Achieving a high cure rate with direct-acting antivirals for chronic Hepatitis C virus infection in Cameroon: a multi-clinic demonstration project.

OBJECTIVES: Highly effective direct-acting antivirals (DAAs) for Hepatitis C treatment are largely inaccessible in sub-Saharan Africa. Data on treatment feasibility and outcomes in clinical settings are limited. We assessed the feasibility of achieving a high (≥90%) cure rate with DAAs in six gastroenterology clinics in Cameroon. METHODS: Patients with chronic Hepatitis C virus (HCV) infection were treated for 12 or 24 weeks with ledipasvir/sofosbuvir, ledipasvir/sofosbuvir/ribavirin or sofosbuvir/ribavirin, depending on the stage of liver disease and HCV genotype. The cure rate was defined as the proportion of patients with a sustained virological response 12 weeks after treatment completion (SVR12) among all treatment completers. RESULTS: We identified 190 HCV RNA positive patients between September-2017 and August-2018, 161 (84.7%) of whom started treatment. 105 (65.2%) were female, median age was 61.3 years [IQR = 55.9-66.9] and 11 (6.8%) were HIV-positive. Median plasma HCV RNA was 6.0 log10 IU/mL [IQR = 5.6-6.4]. HCV genotypes identified were 1 (34.8%), 2 (13.7%), 4 (50.9%), 1 and 4 (0.6%); 46 (28.6%) strains of 160 single-genotype infections were non-subtypeable. Of 158 treatment completers, 152 (96.2%, 95%CI = 91.9-98.6%) achieved SVR12. Six patients did not achieve SVR12: five carried HCV with NS5A resistance mutations and one with NS5B resistance mutations. Three patients died before and two after treatment completion. The most common adverse events were asthenia (12.0%), headache (11.4%) and dizziness (18.9%). CONCLUSION: High cure rates of Hepatitis C with DAAs are achievable in clinical settings of Cameroon. However, the accessibility and provision of HCV screening, diagnosis, treatment, monitoring and care should be addressed for large-scale implementation.

OBJECTIFS: Les antiviraux à action directe (AAD) hautement efficaces pour le traitement de l'hépatite C sont largement inaccessibles en Afrique subsaharienne. Les données sur la faisabilité du traitement et les résultats en milieu clinique sont limités. Nous avons évalué la faisabilité d'atteindre un taux de guérison élevé (≥90%) avec les AAD dans six cliniques de gastro-entérologie au Cameroun. MÉTHODES: Les patients atteints d'une infection chronique par le virus de l'hépatite C (VHC) ont été traités pendant 12 ou 24 semaines avec le ledipasvir/sofosbuvir, le ledipasvir/sofosbuvir/ribavirine ou le sofosbuvir/ribavirine, selon le stade de la maladie du foie et le génotype du VHC. Le taux de guérison a été défini comme la proportion de patients présentant une réponse virologique soutenue 12 semaines après la fin du traitement (SVR12) parmi tous les patients ayant terminé le traitement. RÉSULTATS: Nous avons identifié 190 patients positifs pour l'ARN du VHC entre septembre 2017 et août 2018, dont 161 (84,7%) ont commencé le traitement. 105 (65,2%) étaient des femmes, l'âge médian était de 61,3 ans [IQR = 55,9-66,9] et 11 (6,8%) étaient positifs pour le VIH. L'ARN plasmatique médian était de 6,0 log10 UI/mL [IQR = 5,6-6,4]. Les génotypes du VHC identifiés étaient 1 (34,8%), 2 (13,7%), 4 (50,9%), 1 et 4 (0,6%); 46 (28,6%) souches provenant de 160 infections à génotype unique n'étaient pas sous-typables. Sur 158 patients ayant terminé le traitement, 152 (96,2%, IC95%: 91,9-98,6%) ont atteint la RVS12. Six patients n'ont pas atteint la RVS12: cinq portaient le VHC avec des mutations de résistance NS5A et un avec des mutations de résistance NS5B. Trois patients sont décédés avant et deux après la fin du traitement. Les événements indésirables les plus courants étaient l'asthénie (12,0%), les céphalées (11,4%) et les étourdissements (18,9%). CONCLUSION: Des taux élevés de guérison de l'hépatite C avec les AAD sont réalisables dans les milieux cliniques du Cameroun. Cependant, l'accessibilité et la fourniture du dépistage, le diagnostic, du traitement, de la surveillance et des soins du VHC devraient être adressés pour une mise en œuvre à grande échelle.

Implementation and evaluation of a therapeutic patient education programme during a clinical trial in Yaoundé, Cameroon - Trial ANRS-12286/MOBIDIP.

