Challenges of HIV care in West Africa in the treat all era : epidemiological analysis of the cascade of care and health outcomes, with a gender perspective

Abstract

With nearly 25 million people living with HIV in sub-Saharan Africa, including 5 million in West and Central Africa, the coverage and performance of HIV care programs are still lagging behind in West Africa. And yet, achieving the ambitious targets set by UNAIDS for 2030 depends on the sustained involvement of patients in the care system and the success of treatment. In this context, the aim of this thesis was to analyze some of the current challenges of HIV care in West Africa, from the perspective of the continuum of care, health outcomes, and a gender-sensitive approach. Three main axes were investigated using two data platforms: the IeDEA West Africa observational cohort and the TEMPRANO clinical trial in Côte d'Ivoire. The first axis assessed attrition from HIV care programs over a 10-year period, as well as changes in immunological response to antiretroviral treatment as a function of gender. The results show a very high attrition rate, with an increased risk of attrition among men. At the same time, a better immunological response was obtained in women. The second axis focused on the switch to recent dolutegravir (DTG)-based therapeutic regimens and their metabolic impact. Analyses reveal a progressive but heterogeneous adoption of these regimens across care centers, with a progressively narrowing gap between men and women following initial disparities in access to DTG in favor of men. They also show substantial weight gain in the year following the introduction of DTG, especially in patients previously treated with efavirenz or protease inhibitors. Finally, the third axis studied the effect of the timing of initiation of an early treatment strategy on the occurrence of adverse pregnancy outcomes. No significant difference in risk was found, supporting the recommendation of immediate antiretroviral treatment for all people living with HIV, including women of childbearing age. Ultimately, this work highlights some key persistent challenges for r