Towards HIV Epidemic Control in Cameroon
Overview
This policy briefing synthesizes key insights from the Cameroon Townhall for Healthcare Professionals meeting held in July 2023, at which Dr. Rogers Ajeh, Deputy Permanent Secretary of the National AIDS Control Committee, reviewed the history, current status and future of Cameroon's HIV response.
Context
Cameroon has over half a million people living with HIV and is close to the 95-95-95 targets for adults, but children and adolescents lag behind, viral load coverage is low, and the response depends mainly on the Global Fund and PEPFAR.
Key issues
- Children and adolescents left behind. About 45% of children with HIV are diagnosed, and mortality in children and adolescents is not falling; mother-to-child transmission persists.
- Low viral load coverage. Only 62% of people on treatment had a viral load test in 2022.
- Key populations and PrEP. Legal barriers, weak size estimates and poor PrEP uptake limit prevention where incidence is highest.
- Donor dependence. About 80% of 2024 to 2026 funding comes from the Global Fund and PEPFAR, and health receives less than 5% of the national budget.
- Data and safety gaps. No unique patient identifiers, weak mortality data, few gender data, and no pharmacovigilance sentinel sites, while concerns were raised about weight gain and hypertension on dolutegravir.
Discussion highlights
- Treat all, provider-initiated testing and a stable supply chain were credited for adult progress.
- Injectable PrEP for key populations was seen as the expected first use of long-acting drugs.
- Participants called for health worker sensitisation on PrEP and prioritising pregnant women.
- Pediatric HIV was named the top priority by both the speaker and Dr. Titanji.
- Dual HIV and syphilis testing in antenatal care supports triple elimination.
Recommendations
- Close the pediatric gap. MINSANTE, the NACC and partners should scale early infant diagnosis, antenatal testing and mentor mother programmes, especially in the Far North and crisis-affected regions. First step: a pediatric and adolescent cascade review by region to target the lowest-performing districts.
- Raise viral load coverage. The NACC and regional delegations should expand sample transport and laboratory capacity so every patient on treatment gets an annual viral load test, starting with children, adolescents and pregnant women.
- Expand prevention for those at highest risk. The NACC should use the PrEP evaluation and the key population survey to extend PrEP eligibility, train health workers and community-based organisations on PrEP, and prepare an evidence-based case for injectable PrEP.
- Prepare for transition. MINSANTE and the Ministry of Finance should raise domestic HIV and health funding, use the public-private partnership and universal health coverage, and build local organisations' capacity to manage grants. First step: a costed transition plan agreed with PEPFAR and the Global Fund.
- Monitor drug safety and long-term outcomes. The NACC should set up pharmacovigilance sentinel sites to track weight gain, hypertension and other effects on dolutegravir and integrate screening for non-communicable diseases and cervical cancer into HIV care, as the revised guidelines propose.
- Improve data. Use universal health coverage to assign unique patient identifiers, link HIV systems to DHIS2, and work with civil registration on mortality data. Diaspora researchers can support analysis.
Next steps
The 2024 to 2030 national strategic plan and revised treatment guidelines were due for validation. The Chair invited Dr. Titanji to work with the NACC and to return on HIV cure and aging.
Conclusion
Cameroon has turned HIV from a death sentence into a manageable condition for most adults. Participants agreed that the next gains depend on reaching children, adolescents and key populations, measuring viral suppression for everyone, and making the response less dependent on external funding.
Meeting minutes
Agenda
- Welcome by the Chair, Dr. Munoh Kenne Foma
- Reflections by the moderators and introduction of the speaker by Dr. Bryan Tegomoh
- Presentation by Dr. Rogers Ajeh: HIV in Cameroon, past, present and future
- Discussion and Q&A
- Reflections by Dr. Boghuma Kabisen Titanji
- Closing remarks
Opening remarks
- The Chair said HIV changed modern medicine, from the first treatments for viral infections to the way prevention and sexuality are discussed, and recalled that Ghanaian colleagues had asked him how Cameroon set up its HIV model. He noted that Cameroon created a national AIDS control committee early.
