Individual and healthcare supply-related barriers to treatment initiation in HIV-positive patients enrolled in the Cameroonian antiretroviral treatment access programme
Authors: Coulaud Pierre-Julien , Protopopescu Camélia , Ndiaye Khadim , Baudoin Maël , Maradan Gwenaëlle , Laurent Christian , Spire Bruno , Vidal Laurent , Kuaban Christopher , Boyer Sylvie ,   for the EVOLCam Group, Maradan G , Ambani A , Ndalle O , Momo P , Tong C , Boyer S , Boyer V , March L , Mora M , Sagaon-Teyssier L , de Sèze M , Spire B , Suzan-Monti M , Laurent C , Liégeois F , Delaporte E , Boyer V , Eymard-Duvernay S , Chabrol F , Kouakam E , Ossanga O , Essama Owona H , Biloa C , Mengue M -T , Mpoudi-Ngolé E , Fouda P J , Kouanfack C , Abessolo H , Noumssi N , Defo M , Meli H , Nanga Z , Perfura Y , Tonye M Ngo , Kouambo O , Olinga U , Soh E , Ejangue C , Njom Nlend E , Simo Ndongo A , Abeng Mbozo’o E , Mpoudi Ngole M , Manga N , Danwe C , Ayangma L , Taman B , Njitoyap Ndam E C , Fangam Molu B , Meli J , Hadja H , Lindou J , Bob Oyono J M , Beke S , Eloundou D , Touko G , Ze J J , Fokoua M , Ngum L , Ewolo C , Bondze C , Ngan Bilong J D , S.Maninzou D , Nono Toche A , Tsoungi Akoa M , Ateba P , Abia S , Guterrez A , Garcia R , Thumerel P , Belley Priso E , Mapoure Y , Malongue A , Meledie Ndjong A P , Mbatchou B , Hachu J , Ngwane S , Dissongo J , Mbangue M , Penda Ida , Mossi H , Tchatchoua G , Ngongang Yoyo , Nouboue C , Wandji I , Ndalle L , Djene J , Gomez M J , Mafuta A , Mgantcha M , Moby E H , Kuitcheu M C , Mawe A L , Engonwei Ngam , Bitang L J , Ndam M , Pallawo R B , Adamou Issiakou , Temgoua G , Ndjie Essaga C , Tchimou C , Yeffou A , Ngo I , Fokam H , Nyemb H , Njock L R , Omgnesseck S , Kamto E , Takou B , Buffeteau L J -G , Ndoumbe F , Noah J -D , Seyep I 
Published: November 2020

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.