Transcript FPAE CASS-RT / Un. Ydé I GRAPS / Un. Ydé II Le programme d’évaluation de l’accès aux ARV au Cameroun Projets ANRS Pr.

FPAE
CASS-RT / Un. Ydé I
GRAPS / Un. Ydé II
Le programme d’évaluation de
l’accès aux ARV au Cameroun
Projets ANRS
Pr. Séverin-Cécile Abega, IRSA / UCAC Yaoundé
Pr JeanPaul Moatti, INSERM/IRD/Université UMR 912 Marseille
Dr. Fred Eboko, IRD UR002 Marseille / FPAE Yaoundé -
Ministère de la Santé Publique
du Cameroun
Un enjeu de santé publique,
une réponse scientifique
Le contexte
 Des baisses successives des prix des ARV au Cameroun
 Une politique de décentralisation inédite
 Un enjeu national et international
Un objectif
 Évaluer un processus en cours et proposer des
connaissances objectives
4 projets de recherche ANRS concernant ce programme
concerté d’évaluation sont déjà en cours
- STRATALL
- EVAL
- POLART
- Passage à l’échelle
STRATALL ANRS 12 110
Pr. Delaporte (IRD Montpellier), Dr Kouanfack (HCY Ydé)
Volet sciences sociales : Pr. Moatti (INSERM), Pr. Abega (UCAC)
« Décentralisation de l’accès antirétroviral en Afrique :
Évaluation de la prise en charge des patients sous ARV dans
des hôpitaux de district selon une approche de suivi allégé »
 Objectifs du volet sciences sociales
 Évaluation de la stratégie «allégée» du point de vue :
- de la qualité de vie
- de l’observance
- de la faisabilité socio-économique
EVAL ANRS 12 116
Pr. Moatti (Inserm Marseille), Pr. Abega (UCAC Yaoundé)
« Impact du programme camerounais d’accès aux ARV
sur la prise en charge et les conditions de vie de la
population infectée par le VIH »
Évaluation de l’impact de l’accès au traitement ARV sur
les conditions de vie des PVVS
–
–
–
–
Observance et efficacité médicale
Qualité de vie
Equité dans l’accès aux ARV
Comportements à risque
Évaluation de l’impact sur le système de santé et
notamment sur les connaissances, attitudes, croyances
et pratiques des PS
– Changements introduits dans l’organisation des soins
– Impact sur les connaissances et pratiques médicales
EVAL ANRS 12 116
Pr. Moatti (Inserm Marseille), Pr. Abega (UCAC Yaoundé)
EVAL, une enquête en 3 phases comportant:
Un volet quantitatif :
– Enquête transversale auprès d’un échantillon aléatoire
de 3151 adultes VIH+ interrogés dans 27 CTA/UPEC
(taux de réponse= 82%)
– Enquête transversale auprès d’un échantillon de 317
personnels soignants des 27 mêmes CTA/UPEC
– Recueil de données sur l’offre de soins
Un volet qualitatif
– Entretiens auprès de patients
– Entretiens auprès de soignants
POLART ANRS 12 120
Dr F. Eboko (IRD/FPAE), Pr. Sindjoun (GRAPS, Un. Ydé 2)
« La problématique de l'accès aux médicaments contre le sida au
Cameroun. Enjeux, avancées, limites et perspectives de la
décentralisation d’une offre de soins »
 Objectifs :
- Identifier les acteurs de la décentralisation des ARV et
de la prise en charge
- Analyser leurs rôles et la configuration qu’ils présentent
- Analyser l’effet de l’implication des partenaires
extérieurs dans le processus de décentralisation
- Appréhender les facteurs qualitatifs qui différencient la
PEC d’un site à l’autre
Financial difficulties
in accessing HIV care in Yaounde,
Cameroon:
first results from the national
cross-sectional survey EVAL-ANRS 12-116
Sylvie Boyer1,2, F.Marcellin1,2, P.O. Zogo3, S.C. Abega4,
R. Nantchouang4, B. Spire1,2, J.P. Moatti1,2
1
Health and Medical Research National Institute (INSERM) Research Unit 379, Marseilles, France
South Eastern Health Regional Observatory (ORS-PACA), Marseilles, France
3 Public Health Ministry - Operational Research Department, Yaoundé, Cameroon
4 Socio-anthropological Research Institute (IRSA) - Catholic University of Central African States,
Yaoundé, Cameroon
2
Aids Impact Conference, session 19: Universal Access to care
Study objectives
to study the extent to which user fees created
financial barriers for access to effective ART
among ART-treated patients in Cameroon in
2006
 by describing health expenditures of ARTtreated patients
 by analyzing factors associated with
financial difficulties in purchasing ART
The EVAL survey (ANRS 12-116)
national, cross-sectional
27 HIV treatment centers in Cameroon
between September 2006 and March 2007
random sample of 3000 PLWHA
aged  21 years
diagnosed HIV for  3 months
first phase of the survey (n=707 PLWHA)
conducted in Yaoundé hospitals and its
neighborhood