- Dr. Tegomoh said he had met Dr. Ajeh about ten years earlier through the IeDEA project and that HIV research had shaped how other infectious diseases are approached.
- Dr. Katte said the HIV community broke the paternalistic model of medicine and showed that people living with a condition have an advocacy voice in research and care.
- Dr. Tegomoh introduced Dr. Ajeh as Deputy Permanent Secretary of the National AIDS Control Committee, with a PhD in public health and research on HIV.
Presentation
1. History of the response
Dr. Ajeh traced HIV from the first US reports in 1981 to Cameroon's first case in 1985 and the creation of the National AIDS Control Committee in 1986, the body that leads the multisectoral response. He cited milestones that shaped Cameroon's programme: effective combination therapy in 1996, the Global Fund and PEPFAR (PEPFAR active in Cameroon from about 2008), free antiretrovirals in Cameroon, provider-initiated testing adopted in 2007, and the end of the US travel ban for people with HIV in 2010.
2. Treat all and U=U
Cameroon adopted the treat all strategy in May 2016, after the START and TEMPRANO trials showed better outcomes with early treatment. He said the CD4 thresholds and paid pre-treatment tests used before had caused many patients to be lost before starting treatment, and that his PhD work showed treat all improved uptake, retention and viral suppression. He called 'undetectable equals untransmittable' one of the most important messages in the response: it reduces stigma and gives hope, and IeDEA data showed about 22% of people on treatment were in serodiscordant couples. An evaluation of the current plan found this message was not reaching enough people.
3. Where Cameroon stands (2022)
Of over half a million people living with HIV, about 95 to 96% knew their status, 92% were on treatment, 62% had a viral load test and about 89% of those tested were suppressed. Children were far behind: about 45% diagnosed, 87% of those diagnosed on treatment, 62% viral load coverage and 80% suppression; adolescents had about 57% testing coverage, 46% viral load coverage and 82% suppression. Prevalence has fallen steadily since 2004 and mortality is declining in adults, but not in children and adolescents. Incidence is highest at ages 20 to 24, prevalence is highest in the Centre and Littoral regions with the South West rising, and mother-to-child transmission remains about 5% in the first six months and higher at 18 months (he gave about 17%).
4. Key populations and PrEP
Prevalence is highest among transgender people, then men who have sex with men and female sex workers, but he said the data are weak because laws push these groups into hiding. An integrated biological and behavioural survey was about to start data collection to estimate their size (currently put at about 7,000, which he said is far too low) and their HIV, syphilis and hepatitis prevalence. PrEP is limited by policy to men who have sex with men and female sex workers, uptake has been poor, and a national evaluation was under way to see whether to extend it to people who inject drugs, transgender people and others.
5. The 2024 to 2030 national strategic plan
The new plan, due for validation, aims by 2030 to cut new infections by 70% and HIV-related deaths by 50%, reduce stigma and discrimination while promoting human rights and gender equality, and improve governance and accountability. It needs over US$1 billion. For 2024 to 2026, about US$500 million is needed: the Global Fund provides about 41% (about US$200 million), PEPFAR about 38% (about US$188 million), and the government and partners such as WHO, UNICEF and the Islamic Development Bank the remaining 20%. He said PEPFAR supports about 80% of clinical sites and that gender data remain a major gap.
6. Sustaining the response
With most funding external, the plan is to use current grants to strengthen the health system: HIV workforce training through e-learning and plans to recruit staff in case PEPFAR withdraws, a digital supply chain (about 80% of funds go to commodities), harmonised data systems linked to DHIS2, unique patient identifiers through universal health coverage, and data-driven decisions. He said Cameroon spends less than 5% of its budget on health against the 15% Abuja target, but government HIV funding is rising, a public-private partnership was signed to bring in companies, HIV is covered in the first phase of universal health coverage, and PEPFAR and Global Fund transition plans aim to move funding to local organisations.
7. Preparedness
COVID-19 showed that decades of progress could be lost: his team's study in Central Africa, published in PLOS ONE, documented disruptions to HIV services and commodity stock-outs. Cameroon is reinforcing surveillance, laboratories and emergency coordination, and the Global Fund allowed COVID-19 funds to be reallocated to health system strengthening. He said the HIV response can no longer be separated from health system strengthening and epidemic preparedness.
