Integration of People Living With HIV In The Southwest Region, Cameroon

1. Introduction

People living with HIV in most cases face profound challenges in accepting their situation and reintegrating into community life an issue widely acknowledged in HIV research [15]. In response to this, global health authorities have consistently emphasized the need for psychosocial, community-based, and medical support to improve quality of life and treatment outcomes among PLHIV (WHO, 2017). The Community Initiative AIDS Care and Prevention (CIACP) Program, implemented by the Cameroon Baptist Convention Health Services (CBCHS) and evaluated by HEPRORG, was designed to address precisely these imperatives in the Southwest Region of Cameroon.

The primary goal of CIACP was to reduce HIV and AIDS prevalence, stigma, and discrimination of HIV-infected and affected persons in the Southwest Region, in alignment with globally verified approaches for stigma reduction [10] and with UNAIDS recommendations for community-level integration [17]. The program operated across all six administrative divisions of the region Fako, Kupe Muanenguba, Lebialem, Manyu, Meme, and Ndian deploying support groups, peer education, media sensitization, antenatal care (ANC) male-involvement campaigns, and income-generating activities (IGAs).

This paper presents the findings of the End-of-Project Phase Assessment, which investigated the extent to which CIACP achieved its integration objectives. It examines psychosocial support outcomes, support group dynamics, HIV-related stigma and discrimination patterns, male involvement in ANC and Prevention of Mother-to-Child Transmission (PMTCT), and the design and impact of sensitization packages. The study employs a mixed-methods approach that triangulates qualitative testimonies from 42 key informants with quantitative program data to provide a comprehensive and evidence-grounded evaluation.

The significance of this work lies in its contribution to the evidence base for community-led HIV interventions in Central and West Africa, a setting characterized by persistent gaps between HIV knowledge and action, uneven geographic coverage, and sustainability challenges associated with donor-dependent programming. Findings are intended to inform the design of subsequent HIV program phases in Cameroon and comparable sub-Saharan African contexts.

2. Literature Review

HIV/AIDS research over the past five decades has produced an extensive body of evidence on the determinants of PLHIV integration, the effectiveness of community-based interventions, and the barriers to male participation in reproductive health services. This review synthesizes key findings across five thematic areas most relevant to the CIACP program.

2.1 Psychosocial Support and Wellbeing of PLHIV

Psychosocial support is widely recognized as a key pillar in improving the quality of life for people living with HIV. According to WHO (2017), psychosocial interventions — including counseling, support groups, and community education help PLHIV cope with emotional stress, enhance adherence to antiretroviral therapy (ART), and reduce internalized stigma. Support groups, in particular, provide social belonging and foster empowerment, which have been shown to improve treatment outcomes and self-acceptance [9]. Research in sub-Saharan Africa demonstrates that PLHIV who participate in peer support networks exhibit better medication adherence and greater resilience [3].

The integration of income-generating activities (IGAs) into support groups such as farming and small-scale business ventures has also been shown to enhance social cohesion and financial stability [7]. Economic empowerment is recognized as an essential factor for sustained treatment adherence, as financial stress is a known barrier to retention in HIV care.

2.2 Stigma, Discrimination, and Community Integration

HIV-related stigma remains a significant obstacle in the fight against HIV/AIDS. Studies have identified social stigma, anticipated stigma, and internalized stigma as major factors limiting uptake of HIV testing, treatment adherence, and participation in community structures [17]. However, community-based interventions such as awareness campaigns, pastoral training, and inclusive health communication have been shown to reduce stigma and discrimination considerably [10].

Evidence from West and Central Africa indicates that increases in HIV knowledge are strongly associated with decreased discriminatory attitudes and increased willingness to interact with PLHIV [13]. The normalization of HIV as a chronic condition, alongside ART availability, has also contributed to improved integration of PLHIV into families, workplaces, and social environments [15].

2.3 Community-Based HIV Prevention Programs

Community-led HIV prevention models such as the CIACP program align with global best practices that emphasize participatory approaches. Studies show that programs that collaborate with community leaders, churches, schools, and local councils achieve broader reach and more sustainable outcomes [4]. Such approaches are particularly effective in rural or hard-to-reach areas where health systems face logistical constraints.

Tailored health communication materials posters, drama, radio messages, and educational toolkits are recommended for engaging diverse demographic groups such as youth, men, and illiterate populations [16]. Context-sensitive communication increases comprehension and facilitates behavior change.

