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

<div><p>Background</p><p>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.</p><p>Methods</p><p>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 (<i>on-time pill pick-up</i>), EWI₂ (<i>retention in care</i>), EWI₃ (<i>no pharmacy stock-outs</i>), EWI₄ (<i>dispensing practices</i>), EWI₅ (<i>virological suppression</i>). Poor performance was interpreted as potential HIVDR.</p><p>Results</p><p>Only 33.3% (4/12) of sites reached the desirable performance for <i>“on-time pill pick-up”</i> (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 <i>“retention in care”</i> (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 <i>“no pharmacy stock-outs”</i> (11.1% urban versus 25% rural; p=0.02). All 15 sites reached the desirable performance of 0% <i>“dispensing mono- or dual-therapy”</i>. Data were unavailable to evaluate <i>“virological suppression”</i> 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.</p><p>Conclusions</p><p>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.</p></div

Mapping and size estimates of female sex workers in Cameroon: Toward informed policy for design and implementation in the national HIV program.

BackgroundDue to high HIV prevalence among Female Sex Workers (FSWs) in Cameroon (36.5%), this population is especially vulnerable to HIV acquisition and transmission nationwide. Though being prioritized in the national HIV response, it would be relevant to generate statistics on the number of FSWs in order to guide HIV interventions among FSWs. Our objective was to estimate the size of FSWs within hotspots of Cameroon.MethodsA cross-sectional study was conducted from September-November 2015 in selected cities in Cameroon: Bafoussam, Bamenda, Bertoua, Buea, Douala, Kribi, Limbé, and Yaoundé. A programmatic mapping was used, consisting of interviews with secondary key informants (KI) to identify hotspots of FSWs and their respective estimated numbers. Validation of size estimates was done by interviews with FSW at each hotspot. Size estimations in the councils mapped were extended to others not mapped using a Poisson regression model.ResultsA total of 2,194 hotspots were identified: Douala (760), Yaoundé (622), Bamenda (263), Bafoussam (194), Kribi (154), Bertoua (140), Limbé (35), and Buea (26). The estimated total number (range) of FSWs was 21,124 (16,079-26,170), distributed per city as follows: Douala 7,557 (5,550-9,364), Yaoundé 6,596 (4,712-8,480), Bafoussam 2,458 (1,994-2,923), Bamenda 1,975 (1,605-2,345), Kribi 1,121 (832-1,408), Bertoua 1,044 (891-1,198), Buea 225 (185-266), and Limbé 148 (110-148). The variability of estimates among cities was also observed within the councils of each city. The national predicted estimate of FSW population was 112,580 (103,436-121,723), covering all councils of Cameroon. An estimate of 1.91% (112,580/5,881,526; 0.47%-3.36%) adult female population in Cameroon could be sex workers.ConclusionThere are considerable numbers of FSW in major cities in Cameroon. There is a need to prioritize interventions for HIV prevention toward this population in order to limit the burden of HIV sexual transmission nationwide

Definition of EWIs and their respective performance targets.

<p>EWI, early warning indicator</p><p>EWI₄ is cross sectional in nature and is intended to assess pharmacy dispensing practices for populations on ART after any period of time on ART.</p><p>Definition of EWIs and their respective performance targets.</p

Drug resistance-associated mutations at 12 months of ART.

<p><b>Legend </b><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072680#pone-0072680-t004" target="_blank"><b>table 4</b>:</a> PI: protease inhibitor; NRTI: nucleoside reverse transcriptase inhibitor; NNRTI: non-nucleoside reverse transcriptase inhibitor; HIVDR: HIV Drug Resistance.</p

Socio-demographic and medical data of the study population.

<p><b>Legend </b><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072680#pone-0072680-t001" target="_blank"><b>table 1:</b></a> ART: Antiretroviral therapy; HAART: Highly Active Antiretroviral therapy;</p><p>PMTCT: prevention of mother-to-child transmission; IQR: Interquartile range.</p

HIV drug resistance at enrollment on ART.

<p><b>Legend </b><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072680#pone-0072680-t002" target="_blank"><b>table 2</b>:</a> PI: protease inhibitor; NRTI: nucleoside reverse transcriptase inhibitor; NNRTI: non-nucleoside reverse transcriptase inhibitor; HAART: highly active antiretroviral therapy; VL: viral load; LTFU: lost to follow-up; NVP: nevirapine; 3TC: lamivudine; AZT: zidovudine; d4T: stavudine; EFV: efavirenz.</p

Overall Performance of EWIs.

<p>NA, Not available;</p><p>^❖Poor performance interpreted as “Potential HIVDR”</p><p>Overall Performance of EWIs.</p