Abstract #71  -  Higher risk of unsafe sex and impaired quality of life among patients not receiving ART in Cameroon: results from the EVAL survey (ANRS 12-116)
Authors:   Presenting Author:   Prof Jean-Paul Moatti - INSERM U912
Additional Authors:  Mrs Fabienne Marcellin, Mr Claude Abé, Mr Jérôme Blanche, Mrs Cécile-Renée Bonono, Mrs Maria Patrizia Carrieri, Pr Sinata Koulla-Shiro, Mrs Marie Préau, Dr Bruno Spire, Pr Jean-Paul Moatti,
Aim: The double standard currently used for initiating antiretroviral therapy (ART) in high and in limited-resource settings (with CD4 threshold value at 350 versus 200 cells/l) is controversial both for ethical reasons and for public health considerations. Furthermore, its implications at the individual level are not well documented. This study aimed at evaluating the effect of access to ART at different CD4 levels on health-related quality of life (HRQL), unsafe sexual behaviors, self-reported symptoms and disclosure of HIV status to relatives or friends in a population of HIV-infected outpatients living in Cameroon, a country hardly hit by the AIDS epidemic which has developed a large national program of ART scaling-up with treatment guidelines based on the WHO recommendations.
Method / Issue: The EVAL (ANRS 12-116) survey gathered psychosocial (through face-to-face interviews) and routine clinical data for 3,151 patients attending HIV services (September 2006 - March 2007). Propensity score matching was used to control for differences in demographic/ clinical-immunological characteristics and decentralization level between patients receiving ART or not at the time of the survey. Generalized linear models were used to assess the impact of not receiving ART at different CD4 levels on the normalized SF-12 physical (PCS) HRQL score, inconsistent condom use (ICU) with ones steady partner (either HIV-negative or of unknown HIV status) or with ones casual partners during the previous three months, self-reported symptoms and disclosure of HIV status to at least one person apart from medical staff.
Results / Comments: A total of 2466 patients (78.3%) were receiving ART at the time of the survey, while 685 (27.7%) did not receive any treatment. Each patient from this latter group was matched to a ART-treated patient with similar characteristics, resulting in a study population of 1370 patients. Non-treated patients breakdown was 8.4% (CD4<200 cells/�l or AIDS stage), 5.0% (200<=CD4<=350) and 8.4% (CD4>350). Non-treated patients had significantly (p<0.0001) lower physical HRQL than their treated counterparts (median [IQR] PCS score: 46.3[36.9;53.7] versus 51.5[43.6;56.1]), reported more frequently ICU (56.5% versus 39.5%), more symptoms (6[3;9] versus 5[3;7]) and less frequent disclosure of HIV status to relatives or friends (69.6% versus 78.0%). In the multivariate analysis, not receiving ART was independently associated (p< 0.0001) with impaired physical HRQL, more frequent ICU, more self-reported symptoms and less frequent disclosure of HIV status, whatever the CD4 level.
Discussion: Patients not accessing ART, even with high CD4 level, report impaired psychosocial outcomes. In view of recent data from clinical research in high-resource settings, this pleads for a reconsideration of CD4 threshold values used in treatment guidelines for resource-limited settings in order to maximize the overall impact of ART programmes.
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