Challenges and barriers to HIV service uptake and delivery along the HIV care cascade in Cameroon

Introduction The year 2017 marked a transition period with the end of the implementation of Cameroon´s 2014-2017 HIV/AIDS National Strategic Plan (NSP) and the development of the 2018-2022 NSP. We assessed barriers and challenges to service delivery and uptake along the HIV care cascade in Cameroon to inform decision making within the framework of the new NSP, to achieve the UNAIDS 90-90-90 target. Methods We conducted a cross sectional descriptive study nationwide, enrolling HIV infected patients and staff. Data were collected on sociodemographic characteristics, HIV testing, antiretroviral therapy and viral load testing delivery and uptake and factors that limit their access. Results A total of 137 staff and 642 people living with HIV (PLHIV) were interviewed. Of 642 PLHIV with known status, 339 (53%) repeated their HIV test at least once, with range: 1-10 and median: 2 (IQR: 1-3). Having attained secondary level of education (OR: 2.07, 95% CI: 1.04-4.14; P=0.04) or more (OR: 2.91, 95% CI: 1.16-7.28; P=0.02) were significantly associated with repeat testing. Psychological (refusal of service uptake and existence of HIV), community-level (stigmatization and fear of confidentiality breach) and commodity stock-outs “HIV test kits (21%), antiretrovirals (ARVs) (71.4%), viral load testing reagents (100%)” are the major barriers to service delivery and uptake along the cascade. Conclusion We identified individual, community-level, socio-economic and health care system related barriers which constitute persistent bottlenecks in HIV service delivery and uptake and a high rate of repeat testing by PLHIV with known status. Addressing all these accordingly can help the country achieve the UNAIDS 90-90-90 target.


Introduction
The continuum of care (also referred to as the cascade of care) for successful HIV treatment includes: HIV testing, linkage, engagement in care, and retention on antiretroviral therapy (ART) with viral suppression as the ultimate clinical goal to improve individual health outcomes of people living with HIV/AIDS (PLHIV) and reduce HIV acquisition and transmission, thus conferring community and public health benefits [1]. Over the last decade, millions of individuals in sub-Saharan Africa (SSA) have started ART, however, low HIV testing rates and losses between the point of testing and the initiation of ART have mitigated this success, and the majority of people in need of treatment are not receiving it [2]. Several studies have described the performance of service delivery and uptake or dwelled on barriers to uptake of services and attrition along the HIV care continuum cascade for the general population and in pregnant women across the world including SSA [3][4][5][6][7][8][9][10][11]. The factors identified are individual, socio-economic or community-level or health system related factors.
Efforts are needed to optimize the HIV care continuum in order to achieve the 90-90-90 target, that is by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression [12]. Key to these efforts will be to overcome and/or eliminate legal, social, environmental, and structural barriers that prevent PLHIV from accessing and utilizing HIV services [13]. In 2015, Cameroon subscribed to the UNAIDS 90-90-90 ambitious target which aims to end the AIDS epidemic in 2030. Several efforts have therefore been undertaken by the Cameroonian government to provide HIV services to all Cameroonians by breaking financial, social and geographical barriers in order to achieve this target in 2020. As of 31 st December 2016, 2 418 986 HIV tests were done but the number of people tested is not known. Also, the ART coverage amongst PLHIV was 32% [14] far below the 60% objective set by the 2014-2017 NSP.
Furthermore, only 46 993 viral load tests were done within the same year amongst the 168 349 PLHIV on ART at the end of the year 2015.
As we get close to the year 2020, to achieve the 90-90-90 ambitious target, ART has experienced a rapid scale-up with the adoption of the test and treat strategy, systematic offer of HIV-testing in health facilities, decentralisation through the creation of more ART and option B+ sites across the country, community dispensation of ART to stable PLHIV on ART and the enrollment of 8 reference laboratories to conduct viral load (VL) testing covering the 10 regions of the country and reduction of the cost of the test. It is in this context that we sought to explore factors associated with attrition along the HIV care cascade in an attempt to contribute in the reorientation and reinforcement of strategies within the framework of the new 2018-2022 HIV/AIDS NSP, so as to achieve the UNAIDS ambitious 90-90-90 target. More specifically, we sought to determine the magnitude of repeat testing among PLHIV with a previous HIV diagnosis.

