Abstract
HIV infection remains a major public health concern, especially in sub-Saharan Africa. Scaling up antiretroviral treatment is a major challenge, and requires a genuine cascade of care, i.e. a continuum between infection, diagnosis, care, clinical and laboratory follow-up and achievement of an undetectable viral load – the proxy for infection control -. Decentralization of programs is a prerequisite to widen access to this continuum of care. In this thesis, we will explore some of the pitfalls encountered in the context of decentralization of antiretroviral treatment, through the analysis of data retrieved from 2006 to 2013 in studies performed in the Center Region of Cameroon. In a first article, the impact of task shifting from doctors to nurses is assessed using data from the cohort of patients followed in the nine rural district hospitals of the Stratall trial. Our analysis shows that this solution to address the shortage of physicians preserves the clinical and biological outcomes of patients in the first two years of antiretroviral treatment. In a second article, the accuracy of several criteria for identifying treatment failure is assessed for predicting the onset of HIV drug resistance. Notwithstanding the difficulties of deploying biological monitoring tools, our results highlight the importance of evaluating viral load to predict the emergence of resistance, and particularly rapid re-testing after the first notion of detectability to switch patients to second line in a timely manner. The third part of the thesis handles individual issues, and more specifically the gender issue. Our results show that men and women followed in decentralized areas reach similar levels of adherence, but that men's vulnerability under treatment - especially through higher failure rate- is independent of adherence. Finally, the fourth part focuses on routine care provided in the District Hospital of Mfou, Cameroon. Our results add to the growing body of evidence to enable the formulation of public health recommendations on task shifting and definition of treatment failure. They also raise research perspectives as they impair the paradigm of adherence to explain a difference in treatment efficiency between men and women.