MAXIMIZING POSITIVE SYNERGIES - World Health Organization

ased on WHO recommendations for scaling-up ART in resource-limited settings [11, 12]. This
approach allows ART initiation even when CD4 count is not available, using total lymphocytes
count and clinical stage of the disease.
Public subsidies were also devoted to ARV drugs, leading to a progressive reduction in out-ofpocket
payments by HIV-infected patients at the point of delivery, until the achievement of free
access to ART for all eligible patients in May 2007. Foreign aid, in particular from the Global Fund
contributes substantially to the financing of the national programme for access to ART.
In June 2008, 53 238 persons living with HIV/AIDS (PLWHA) – 58% of the estimated number of the
Cameroonians requiring ART according to the National AIDS Control Committee (See Table 1) –
were receiving treatment. This figure constitutes a significant scale-up from the 600 Cameroonians
on ART in 2001, and gives the country one of the highest rates of ART coverage in the world.
In 2006, the Ministry of Public Health of Cameroon requested an evaluation of the national ART
programme.
Researchers from the Universities of Yaoundé and the French Agency for AIDS Research (ANRS)
jointly carried out the evaluation which aimed to assess the programme’s performance according
to the level of HIV-care delivery in the following main areas: (i) early entry to care for HIV patients
and quality of care for ART treated patients, (ii) financial accessibility of HIV-services and equity in
access to treatment, (iii) prevention behaviours.
The evaluation was based on cross-validation of quantitative and qualitative surveys aimed at
collecting original data from patients, health care professionals and public health decision makers.
These data were compared with secondary analysis of existing sources (reports from the Ministry
of Public Health, National AIDS Control Committee (NACC), National Centre for the Supply of
Essential Drugs and Medical Consumables (CENAME), UN and bilateral organizations, the Global
Fund etc.).
A national, cross-sectional survey was conducted in Cameroon from September 2006 to March
2007. Participants were recruited in 27 hospitals delivering HIV care (eight “central” Accredited
Treatment Centres (ATCs) of the two main cities, six ATCs in the provincial capitals and 13 district
managing units (MUs) located in six provinces around the country. Those eligible to participate in
the survey were aged 21 years or older and had been diagnosed as HIV-positive for at least three
months. Participation was proposed to eligible patients who came for a consultation during the
survey period, according to a random selection procedure. At the time of the survey, ARV drugs
were not free; they were delivered to patients at the price of 3000 CFA (Communaute Financiere
Africaine) Francs, or about 6 United States dollars (US$), for Triomune, and 7000 CFA francs, or
about US$ 14, for other treatments (at US$ 1 = 492.6 FCFA).
Among the 3488 patients approached, 3170 (91%) agreed to participate in the survey, and 99% of
those patients filled out the questionnaire, leading to a total sample of 3151 respondents (global
response rate = 90%).
Quality of care according to the level of health care delivery was assessed in the subsample of
patients who had been ART-treated for at least six months by using four main criteria: (1) average
monthly gain in CD4 cells/mm 3 since initiation of treatment; (2) adherence to ART 6 ; (3) occurrence
6 Adherence to ART was measured using a validated list of questions concerning dose taking during the previous four
days, as well as with respect to the time schedule and occurrence of treatment interruptions during the previous four
weeks. These data enabled us to compute two scores for adherence, concerning the previous four days and the previous
four weeks, often used in previous cohort studies.
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