Providing ARV treatment in a continuum of care

The situation when MSF decided to launch those projects was quite worrying: the average HIV prevalence was of 11%, knowing that only 0.5% of the population was infected 13 years before. This rapid evolution was due to the failure of a weak national prevention policy pursued during the previous 15 years. Confronted to the magnitude of the epidemic, the Cameroonian authorities began to show a true will to fight HIV/AIDS and of the medical institutions to widen access to ARV treatment. When MSF arrived in the country, some attempts had already been made to regulate the situation.

In January 2001, Cameroon became the first country in Africa where MSF introduced ARV treatment for people with limited resources. The first project, in Yaoundé, was opened in January 2001 in a referral hospital, which implies a higher quality of health infrastructures than in the district hospitals. The second project, in Douala, was opened in August 2001 and – unlike as in Yaoundé – concentrated in a district hospital and a sub-divisional medical center: this was the first attempt of decentralizing AIDS treatment in Cameroon. Needless to say, decentralisation must go hand in hand with simplification of treatment protocols and full integration of HIV/AIDS patients into non-specific HIV/AIDS health structures, thereby reducing stigmatisation. The outcome, in 2004, is positive: both projects have reached a high compliance rate and a low drop out of patients.

It is however important to recall that MSF interventions are not only medical, since HIV/AIDS is not only a health problem, but also leads to sociological, political and economical issues. In Cameroon, MSF has provided voluntary counselling and testing (VCT), home based care (HBC), and psychological support to boost good adherence to treatment.

Pharmaceutical implication is also decisive: MSF assisted the Cameroonian public drug procurement agency to get information on ARV patents, and by so doing helped the Cameroonian government to ensure that through the importation and use of generic drugs needed medicines remain available at affordable prices. In 2000, all drugs were purchased from originator companies, but since 2001, generic Indian drugs have been available in the country. This has led to first-line ARV prices dropping from 10 000 US $ to 277 US$ (2001 figures).

Experience gathered in HIV/AIDS comprehensive treatment must then be shared in order to provide and increase know-how: in collaboration with the CNLS (Comité National de Lutte contre le sida), MSF has developed several professional training sessions on medical and psycho-social support, gathering health workers, people living with HIV/AIDS and other actors. Moreover, MSF has committed itself into the empowerment of civil society against HIV/AIDS by supporting the first community access initiative, ICAM (Initiative Camerounaise d’Accès aux Médicaments).

Besides the successes, there are still various difficulties that must be considered and duly solved. In Cameroon, as in other countries, there is still a weak link with TB programs, no strong answer to hepatitis co-infection whose treatment is still very expensive, growing demand of patients for treatment in small health structures, constant need for trained staff, and need to make treatment available for free. But these difficulties are not insurmountable, and should be understood as challenges.

All care providers and related actors have an ethical responsibility to not ever falter in front of such challenges: the only way to go forward is to commit now by providing comprehensive ARV treatment and to collaborate, each to its own capabilities, to avoid duplication of efforts and to maximise efforts.

* Beata Umubyeyi, Médecins Sans Frontières. Contact : beata_fr@yahoo.fr. The PowerPoint slides of her presentation are available on the conference website.