Y OF n The Integration of Geospatial Data Into the Surveillance and Management of HIV/AIDS in Cameroon Thesis submitted for the degree of Doctor of Philosophy Paul Foka Lukong 8.4., M. Env. St. School of Social Sciences Geographical and Environmental Smdies National Center for the Social Application of GIS IVlay 2004 . '. THE UÎüIVERSITV LËåät RE#fglruue IF TABLE OF CONTENTS Title page I Table of content ii Abstract X Declaration xiii Acknowledgement xiv Glossary and acronyms XV PART ONE CHAPTER 1 : Introduction 1 1.1 : The global HIV/AIDS situation I 1.2: The Cameroon context 5 1.3: Definition of HIV/AIDS 8 1.4: Origin and transmission of HIV/AIDS virus to humans ll 1.5: Thesis aims and objectives l3 1.6: Outline ofthe Thesis t4 CHAPTER2: Data and Methods t7 2.1: Introduction t7 2.2:}lIY/AIDS data t8 2.3 Types of HIV/AIDS data t9 2.4: Case reporting in Cameroon t9 2.5 : Sentinel surveillance 2l 2.6: Sentinel surveillance in Cameroon (March-July 2000) 24 2.7: Socio-economic data JJ 2.8: Population data 36 2.9:The HIV/AIDS suvey 2001-2002 37 2.10: Ethical clearance and authorizations 38 2.1 I : Pre-testing of questionnaires 40 ll 2.12: Major problems encounter in the field research 45 2.73:Dataon prevention of Mother-to-Child Transmission (PMTCT) of HIV 47 2:14:Data analysis 5l 2 15: Limitations of data from Cameroon 51 2:76: Conclusion 55 CHAPTER 3: The HIV/AIDS Situation in Sub Sahanan Africa and Cameroon 50 3.1: Introduction 56 3.2: Heterosexual transmission 63 3.3: Subpopulations at low-risk of HIV/AIDS: Pregnant women and blood donors 66 3.4: Subpopulations at high-risk of HIV/AIDS: Commercial sex workers, truckers and the military. 72 3.5: Conclusion 18 CHAPTER 4: Access to Preventive and Care Services in Cameroon 79 4.l:Introduction 79 4.2:F,quality, accessibility and Cameroon 81 4.3: Equity and accessibility in Cameroon 84 4.4: Determinants of accessibility to preventive and care services in Cameroon 86 4.5: Expenditures on health services 88 4.6: Household expenditure on health services 88 4.7: Govemment expenditures on health services in Cameroon 9l 4.8: Foreign aid 93 4.9: Availability of preventive and care service personnel 94 4.10: Availability of infrastructure and equipment 97 4.1 1: Cultural influences and accessibility 101 4.12: Physical determinants of accessibility 104 4.l3:Conclusion 109 CHAPTER 5: Current HIV/AIDS Intervention Strategies in Cameroon 110 5.1 : Introduction 110 5.2: Political leadership I l0 5.3: HIV/AIDS programs in Cameroon 112 5.4: Conferences and meetings 115 5.5: Condom use 115 5.6: Treatment of sexually transmitted diseases (STDs) 120 5.7: HIV/AIDS detection in Cameroon t2t 5.8: Peer education 123 5.9: Combating Poverty 125 5.10: Voluntary counselling and testing (VCT) 127 5.11: HIV/AIDS treatment in Cameroon 132 5.12: Barriers to current intervention strategies in Cameroon 139 PART TWO CHAPTER 6: Dealing with HIV/AIDS in Sub Saharan Africa: Benefits and Challenges of a Spatial Approach in Cameroon 142 6.1: Introduction 142 6.2: Potential benefits of spatial data in the management of HIV/AIDS in Cameroon 142 6.3: Geographic information system development in Sub Saharan Africa: The case of Cameroon 149 6.4: Overcoming spatial data deficiencies in Sub Saharan Africa and Cameroon 152 6.5: Conclusion 154 CHAPTER 7: A Spatial Analysis Of HIV-I Prevalence Among Pregnant Women In The Northwest Province of Cameroon 155 7.1: Introduction 155 7.2:The PMTCT data in the Northwest Province 155 7.3: Methodology 159 7.4: Results 162 7.5: Discussion 168 7.6: Conclusion 176 IV CHAPTER 8: A Study of Access to Preventive and HMare Serryices in the Northwest Province of Cameroon 178 8.1 : Introduction 178 8.2: The Data l8l 8.3: Methodology 182 8.2: Results 184 8.5: Discussion 189 8.6: Conclusion 198 CHAPTER 9: Planning Health Serryice Location: The Application of Location-Allocation Models in the Northwest Province of Cameroon 199 9.1: Introduction 199 9.2: Methods 201 9.3: Results 203 9.4: Discussion 210 9.5: Conclusion 213 CHAPTER 10: Recommendations and Conclusions 214 10.1 : Introduction 214 10.2: Major outcomes ofthe study 214 10.4: Implications for the spread of the disease and HIV/AIDS policy 223 10.5: Priorities for the future 228 10.6: Conclusion 230 APPENDICES 231 Appendix 1 231 Appendix 2 233 BIBLIOGRAPHY 243 LIST OF FIGURES Figure 1.1: Global distribution of people living with HIV/AIDS at the end of 2003 J Figure L2: Location'rf Capreroon in Sub Saharan African 5 Figure 1.3: Location of the Northwest Province, Cameroon 7 Figure 1.4: Trends in the prevalence rates of HIV-lAvI and O strains in Cameroon l0 Figure 2.1 : Reported cases of AIDS in Cameroon, 1985-1998 20 Figure 2.2:The first sentinel HIV surveillance sites in Cameroon, 1989-1993 22 Figure 2.3: Sentinel surveillance sample size distribution,200l 26 Figure 3.1: HIV/AIDS seroprevalence