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Financial Barriers to HIV Treatment in Yaoundé, Cameroon: First Results Of

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Financial Barriers to HIV Treatment in Yaoundé, Cameroon: First Results Of Financial barriers to HIV treatment in Yaoundé, Cameroon: first results of a national cross-sectional survey Sylvie Boyer,a Fabienne Marcellin,b Pierre Ongolo-Zogo,c Séverin-Cécile Abega,d Robert Nantchouang,e Bruno Spire a & Jean-Paul Moatti a Objective To assess the extent to which user fees for antiretroviral therapy (ART) represent a financial barrier to access to ART among HIV-positive patients in Yaoundé, Cameroon. Methods Sociodemographic, economic and clinical data were collected from a random sample of 707 HIV-positive patients followed up in six public hospitals of the capital city (Yaoundé) and its surroundings through face-to-face interviews carried out by trained interviewers independently from medical staff and medical questionnaires filled out by prescribing physicians. Logistic regression models were used to identify factors associated with self-reported financial difficulties in purchasing ART during the previous 3 months. Findings Of the 532 patients treated with ART at the time of the survey, 20% reported financial difficulty in purchasing their antiretroviral drugs during the previous 3 months. After adjustment for socioeconomic and clinical factors, reports of financial difficulties were significantly associated with lower adherence to ART (odds ratio, OR: 0.24; 95% confidence interval, CI: 0.15–0.40; P < 0.0001) and with lower CD4+ lymphocyte (CD4) counts after 6 months of treatment (OR: 2.14; 95% CI: 1.15–3.96 for CD4 counts < 200 cells/µl; P = 0.04). Conclusion Removing a financial barrier to treatment with ART by eliminating user fees at the point of care delivery, as recommended by WHO, could lead to increased adherence to ART and to improved clinical results. New health financing mechanisms based on the public resources of national governments and international donors are needed to attain universal access to drugs and treatment for HIV infection. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español Introduction nent for reaching the goal of universal access to HIV/AIDS care and treatment by 2010.11 After the Bamako Initiative, which was launched at a meeting Cameroon has initiated one of the most dynamic ART of African ministers of health in Mali in 1987, many develop- programmes in Africa, with more than 55 000 HIV-positive ing countries introduced or expanded cost recovery policies patients benefiting from ART in June 2008. This figure rep- by charging patients new or higher user fees at the point of resented about 58% of the estimated number of patients in care delivery, since this was recommended as a way to increase the country requiring ART.12 Until May 2007, treated patients health-care funding and improve access to primary health care had to pay user fees for ART as well as for laboratory tests and 1 and public health services. In all sub-Saharan African coun- physicians’ consultations, even though 40% of the population tries, which pay the highest toll to the AIDS pandemic, more lived under the poverty line.13,14 than half of total health expenditures are borne by households Data from the first phase of the national survey EVAL in the form of direct out-of-pocket payments at the point of (ANRS 12–116) allowed us to assess the extent to which service delivery.2,3 Increasing empirical evidence suggests, user fees created a financial barrier for access to care among however, that the persistence of user fees for antiretroviral ART-treated HIV-positive patients in Yaoundé, the capital of therapy (ART) and HIV/AIDS care decreases adherence 4–8 Cameroon. and treatment effectiveness.9 Other evidence also highlights that user fees undermine both access for the poor and the Methods equity of ART programmes, even when associated with subsidizing schemes and exemption mechanisms targeted at Setting the poorest sectors of the population.10 WHO’s public health The Cameroonian health-care sector includes the public and approach for scaling up access to treatment for HIV/AIDS in private (lucrative and non-lucrative) sectors and a traditional developing countries has explicitly endorsed the provision of sector. Following the recommendations of the Conference “free-of-charge ART at the point of delivery” as a key compo- of Harare on strengthening district health systems based on a INSERM / IRD U912 (SE4S), Université Aix Marseille, 23 rue Stanislas Torrents, 13006, Marseille, France. b ORS-PACA, Observatoire Régional de la Santé Provence Alpes Côte d’Azur, Marseille, France. c Ministry of Public Health, Division of Health Operations Research, Yaoundé, Cameroon. d Socio-anthropological Research Institute, Catholic University of Central African States, Yaoundé, Cameroon. e Social Integration Research and Study Group, Catholic University of Central African States, Yaoundé, Cameroon. Correspondence