Abstract
BackgroundRapid scale-up of antiretroviral therapy (ART) and limited access to genotyping assays in low-resource settings (LRS) are inevitably accompanied by an increasing risk of HIV drug resistance (HIVDR). The current study aims to evaluate early warning indicators (EWI) as an efficient strategy to limit the development and spread of preventable HIVDR in these settings, in order to sustain the performance of national antiretroviral therapy (ART) rollout programmes.MethodsSurveys were conducted in 2008, 2009 and 2010 within 10 Cameroonian ART clinics, based on five HIVDR EWIs: (1) Good prescribing practices; (2) Patient lost to follow-up; (3) Patient retention on first line ART; (4) On-time drug pick-up; (5) Continuous drug supply. Analysis was performed as per the World Health Organisation (WHO) protocol.ResultsAn overall decreasing performance of the national ART programme was observed from 2008 to 2010: EWI1 (100% to 70%); EWI2 (40% to 20%); EWI3 (70% to 0%); EWI4 (0% throughout); EWI5 (90% to 40%). Thus, prescribing practices (EWI1) were in conformity with national guidelines, while patient adherence (EWI2, EWI3, and EWI4) and drug supply (EWI5) were lower overtime; with a heavy workload (median ratio ≈1/64 staff/patients) and community disengagement observed all over the study sites.ConclusionsIn order to limit risks of HIVDR emergence in poor settings like Cameroon, continuous drug supply, community empowerment to support adherence, and probably a reduction in workload by task shifting, are the potential urgent measures to be undertaken. Such evidence-based interventions, rapidly generated and less costly, would be relevant in limiting the spread of preventable HIVDR and in sustaining the performance of ART programmes in LRS.
Highlights
Rapid scale-up of antiretroviral therapy (ART) and limited access to genotyping assays in low-resource settings (LRS) are inevitably accompanied by an increasing risk of HIV drug resistance (HIVDR)
Six strongly recommended and two optional early warning indicators (EWI) are proposed by the World Health Organisation (WHO), among which ≥4 feasible EWIs should be chosen for an effective ART programme evaluation [15]
By the end point, a total 27,826 patients were on ART in the entire study clinics, and staffs were all trained on the routine management of people living with HIV
Summary
Rapid scale-up of antiretroviral therapy (ART) and limited access to genotyping assays in low-resource settings (LRS) are inevitably accompanied by an increasing risk of HIV drug resistance (HIVDR). With limited access to reference laboratory equipment (CD4 count, HIV viral load, HIVDR testing) and the use of drugs with low genetic barrier for resistance, HIVDR population-based surveillance and prevention are recommended to ensure long term efficacy of treatment guidelines [8,9,10,11] As response to this crucial need, a national HIVDR working group (HIVDRWG) was created based on the WHO global HIVDR prevention and assessment strategy which includes the laboratory-based surveys of transmitted and acquired HIVDR, and monitoring of HIVDR early warning indicators (EWIs); with the guidelines being recently revised and updated in 2012 [12,13,14,15,16,17]. Results presented in this study are based on WHO HIV drug resistance early warning indicator guidance [15], and not upon the updated 2012 guidance as presented in the latest WHO HIV drug resistance early warning indicator meeting report [16]
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