on ART in Cameroon, dispensing practices are appropriate, while adherence to ART program and viral load coverage are better in urban settings. However, in both urban and rural settings, pharmacy stock outs, poor viral suppression and inadequate switch to second-line among adolescents require corrective public-health actions to limit HIVDR and to improve transition towards adult care in countries sharing similar programmatic features.

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Population-Based Monitoring of Emerging HIV-1 Drug Resistance on Antiretroviral Therapy and Associated Factors in a Sentinel Site in Cameroon: Low Levels of Resistance but Poor Programmatic Performance

Serge Billong, Joseph Fokam, Avelin Aghokeng … (2013)

Background Scale-up of antiretroviral therapy (ART) in resource-limited settings has drastically reduced HIV-related morbidity and mortality. However, challenges in long-term ART, adherence and HIV drug resistance (HIVDR) itself, require monitoring to limit HIVDR emergence among ART-experienced populations, in order to ensure regimen efficacy. Methods A longitudinal study was conducted from 2009–2011 in a cohort of 141 HIV-infected adult patients (aged >21) at the national social insurance centre hospital in Yaounde, Cameroon. As per-WHO HIVDR protocol, HIV-1 protease-reverse transcriptase genotyping was performed at baseline and at endpoint (12 months) on first-line ART using ViroSeq™ Genotyping kit. Results At baseline, a prevalence of 3.6% (5/139) HIVDR was observed [protease inhibitors M46I (1/5), G73A (1/5), L90LM (1/5); nucleoside reverse transcriptase inhibitors: M184V (1/5), T215F (1/5); non-nucleoside reverse transcriptase inhibitors: K103N (1/5), Y181Y/C (2/5), M230ML (1/5)]. At endpoint, 54.0% (76) patients were followed-up, 9.2% (13) died, and 3.5% (5) transferred, 38.5% (47) lost to follow-up (LTFU). 69.7% (53/76) of those followed-up had viremia <40 copies/ml and 90.8% (69/76) <1000 copies/ml. 4/7 patients with viremia ≥1000 copies/ml harbored HIVDR (prevalence: 5.3%; 4/76), with M184V/I (4/4) and K103K/N (3/4) being the most prevalent mutations. LTFU was favored by costs for consultation/laboratory tests, drug shortages, workload (physician/patient ratio: 1/180) and community disengagement. Conclusions Low levels of HIVDR at baseline and at endpoint suggest a probable effectiveness of ART regimens used in Cameroon. However the possible high rate of HIVDR among LTFUs limited the strengths of our findings. Evaluating HIVDR among LTFU, improving adherence, task shifting, subsidizing/harmonizing costs for routine follow-up, are urgent measures to ensure an improved success of the country ART performance.

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

Joseph Fokam, Jean-Bosco Elat, Serge Billong … (2015)

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.

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Declining trends in early warning indicators for HIV drug resistance in Cameroon from 2008–2010: lessons and challenges for low-resource settings

Joseph Fokam, Serge Billong, Anne C ZK Bissek … (2013)

Background Rapid scale-up of antiretroviral therapy (ART) and limited access to genotyping assays in low-resource settings (LRS) are inevitably accompanied by an increasing risk of HIV drug resistance (HIVDR). The current study aims to evaluate early warning indicators (EWI) as an efficient strategy to limit the development and spread of preventable HIVDR in these settings, in order to sustain the performance of national antiretroviral therapy (ART) rollout programmes. Methods Surveys were conducted in 2008, 2009 and 2010 within 10 Cameroonian ART clinics, based on five HIVDR EWIs: (1) Good prescribing practices; (2) Patient lost to follow-up; (3) Patient retention on first line ART; (4) On-time drug pick-up; (5) Continuous drug supply. Analysis was performed as per the World Health Organisation (WHO) protocol. Results An overall decreasing performance of the national ART programme was observed from 2008 to 2010: EWI1 (100% to 70%); EWI2 (40% to 20%); EWI3 (70% to 0%); EWI4 (0% throughout); EWI5 (90% to 40%). Thus, prescribing practices (EWI1) were in conformity with national guidelines, while patient adherence (EWI2, EWI3, and EWI4) and drug supply (EWI5) were lower overtime; with a heavy workload (median ratio ≈1/64 staff/patients) and community disengagement observed all over the study sites. Conclusions In order to limit risks of HIVDR emergence in poor settings like Cameroon, continuous drug supply, community empowerment to support adherence, and probably a reduction in workload by task shifting, are the potential urgent measures to be undertaken. Such evidence-based interventions, rapidly generated and less costly, would be relevant in limiting the spread of preventable HIVDR and in sustaining the performance of ART programmes in LRS.