to Sylvie Boyer (e-mail: [email protected]). (Submitted: 20 November 2007 – Revised version received: 2 June 2008 – Accepted: 14 August 2008 – Published online: 20 February 2009 ) Bull World Health Organ 2009;87:279–287 | doi:10.2471/BLT.07.049643 279 Research Financial barriers to HIV treatment in Cameroon Sylvie Boyer et al. primary care (1987), the government Patients who agreed to participate had reported financial difficulties, after adopted a three-level pyramidal health- to complete a written informed consent adjustment for potential confounding care model with health districts as the form and were referred to a trained in- factors. SPSS software, version 14.0 cornerstone. Cameroon also agreed to terviewer after their clinic visit. At the for Windows (SPSS Inc., Chicago, IL, the above-mentioned Bamako Initiative end of a 45-minute interview, a blood United States of America) was used for in 1987 and by the beginning of the sample was collected for a CD4 count. all analyses. 1990s, fees for inpatient and outpatient services, drugs and biological tests were Data collection Results being charged in all health-care facili- Clinical data, including type of ART ties.15 Characteristics of the study regimens prescribed and immunologi- population Monthly ART prices were estab- cal status (CD4 counts) at ART initia- lished for all HIV treatment centres tion, were obtained from medical files A total of 843 HIV-positive patients until May 2007 at 3000 francs de la com- by care providers. During face-to-face were randomly selected among eligible munauté financière africaine (FCFA), interviews, information was obtained patients who attended the six public or about 6 United States dollars (US$), hospitals during the survey period, and from patients on sociodemographic and for Triomune , and 7000 FCFA, or economic characteristics, disease his- 707 of them agreed to participate in about 14 US$, for other treatments (at tory, treatments and medical follow-up, the survey (response rate, 83.9%). No 1 US$= 492.6 FCFA). The price for adherence to ART, detailed health care significant differences were found -be an initial biological check-up and bi- expenditures over the previous month tween participants and non-participants annual biological monitoring, including and occupational status. except for median CD4 counts (par- CD4 count, was established at 3000 Financial difficulties in purchasing ticipants: 315 cells/µl; non-participants: FCFA.16 Amounts for other services, ART were assessed with the question: 212 cells/µl: Mann-Whitney test, such as medical consultations, drugs for < “During the last 3 months, were you P 0.0001) and transportation time opportunistic infections and hospital- < ever unable to buy your HIV medicines to the hospital ( 1 hour for 72.6% ization, were fixed by each health-care because of lack of money?” Adher- of participants versus 22.9% for non- provider irrespective of a patients’ so- < ence to ART was measured through participants; c² test, P 0.0001). cioeconomic status. a validated list of questions17,18 about Among the 707 participants, 532 In addition, patients who were the doses taken and compliance with (75.2%) were on ART at the time of identified as “indigent” could be ex- the dosing schedule during the prior the survey. Of the non-treated patients, empted from user fees for ART, up to 4 days. This allowed us to compute 73 (41.7%) fulfilled the clinical and a maximum of 10% of patients in each immunological criteria for ART accord- HIV-treatment centre. In practice, how- scores for “high”, “moderate” and “low” adherence to ARV drugs; for the multi- ing to existing guidelines in Cameroon. ever, assessment of indigence, which ART-treated patients had significantly variate analysis, adherence scores were social workers carried out on the basis higher sociocultural status than patients dichotomized into two categories: high of occupation, marital status, number of who were not treated even though they and moderate/low. dependants and availability of financial were eligible for treatment at the time support from a family member, was not Statistical analysis of the survey, both in terms of educa- completely standardized between health- tion and living conditions: 77.2% had care facilities. The present analysis was focused only a high school or university education on the subsample of patients who were versus 67.1% of non-ART-treated Study design on ART at the time of the survey (study eligible patients (P = 0.05), and 41.9% EVAL (ANRS 12–116) is a national population). However, we applied the had tap water at home versus only cross-sectional multicentre survey c² or Fisher test to compare their socio- 26.0% of non-ART-treated patients funded by the French National Agency demographic characteristics with those (P = 0.009). for Research on AIDS and Viral Hepa- of patients eligible for ART who did not As shown in Table 1, the aver- titis and approved by the Ministry of effectively have access to the treatment.
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