Methods
Study setting: the study was conducted on the national scale in health facilities (ART and PMTCT services, laboratories, and outpatient department), regional drug procurement/distribution institutions (regional funds for the promotion of health (RFPH)), regional technical groups (RTG) for the fight against AIDS and reference laboratories for viral load testing (a total of 8 laboratories were operating as of 31 December 2016). ART and PMTCT sites provide HIV screening and treatment services to the general population and pregnant women respectively. There are two categories of ART sites: approved treatment centers (ATC) which are found in health facilities of 1 st , 2 nd and 3 rd , categories of our health system and HIV management units (HMU) found in 4 th , 5 th and 6 th category facilities.
Study design and population: we conducted a cross-sectional and descriptive study from 8 th May to the 10 th of July 2017 to assess service delivery and uptake at the various stages of the HIV care cascade. Participants for this study were PLHIV enrolled on ART and staff in: i) health facilities (ART services, PMTCT services, laboratories and outpatient department): medical doctors and nurses, ii) national and regional drug procurement and distribution institutions (pharmacist or ware house in-charge) and iii) HIV viral load testing reference laboratories (laboratory in-charge), iv) mobile HIV testing units in RTGs (psychosocial support agents). A total of 25 sites were sampled nationwide of which 12 rural and 13 urban, 9 ATC and 16 HMU, 19 public and 6 private. The sample size of PLHIV was calculated using the formula: [15] Where n = sample size, Z(1-α/2 )= upper (1-α/2) quantile of the standard normal distribution, P= proportion of PLHIV with a previous HIV diagnosis who repeat their HIV test (we don´t have much information on the subject to begin with, so we assumed that half of PLHIV repeat their HIV test after previous HIV diagnosis) and d= precision.
Assuming a level of precision of 4% and a confidence level at 95%, we calculated a sample size n= 1.962 x 0.5 x (1-0.5)/0.042 = 600 PLHIV. An additional 10% was added to account for non-respondents, resulting in a sample size of n= (0.1x600) + 600 = 660. The sample size obtained was then distributed to the sites proportionally to the size of regular PLHIV ART users. A systematic sampling technique was used to select PLHIV in ART sites from a list which was drawn and numbered. Staff were conveniently sampled. Data was collected with the use of semi-structured questionnaires which were administered in the study sites during a face-to-face interview by trained interviewers in the participants´ preferred official language (French or English).
Interviewers were made up of staff from NACC, RTG and facilities (psychosocial agents). The questionnaires included sociodemographic characteristics, knowledge and questions regarding HIV testing, care and treatment and viral load testing service delivery and uptake.
Statistical analysis: at the end of data collection, questionnaires were sorted out to check for errors and any missing information. Data was entered and analysed with Epi info 7 software. Data double checking was done before analysis to ensure consistency and accuracy. Some variables were recoded to facilitate analysis. We used descriptive statistics in the form of proportions (%) for categorical data, mean if data followed normal distribution with standard deviation otherwise median with interquartile range for continuous data. Chi-square and Fisher´s exact test (if expected counts less than 5) were used to compare proportions and associations with outcome variables (repeat testing and ART discontinuation). For bivariate analyses, associations between outcome variable and covariates were quantified using odd ratios (OR) with 95% confidence interval (CI). Variables found to be associated with p-values less than 0.25 were reexamined in a logistic regression model. P-values less than 0.05 were considered statistically significant.
Ethical considerations: administrative authorizations (hospital, regional fund and viral load testing laboratory directors, regional coordinators for the fight against HIV) were obtained. Ethical clearance was obtained from the national ethics committee for human research. Informed consent was also obtained from study participants and each was assigned a unique identification code which was written on the questionnaire.
The age ranged from 12 to 78 years and the mean age was 41±11.03 years. Most PLHIV interviewed were married (43%), and more than half attended secondary school while more than 1/4 had never been to school ( Table 1). As shown in Table 2  Barriers to HIV testing were identified at all levels: health system, community-level and patient-level. PLHIV (N=995) reported stigmatisation (53%), fear of confidentiality breach (21%) and insufficient counselling (11%) as major barriers to HIV screening uptake while staff (N=146) reported refusal by patients to get tested (25%), HIV test kits stock-outs (21%), and fear to know HIV status (10%) as the major barriers to HIV screening delivery. Also, 5% (52/995) of PLHIV and 8% (11/146) of staff in health facilities reported the cost of the HIV test was a barrier to HIV testing (Table 3).
On assessment of barriers to ART uptake by PLHIV (n=986), stigmatization (51%), fear of confidentiality breach (20%) and insufficient counseling (12%) were the most reported while staff reported refusal by patients to initiate ART (2/5) and their clinical condition (2/5) as the most common barriers to ART delivery (Table 4). In health facilities and regional drug procurement and distribution institutions, most staff interviewed (20/28, 71.4%) reported pediatric ARV stock-outs within the last 3 months before the study and the length of stock-outs ranged from 7 to 60 days (Table 5).
Concerning viral load testing delivery and uptake, of the 7 VL reference laboratories surveyed, 6 reported interruption of viral load testing delivery within the last 12 months before the study and all these laboratories encountered reagent stock-out as main reason for interruption. Other reasons included VL testing machine breakdown (1/6) and staff shortages (1/6) ( Table 6). Despite the fact that VL testing was recently instituted as a work-up for follow-up, 71% (456/642) of patients interviewed were aware of VL testing and 78% of these (358/456) had performed a VL test at least once since they initiated ART. Viral load testing reagent stock-out (49%), viral load testing machine breakdown (12%), lack of information/ignorance (9%) and distance to laboratory (6%) were the most reported barriers to VL testing delivery (Table 7). We assessed staff availability for the delivery of services along the HIV care cascade, of 106 staff interviewed in facilities, 53% (56/106) reported staff shortage.