Quantitative data collected
patient questionnaire (anonymous, face-to-face)
147 questions including especially:
- socio-demographic and economic aspects
 monthly household income
- disease history, treatments and medical follow-up
- adherence to ART


dose taking during the prior 4 days
respect of time schedule and treatment interruption
- health care consumption and expenditures
 detailed health expenditures of the previous month
 difficulties paying for ART drugs and biological tests
medical questionnaire
blood sample for CD4 count assessment
First phase of the survey (Sept.-Oct.2006)
6 HIV treatment centers in Yaoundé and its
neighborhood
843 eligible PLWHA randomly selected
707 participants (84%) including:
- 532 (75%) ART-treated patients (study sample)
- 83 (12%) waiting for biological results before starting ART
- 78 (11%) never treated and not in process of initiating ART
- 15 (2%) having stopped ART for medical reasons
Healthcare expenditure
total healthcare expenditure in the previous
month
median [IQR] ´106 FCFA
% of monthly household income
9.8 [6.3; 18.6]
15 [7; 34]
 catastrophic health expenditure for 40% of patients
distribution between the main items of health
expenditure (median)
- ART drugs
- transport to hospital
- consulting fees
47%
12%
6%
assistance received
- financial help outside of household or loan
- regular financial help to purchase ART
- free ART
40%
42.5%
4.5%
Financial difficulties in access to care
« During the last 12 months,
did you have difficulties in paying for your lab
tests for the follow-up of your illness? »
yes
no
440 (83%)
267 (17%)
« During the last three months,
has it ever happened that you couldn’t buy
your ART drugs because of a lack of money? »
yes, at least once 107 (20%)
no never
425 (80%)
Univariate models
Not significantly associated with financial difficulties (p>0.05)
gender
educational level *
living in a stable relationship
no. of children in the household
no. of adults in the household
previous month’s health expenditures
CD4 at initiation of ART
history of AIDS-defining events
no. of hospitalizations during the previous 6 months *
time since ART initiation *
* eligible for multivariate analysis (p<0.25)
Univariate models
Financial difficulties
Variables
With
OR [95%CI]
Without
1. Sociodemographic and economic characteristics
age - mean( SD)- years, OR for 10 years
36 (8)
39 (9)
0.7 [0.5; 0.9]
son/daughter of the head of household
10.3%
17.4%
0.5 [0.3; 1.1]
20 [0; 45]
20 [0; 80]
0.3 [0.2;0.6]
19% [8; 47]
13%[6; 33]
1.6 [1.1; 2.3]
monthly household income X 10.6 FCFA
median [IQR]
Previous month health expenditures
as % of monthly household income
median [IQR]
2. Clinical and HIV-related characteristics
CD4 count at the time of survey<200
85%
84%
1.8 [1.1; 2.8]
high adherence to ART
30%
63%
0.2 [0.1; 0.4]
Multivariate models
Variables
OR [95%CI]
p-value
age - OR for 10 years
0.6 [0.5; 0.8]
0.001
son/daughter of the head of
household
monthly household income
0.4 [0.2; 0.7]
0.006
0.3 [0.2; 0.6] <0.0001
Financial difficulties, adherence
and CD4 count
Patients with financial difficulties
are less likely to be adherent to ART
adjusted OR [95% CI] 0.2 [0.1; 0.4] (p<0.0001)
are more likely to have CD4 count < 200 cells/µl
after 6 months of ART
adjusted OR [95% CI]
2.1 [1.1; 3.9] (p=0.02)
Conclusions ...
user fees remain a major barrier to the delivery of
appropriate ART
age, household income and relationship with the
head of household are predictors of financial
difficulties in purchasing ART
patients having financial difficulties are less likely
to be adherent to ART and more likely to be
immunodepressed
... perspectives …
extension of the results to the rest of the country
analysis of the impact of user fees on access to
ART for patients not being treated at the time of
survey
And health financing policy implications
review of the user fees system
- free ART since May 2007 in Cameroon
but ...
26% of patients in our sample will still encounter
catastrophic health expenditures
- free care for PLWHA
development of public financing and new forms
of financing procedures
- Senegal experience
Acknowledgements
PLWHAs who participated in the study
Public Health Ministry of Cameroon
French national agency for research on AIDS
and viral hepatitis B and C (ANRS)
The EVAL team
Healthcare professionals in the 27 hospitals