Catastrophic healthcare expenditures and working difficulties with HIV in low-resource settings: the Cameroonian experience Jean-Paul Moatti 1,2,3, Sandrine Loubiere 1,2,3, Sylvie Boyer 1,2,3, Fabienne Marcellin 1,2,3, Séverin-Cécile Abega 4, Maria Patrizia Carrieri 1,2,3 and Bruno Spire 1,2,3 Results from the EVAL survey (ANRS ) 1 INSERM, U912 (SE4S), Marseille, France 2 Université Aix Marseille, IRD, UMR-S912, Marseille, France 3 ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d’Azur, Marseille, France 4 Socio-anthropological Research Institute (IRSA) - Catholic University of Central African States, Yaoundé, Cameroon

ART-treated pts (n=2,206) Not treated pts (n=674) P-value DIRECT COSTS Total monthly healthcare expenditures - mean 95%CI (F CFA) 7,680 [6,891-8,468] 12,083 [9,846-14,320] <.0001 Catastrophic HIV expenditures24.8%32.2%<.0001 INDIRECT COSTS Working status -Employed at the time of the survey55.8%49.1%.003 For active participants (n=1,565) -Unable to work at least one day during the last 6 months 15.0%21.0%.008 HIV care expenditures and indirect costs of HIV among PLWHA in Cameroon

In a multivariate analysis, catastrophic HIV expenditures were associated with: Among both ART-treated and not treated patients: hospitalization, visit to a doctor outside the hospital, living at >1 hour from the hospital Among ART-treated patients: younger age, matrimonial status (unmarried), unemployment, no. of self-reported symptoms, follow-up in a major hospital Among not treated patients: low educational level, low CD4 count, follow-up in a central or provincial hospital

CONCLUSIONS High direct & indirect costs of HIV disease Lower healthcare expenditures in patients who get access to ART Inequities in access to high-quality care Need for a successful implementation of a free healthcare policy in resource-limited settings