Discussion
In our study we found a high proportion of repeat HIV testing amongst PLHIV who know their status, especially within the first 3 months following initial diagnosis. Our reporting system double counts all the HIV positive individuals and sums them, thus inflating the number of PLHIV making it appear that there is a greater loss to follow-up between testing positive and enrolling in care than actually exists. This has a serious impact on planning and response to the HIV epidemic as resources might be wasted. Contrary to our findings, repeat/multiple testing has been mostly reported in people with prior HIV negative or unknown statuses [16][17][18][19][20]. Secondary and higher levels of education were associated with increasing odds of ever being tested, similar to findings in studies in SSA and Europe [16,17,20].
Sex was not associated with repeat HIV testing in our study as

What is known about this topic
• There exist barriers to HIV testing, access to antiretroviral therapy and viral load testing at the patient-level, community-level and health-system; • Staffing shortage in the health system is a challenge for HIV service delivery.

What this study adds
• There is a high rate of repeat testing among PLHIV with a previous HIV diagnosis which is not properly captured by the reporting system. Our data collecting system is still mainly paper-based, the use of unique identifier code, case based surveillance and electronic medical records therefore appear as necessities. There is also a need to understand and better address reasons for repeat testing among PLHIV with known status.

Competing interests
The authors declare no competing interests.

Authors' contributions
Albert Frank Zeh Meka, Serge Clotaire Billong, Ismael Diallo, and Georges Nguefack-Tsague designed the study, coordinated data collection and interpretation of data and revised the manuscript.
Albert Frank Zeh Meka did the data analysis and drafted the manuscript. Ousseni Wendlassida Tiemtore contributed to the design of the study and interpretation of data and revised the manuscript, Brian Bongwong contributed to the design of the study, data collection and interpretation of data and revised the manuscript. All authors approved the final version of manuscript.

Acknowledgments
We are grateful to all staff in the various institutions and facilities that were involved in the study and all the study participants that consented to participate in the study. Table 1: socio-demographic characteristics of patients   Table 4: barriers to ART uptake and delivery Table 5: history of ARV stock-outs in ART sites and supplying institutions Table 6: history of and reasons for interruption of viral load testing activities in reference laboratories within the last 12 months before the study       1 25 *Staff from ART sites and Regional Funds for the Promotion of Health, which supply all health facilities with ARV ** Staff reported only pediatric ARV experienced stock-outs. The mean length of pediatric ARV stock-outs was 28 days