rate in Africa at the end of 2002 56 Figure 3.2:HIYIAIDS seroprevalence rate in Africa at the end of 1999 58 Figure 3.3: Percentage increase in prevalence rate in selected Sub Saharan African countries, 1999 -2002 59 Figure 3.4: Percentage decrease in prevalence rate in selected Sub Saharan African countries, 1999 -2002 59 Figure 3.5: Trend in HIV/AIDS prevalence rates in Cameroon, 1986-2000 60 Figure 3.6: HIV/AIDS seroprevalence rates in Cameroon at the end of 2001 6t Figure 3.7: Spatial (Division) distribution of HIV/AIDS seroprevalence rates in Cameroon at the end of 2001 62 Figure 3.8: Inter-generation transmission of HIV/AIDS 65 Figure 3.9: Prevalence rates of antenatal women in some towns of Cameroon 68 F'igure 3.10: HIV prevalence rates among blood donors in two major cities: Douala and Yaounde, 1987 -1997 7l Figure 3.11. Seroprevalence rate for commercial sex workers in selected Sub Saharan African towns, 2000 75 Figure 4. 1 : Percentage of population within 5 km of a health centre in Cameroon, 1999 82 Figure 4.2: Sources of financing health services in Cameroon,1999 89 Figure 4.3: Assistance during births by geographic location 96 Figure 4.4: The indicators of health service availability in Cameroon at the end of 1999 98 Figure 4.5: Accessibility (Yù to district hospital in Cameroon provinces 108 VI Figure 6.1: Seroprevalence of HIV-l for antenatal women in Southem Africa at the end of 1999 144 Figure 7.1: PMTCT health facilities in the Northwest Province of Cameroon at the end of2002 156 Figure 7 .2: The spatial distribution of antenatal attendees tested in the Northwest Province of Cameroo n, 2000-2002 157 Figure 7.3: Seroprevalence rates (%) for villages in the Northwest Province of Cameroon 162 Figure 7 .4: Crude seroprevalence rates (%) among antenatal attendees in the Northwest Province of Cameroon t64 Figure 7.5: Empirical Bayesian HIV/AIDS prevalence rates (%) among antenatal attendees in the Northwest Region Of Cameroon 167 Figure 8.1: Antenatal attendees who tested for HIV virus per facility in the Northwest Province at the end of 2002 180 Figure 8.2: I{IV/AIDS prevalence rates (%)bV PMTCT facility in the Northwest Province of Cameroon at the end of 2002 l8l Figure 8.3: Geographic Distances (kilometers) from population centers to PMTCT facilities in the Northwest Province of Cameroon 186 Figure 8.4: Accessibility index to PMTCT clinics in the Northwest Province of Cameroon 187 Figure 9.1: The current location of PMTCT health clinics in the Northwest Province 204 Figure 9.2: Optimised location of 27 PMTCT health clinics in the Northwest Province of Cameroon 205 Figure 9.3: The existing and optimised average weighted distances to PMTCT facilities in the Northwest Province 206 Figure 9.4: Improvements in health service coverage in the Northwest Province 207 Figure 9.5: Optimal location of 50 health facilities in the Northwest Province 208 Figure 9.6: Spatial distribution of 50 optimal locations of health facilities in the Northwest Province 209 vll LIST OF PLATES Plate 5.1: A roadside kiosk displays apacket of Prudence condoms in Cameroon 119 t/)^ Plate 5.2: AIDS information and education in Cameroon rL7 , Plate 8.1: Front view of a traditional treatment center in Bambui in the Northwest Province of Cameroon t96 Plate 8.2: Traditional medicine used to treat illnesses in the "AIDS treatment camp" in Bambui in the Northwest Province of Cameroon t9 vlll LIST OF TABLES Table 1. I : Global distribution of new HIViAIDS infections and deaths in 2003 4 Table 1.2: Multiple t1'¡re: ciFII\'rlAiÐS subt¡zpes irr Camerccn 9 Table 2.1:Partner's occupation and risk of HIV/AIDS infection 27 Table 2.2: Sample size and seroprevalence by age group among antenatal attendees 29 Table 2.3: Survey respondents by gender and marital status per hospital facility 44 Table 2.4: Respondents by age group per hospital facility 44 Table 2.5: Respondents by occupation and by hospital facility 45 Table 2.6: Antenatal women tested for HIV in PMTCT facilities in Cameroon, 2000-2003 50 Table 3.1: Percentage HIV positive among blood donors in the Yaounde Central Hospital 70 Table 4.1: The comparative structure of mean annual expenditures per capita 90 Table 4.2: Expenditures on health services compared with other Sub Saharan African countries, I 990-1998 93 Table 4.3: Evolution in salaries of govemment workers,1992-1993 (US $) 95 Table 7.1: Antenatal attendees tested, number positive, crude and Bayesian estimates of Subdivisions in the Northwest of Cameroon, 2000-2002 165 Table 8.1: Accessibility (%) of HlV-positives in Shisong and Bamenda General Hospitals, Northwest Province, Cameroon 194 IX ABSTRACT in Cameroon, as in other Sub Saharan Âfiican c(,untîics, HIV/AIDS is a le¡ding cause of morbidity and mortality, with an estimated 1,000,000 HIV infections and an increasing seroprevalence.