OBJECTIVES: High adherence is needed to maintain antiretroviral therapy efficacy. Few attempts at therapeutic patient education (TPE) have been made in sub-Saharan Africa. We describe patients' achievements before intervention and identified needs, TPE programme implementation and evaluation, and patients' satisfaction. METHODS: The TPE programme was proposed to patients in the ANRS-12286/MOBIDIP trial. Beforehand, a directory of competences to manage HIV infection was designed. Patients' HIV-related knowledge and skills assessment was realised, leading to an educational contract. Evaluation was performed using a standardised collection form and a satisfaction survey. RESULTS: Of 154 patients, 146 underwent TPE. During a median of 1.8 years, 47% of patients had ≥3 consultations. Educational assessment revealed limited knowledge about HIV disease. Conversely, patients had frequently managed issues of adherence or disclosure. A median of 12 objectives were considered per patient, and 75% were attained. Objectives from the cognitive domain were less frequently attained. Patients appeared satisfied with the intervention: more emphasis was placed on psycho-affective aspects or experience-sharing than on the acquisition of knowledge. CONCLUSION: Active listening, know-how and a space for discussion appear more important for patients than knowledge on disease or treatments. PRACTICE IMPLICATIONS: In HIV care, the directory of learning objectives should be revised to include more objectives concerning practical skills for disease management.

Prevalence of HIV infection among people with disabilities: a population-based observational study in Yaoundé, Cameroon (HandiVIH).

BACKGROUND: In resource-limited settings, people with disabilities have been left behind in the response to HIV. In the HandiVIH study, we estimate and compare HIV prevalence and associated risk factors between people with and without disabilities. METHODS: In this cross-sectional, population-based, observational study, we used two-phase random sampling to recruit adults with disabilities and a control group matched for age, sex, and residential location from households of the general population. We used the Washington Group Short Set of Questions on Disability to identify people with disabilities. We administered an HIV test and a life-course history interview to participants. The primary outcome was the prevalence of HIV among participants with and without disabilities. FINDINGS: Between Oct 2, 2014, and Nov 30, 2015, we recruited 807 people with disabilities and 807 participants without disabilities from Yaoundé, Cameroon. 28 of 716 people in the control population had a positive HIV test result (crude prevalence 3·9%, 95% CI 2·9-5·3) compared with 50 of 739 people with disabilities (6·8%, 5·0-8·6; conditional odds ratio [OR] 1·7; p=0·04). Women with disabilities were more often involved in paid sexual relationships than were women without disabilities (2·5% vs 0·5%, p=0·05). People with disabilities were also at increased risk of sexual violence than were women without disabilities (11·0% vs 7·5%, OR 1·5; p=0·01). Sexual violence and sex work were strongly associated with increased risk of HIV infection among participants with disabilities but not among controls (OR 3·0, 95% CI 1·6-5·6 for sexual violence and 12·3, 4·4-34·6 for sex work). Analyses were done in men and women. INTERPRETATION: The higher prevalence of HIV infection in people with disabilities than people without disabilities reflects a higher exposure to HIV infection as well as the presence of disability-associated HIV infection. The susceptibility of people with disabilities to HIV infection seems to be shaped by social and environmental factors. Research is needed to inform firm recommendations on how to protect this vulnerable population. FUNDING: Agence nationale de recherches sur le sida et les hépatites virales (ANRS-Inserm) and the 5% Initiative.

HandiVIH--A population-based survey to understand the vulnerability of people with disabilities to HIV and other sexual and reproductive health problems in Cameroon: protocol and methodological considerations.

INTRODUCTION: In resource-limited countries, people with disabilities seem to be particularly vulnerable to HIV infection due to barriers to accessing information and services, frequent exposure to sexual violence and social exclusion. However, they have often been left behind in the HIV response, probably because of the lack of reliable epidemiological data measuring this vulnerability. Multiple challenges in conducting good quality epidemiological surveys on people with disabilities require innovative methods to better understand the link between disability and HIV. This paper describes how the design and methods of the HandiVIH study were adapted to document the vulnerability of people with disabilities to HIV, and to compare their situation with that of people without disabilities. METHODS AND ANALYSIS: The HandiVIH project aims to combine quantitative and qualitative data. The quantitative component is a cross-sectional survey with a control group conducted in Yaoundé (Cameroon). A two-phase random sampling is used (1) to screen people with disabilities from the general population using the Washington Group questionnaire and, (2) to create a matched control group. An HIV test is proposed to each study participant. Additionally, a questionnaire including a life-event interview is used to collect data on respondents' life-course history of social isolation, employment, sexual partnership, HIV risk factors and fertility. Before the cross-sectional survey, a qualitative exploratory study was implemented to identify challenges in conducting the survey and possible solutions. Information on people with disabilities begging in the streets and members of disabled people's organisations is collected separately. ETHICS AND DISSEMINATION: This study has been approved by the two ethical committees. Special attention has been paid on how to adapt the consenting process to persons with intellectual disabilities. The methodological considerations discussed in this paper may contribute to the development of good practices for conducting quantitative health surveys on people with disabilities. TRIAL REGISTRATION NUMBER: NCT02192658.