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Author and article information

Contributors

Joseph Fokam:

ORCID: http://orcid.org/0000-0002-1501-2763

josephfokam@gmail.com , fokamjoseph@circb.cm

Armanda Nangmo: armanda_nangmo@yahoo.com

Carlson Wandum: wandumcarls@gmail.co

Desire Takou: dtakou@yahoo.com

Maria Mercedes Santoro: santormaria@gmail.com

Anne-Esther Njom Nlend: anne.njom@gmail.com

Francis Ndongo Ateba: atebfranc@gmail.com

Paul Koki Ndombo: koki_paul@hotmail.com

Nelly Kamgaing: kmnelly2007@gmail.com

Cedric Kamta: lacmago_cedric@yahoo.fr

Andre Essiane: essio@hotmail.fr

Virginie Lambo: chancecm@yahoo.fr

Charles Fokunang: charlesfokunang@yahoo.co.uk

Dora Mbanya: dmbanya1@yahoo.co.uk

Vittorio Colizzi: colizzi@bio.uniroma2.it

Carlo-Federico Perno: cf.perno@uniroma2.it

Alexis Ndjolo: andjolo@yahoo.com

Journal

Journal ID (nlm-ta): AIDS Res Ther

Journal ID (iso-abbrev): AIDS Res Ther

Title: AIDS Research and Therapy

Publisher: BioMed Central (London )

ISSN (Electronic): 1742-6405

Publication date (Electronic): 12 May 2020

Publication date PMC-release: 12 May 2020

Publication date Collection: 2020

Volume: 17

Electronic Location Identifier: 14

Affiliations

[1 ]Virology Laboratory, Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management (CIRCB), P.O BOX: 3077, Messa, Yaoundé, Cameroon

[2 ]GRID grid.412661.6, ISNI 0000 0001 2173 8504, Faculty of Medicine and Biomedical Sciences (FMSB), , University of Yaoundé I, ; Yaoundé, Cameroon

[3 ]GRID grid.415857.a, ISNI 0000 0001 0668 6654, National HIV Drug Resistance Working Group (HIVDRWG), Ministry of Public Health, ; Yaoundé, Cameroon

[4 ]GRID grid.449799.e, ISNI 0000 0004 4684 0857, Faculty of Health Sciences (FHS), , University of Bamenda, ; Bambili, Cameroon

[5 ]GRID grid.6530.0, ISNI 0000 0001 2300 0941, University of Rome Tor Vergata (UTV), ; Rome, Italy

[6 ]National Social Welfare Hospital (NSWFH), Yaoundé, Cameroon

[7 ]Mother–Child Centre of the Chantal BIYA’s Foundation (MCC-CBF), Yaoundé, Cameroon

[8 ]University Teaching Hospital (UTH), Yaoundé, Cameroon

[9 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, University of Milan (UM), ; Milan, Italy

[10 ]Mfou District Hospital (MDH), Mfou, Cameroon

[11 ]Mbalmayo District Hospital (MDH), Mbalmayo, Cameroon

[12 ]Nkomo Medical Center (NMC), Nkomo, Cameroon

Author information

Joseph Fokam http://orcid.org/0000-0002-1501-2763

Article

Publisher ID: 270

DOI: 10.1186/s12981-020-00270-7

PMC ID: 7216382

PubMed ID: 32398107

SO-VID: ef2741b7-f6e3-44a1-b4ac-6bd5d7407e4e

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 4 October 2019

Date accepted : 4 May 2020

Funding

Funded by: European and Developing Countries Clinical Trials Partnership (NL)

Award ID: Career Development Fellowship - Training

Award ID: Mobility Action Number 1027

Award Recipient : Joseph Fokam

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ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: programme quality indicators,hiv drug resistance,antiretroviral treatment,adolescents,cameroon

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ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: programme quality indicators, hiv drug resistance, antiretroviral treatment, adolescents, cameroon

Programme quality indicators of HIV drug resistance among adolescents in urban versus rural settings of the centre region of Cameroon

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Most cited references 15

Population-Based Monitoring of Emerging HIV-1 Drug Resistance on Antiretroviral Therapy and Associated Factors in a Sentinel Site in Cameroon: Low Levels of Resistance but Poor Programmatic Performance

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

Declining trends in early warning indicators for HIV drug resistance in Cameroon from 2008–2010: lessons and challenges for low-resource settings

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