Community participation in the retention of adults in HIV care in the Muyuka Health District, South-West Region, Cameroon

Introduction Antiretroviral therapy (ART) is vital for people living with HIV (PLWHIV) and a substantial number of HIV/AIDS patients still face stigmatization from family and other members of the community. Stigma could lead to poor retention in HIV care and consequently result in decreased chances of survival and increased risk of HIV transmission. The aim of this study was to determine the retention of patients in HIV care and community participation in the retention of patients in HIV care at the Muyuka Health District, South-West Region, Cameroon. Methods This was an analytic cross-sectional retrospective study where 385 hospital records of people living with HIV (PLWHIV) enrolled in HIV care were reviewed, and we administered 348 questionnaires to community members. Data were collected and analysed using bivariate analysis and chi-square test. The Susan Rifkin's scoring method was used to measure community participation. Statistical significance was set at P-value < 0.05. Results A total number of 112(29.1%) of people living with HIV (PLWHIV) enrolled in HIV care were retained in HIV care against 273(70.9%), who were lost to follow-up over a two year and four months period. Patients on a Zidovudine containing ART regimen were about 7 times more likely to be lost to follow-up (OR 6.92; 95% CI 1.80-26.60, P-value = 0.005). The overall community participation in the retention of adults in HIV care in the Muyuka Health District was low; mean resource allocation score = 2.43, mean leadership score = 1.0; mean organization factor score = 1.30; but the mean needs assessment score was good (4.0). Conclusion retention of patients enrolled in HIV care, and the community participation in the retention were low. Collaborations between health care structures and community initiatives should be resourced to foster continuum of care for people living with HIV (PLWHIV).


Introduction
Antiretroviral therapy (ART) is essential for Human Immunodeficiency Virus (HIV) infected patients to ensure increased survival and decreased HIV transmission. Retention in care is the ability to adhere to critical aspects of care such as attending regular follow-up appointments, scheduled laboratory tests and other monitoring activities as prescribed by the health care provider [1]. Majority of the people living with HIV worldwide are in sub-Saharan Africa, with an estimated 25.5 million cases out of the 36.7 million cases recorded worldwide [2]. Among this group, 19.4

million are living in East and
Southern Africa which saw 44% of new infections globally in 2016 [2]. As of July, 2017 out of the 36.7 million people living with HIV, an estimated 20.9 million people living with HIV (PLWHIV) were accessing ART globally implying that 15.8 million people living with HIV (PLWHIV) do not have access to antiretroviral therapy [2]. In consequence, 1 million people died from AIDS-related illness in 2016 [2]. In 2016, it was recorded that there are about 560,000 PLWHIV in Cameroon and only about 37% of these patients have access to ART [3]. Since the year 2000, an estimated 25 million deaths have been recorded among people living with HIV with most of these deaths observed in Sub-Saharan Africa [4]. Due to the HIV/AIDS related mortality, there have been tremendous global efforts from the global health community, leading governments and civil society organizations by scaling-up treatment for HIV patients [5]. The HIV pandemic does not only affect the health of individuals but has an impact on households, communities, and the development of economic growth of nations since majority of these countries, mostly affected by the pandemic, also suffer from other infectious diseases, food security and other serious problems [6]. A consensus was reached on the fact that communities should be actively involved in improving their own health [7]. Community participation in health programmes consists of an adequate response to the needs of the community, designing health programmes aimed at mitigating health problems that greatly affect the community, and foster the increase of public accountability of health problems [7,8]. The growing HIV burden on families and health systems is exerting a shift toward community care-givers and increasing the demand for functional community systems [6]. In Cameroon, the HIV pandemic is against a weak health system where, the role of the community is poorly understood. It was therefore imperative to conduct a study on community participation in the retention of adults in HIV care in the Muyuka Health District (MHD).

Methods
This was an analytic cross-sectional retrospective study, conducted at The limitations of this study entailed that the retrospective nature of the study at its discretion reduce the statistical power and lead to biased estimates attributable to missing data from patient files and the cross-sectional nature of the study may not lead to the study of cause and effect.

Results
The study participants were females 284 (73.8%) and 101 (26.2%) were males (  ART regimen were about 7 times more likely to be lost to follow-up (OR 6.92; 95% CI 1.80-26.60, P-value = 0.005), compared to those on a Tenofovir containing ART regimen ( Table 3). The overall level of community participation of adults enrolled in HIV care was low. The mean score of the needs assessment factor was very good (mean score of approximately 4/5), the mean score of the leadership factor was very low (mean score of approximately 1/5). The mean score on the resource allocation factor was low (mean score of 2.43/5). In addition, the mean score on the organizational factor was very low (mean score of 1.3/5) (Figure 3).

Discussion
This study was conducted to determine community participation in the retention of adults in HIV care in the Muyuka Health District. In this study, the overall retention rate (29.1 %) was different from that described in a systemic review of patient retention in ART programs in sub-Saharan Africa (60%) [10,11]. The findings from this study were also different from a study conducted in South Africa which showed that, lower health facilities were quite effective managing patients once task shifting, mentoring and community support for the patients were made an integral part of the scale up of HIV care [12].
On the other hand, the low retention rate of this study was similar to a study conducted in Uganda where patients enrolled in HIV care had a retention rate of 48%, because patients in this study were not routinely followed-up at the level of the community [13]. Possible explanations of the poor retention in HIV care in the MHD could be due to financial constraints, patient feeling better after registering some improvements, poor social support from partners and family members, fear of being stigmatized and low community-based followup of patients accessing care at the MHD, and the ongoing sociopolitical crises in the South West region of Cameroon. Loss to followup in this study within two years and four months was high (70.9%).
This was different from findings of the ART-link Collaboration that analysed 18 HIV cohorts across developing countries which reported a 15% loss to follow-up in the first year [14]. Possible reasons leading to loss to follow-up in this study could be due to financial constraints limiting repeated travel to the unit, myths about ART, competition with traditional medicine, lack of disclosure, lack of home based support and fears of losing one's social status. There was a statistically significant association between ART regimen and appointment adherence. Patients on a Zidovudine containing ART regimen were more likely to be loss to follow-up compared to patients on a Tenofovir containing ART regimen. This could be due to the fact that Zidovudine has more serious side effects than Tenofovir and could lead to lack of interest to continue treatment on the part of the patient [15]. There was no statistically significant association between gender, age groups, weight, CD4 lymphocyte count and WHO staging of HIV patient. The overall community participation was low. Although there are not many readily available publications providing adequate evidence supporting our findings from this research, a few of the available literature shows an unambiguous positive impact of community support on a wide range of aspects, including access and coverage, adherence, virological and immunological outcomes, patient retention and survival [12,16]. The evidence suggests that a durable programme of universal access to ART will not only require a new level of performance of the regular health system, but also the mobilisation of additional human resources namely: the community as a whole and community care givers in particular [17,18]. In addition, the review demonstrates that community support initiatives are effective strategies to address the current HIV/AIDS epidemic.
Given the pressure on health systems and their professional staff, the existing evidence suggests that programmes on community health workers, although not necessarily cheap or easy, remain a good investment to improve coverage of communities with much needed health services, such as ART [13,19].

Conclusion
The retention rate of patients enrolled in HIV care was low (29.1%) as well as the level of community participation in the retention of adults in HIV care. We recommend that community members should participate more in activities that enhance the retention of patients in

Acknowledgments
Authors acknowledge the enormous support of all those who contributed to the success of this study.