Discussion and Q&A
- Dr. Bryan Tegomoh: which evidence-based interventions have had the most impact, and what are the research priorities? Dr. Ajeh credited the treat all strategy of 2016, backed by START and TEMPRANO, together with provider-initiated testing, HIV self-testing for key populations, and a supply chain that keeps test kits and antiretrovirals available. Research priorities, set jointly with PEPFAR, the Global Fund and WHO, include a stigma index study (target: under 10% of people with HIV facing stigma), the integrated biological and behavioural survey of key populations, the PrEP evaluation, and sentinel surveillance of HIV and syphilis in antenatal clinics. He said funding limits what can be done.
- A researcher who worked on early HIV incidence studies: is Cameroon moving to long-acting drugs such as lenacapavir, and how is the response reaching people in the crisis-affected North West, South West and Far North? He said long-acting injectables are promising but too expensive and scarce; Cameroon would start with injectable PrEP for key populations, and a feasibility study by a Cameroonian research group was under way. Adult retention and suppression remain high, but antenatal coverage in the Far North is low, so a project funded by the government, the Islamic Development Bank and UNICEF uses mentor mothers to bring pregnant women to clinics.
- The Chair: are integrase inhibitors consistently available? He said they are sustainable and that stock-outs are now mostly local and logistical rather than national, with last-mile delivery support and an online ordering system for health facilities.
- A doctor now in South Africa: how far has the shift to dolutegravir gone, and are health workers discouraging PrEP? He said the transition started in early 2020, most patients and all new patients are on dolutegravir, and remaining efavirenz stock had to be used up. He then said dolutegravir is not a perfect solution: according to data from the NAMSAL trial presented by the team at Yaoundé Central Hospital, it was not superior to efavirenz on viral suppression over time, and women gained significant weight while men developed hypertension. He said that if Cameroon had its own means it would suspend dolutegravir, but it depends on Global Fund financing. On PrEP he agreed that community-based organisations and health workers need sensitisation.
- A participant who worked on the NAMSAL trial: should pregnant women be prioritised for dolutegravir, what about male circumcision, and how is mortality measured without good death registration? He said male circumcision is in the strategic plan and child circumcision is near universal in the south (participants put it above 90%), though he had no figures for adults. Mortality is estimated from programme registers, with tracing of patients who stop coming, and from Spectrum modelling, and he agreed better data are needed.
- Chat questions: injectables, clinical trials, and PEPFAR's requirements on LGBT populations He said injectables are not yet in use and that Cameroon has a clinical trial record (including NAMSAL) and the new Gates-funded DAC-Africa initiative, which the Chair credited Elvis Ndansi with bringing to Cameroon; Dr. Ajeh urged that it build clinical trial training into state universities. Key populations are in the national plan that all partners must align with, but legal barriers mean daily negotiation with the justice ministry and security services, including when key population trainings are raided.
- Dr. Boghuma Kabisen Titanji (Emory University): reflections She said pediatric HIV is the most worrying gap, with about 50,000 children under 15 living with HIV and fewer than half of children in sub-Saharan Africa reaching age 18, asked how sexually transmitted infections are addressed alongside PrEP, and stressed that HIV is now a manageable chronic condition with long-acting options coming. She said current antiretrovirals are far safer than older regimens and that untreated HIV carries more risk than drug side effects. Dr. Ajeh replied that pediatric HIV is a top priority (he cited about 30,000 children), that STIs are in the plan with a dual HIV and syphilis test now used for pregnant women toward triple elimination with hepatitis B, that revised treatment guidelines add non-communicable diseases and cervical cancer screening, and that Cameroon lacks pharmacovigilance sentinel sites.
Calls to action and closing
- The Chair thanked Dr. Ajeh for accepting at short notice and invited Dr. Titanji to work with the National AIDS Control Committee and to return to the town hall on HIV cure and aging.
- He invited Cameroonians at home and in the diaspora with ideas for change to use the town hall, and invited Dr. Ajeh to come back.
Submitted by the Co-Moderators, Cameroon Town Hall for Healthcare Professionals.