2.4 Male Involvement in Prevention of Mother-to-Child Transmission (PMTCT)

Male partner participation in ANC and PMTCT processes remains low in many African contexts despite its demonstrated benefits. Lack of male engagement is associated with cultural norms, fear of HIV testing, time constraints, and gendered perceptions of pregnancy as a women-only issue [12]. Yet, evidence consistently shows that male involvement significantly improves ART adherence, early ANC attendance, and overall PMTCT outcomes [1]. Interventions such as invitation letters, community sensitization, church-based education, and couple-focused HIV counseling have been shown to increase male engagement [6].

2.5 Support Group Dynamics and Sustainability

Support groups for PLHIV remain vital for psychosocial wellbeing, but long-term sustainability depends on consistent funding, capacity building, and local ownership. Studies indicate that groups dependent solely on external funding often face decline when donors withdraw [14]. Successful models integrate support groups into existing health structures, link them with income-generating schemes, and build leadership capacity among members. Collaboration with local councils, NGOs, and health services strengthens sustainability and institutional support.

3. Theoretical Framework

This study is analytically grounded in three complementary theoretical perspectives widely applied in HIV program evaluation and community health research.

The Social Ecological Model (SEM) provides the overarching framework, emphasizing that health behaviors including HIV treatment adherence, testing uptake, and stigma-related responses are shaped by multiple interacting levels: individual, interpersonal, community, organizational, and policy ([2]; [11]). The CIACP program's multi-level design combining support group counseling, peer education, community sensitization, media campaigns, and institutional partnerships directly reflect this model, making SEM particularly appropriate for evaluating its outcomes.

Community Empowerment Theory complements this by highlighting the role of collective action and local ownership in sustaining health interventions [18]. The program's investment in income-generating activities, peer leadership capacity, and linkages with traditional authorities and local councils operationalizes core empowerment principles.

Finally, the Stigma Framework developed by [5] and extended by Link and Phelan (2001) for HIV contexts guides the analysis of stigma and discrimination dynamics. This framework distinguishes between enacted stigma (actual discrimination), anticipated stigma (fear of being stigmatized), and internalized stigma (self-stigma) all of which were documented in participant testimonies across the six divisions.

4. Methodology

4.1 Research Design

This study employed a mixed-methods evaluation design, combining qualitative and quantitative data collection an approach widely validated in HIV program evaluations [6]. The qualitative component captured lived experiences, perceptions, and community dynamics, while the quantitative component enabled documentation of program trends and outcomes. The integration of both methods allowed for triangulation of evidence, enhancing the validity and comprehensiveness of findings.

4.2 Study Setting

The evaluation was conducted across all six administrative divisions of the Southwest Region of Cameroon: Fako, Kupe Muanenguba, Lebialem, Manyu, Meme, and Ndian. Given its higher population density and the presence of four health districts (Buea, Limbe, Muyuka, and Tiko), the number of key informants in Fako Division was doubled to ensure adequate representation.

4.3 Participants and Sampling

A purposive sampling strategy was employed to recruit 42 key informants across the six divisions. Participants included: eight support group leaders of PLHIV; 14 community resource persons; ten media resource persons from radio stations (Eden Radio Limbe, Revival Gospel Radio Buea, CRTV Buea, Ocean City Radio); 15 men who had fathered a child within the preceding four years; and members of the CIACP coordination team. Sampling was conducted randomly within each category from available group leadership teams and resource person rosters.

4.4 Data Collection

Qualitative data were collected through in-depth interviews (IDIs) using semi-structured guides with open-ended questions, allowing participants to freely express their experiences. Separate interview guides were developed for support group members/resource persons and for male informants. An additional sustainability theme was included in CIACP team interviews. Quantitative data were collected through structured document review and abstraction of program monitoring data, including HIV prevalence figures, ANC/PMTCT uptake, male partner participation rates, ART uptake among HIV-positive pregnant women, and mother-to-child transmission rates. PMTCT data were obtained from the Regional Delegation of Public Health; voluntary counseling and testing (VCT) data were sourced from CIACP interim reports.

4.5 Data Analysis

Qualitative data from handwritten notes were translated, transcribed, and entered into a word processing program. A preliminary codebook of a priori codes was developed based on study objectives and interview guide themes. Data were coded using this codebook to identify thematic patterns, and the codebook was iteratively refined as new themes emerged. Coded data were organized into a hierarchy of themes showing patterns, relationships, and explanations. Analytic memos were used throughout to develop conceptual categories and track interpretive insights. Comparative analysis was conducted across respondent categories and across divisions to identify convergences and divergences. Quantitative data were organized into tabular summaries for trend analysis and cross-referenced with qualitative findings.

4.6 Ethical Considerations

The evaluation was conducted in adherence to ethical principles of voluntary participation, informed consent, confidentiality, and anonymity. Participants were assured that their testimonies would be used solely for program evaluation purposes and that no identifying information would be disclosed in reporting.

5. Results

5.1 Psychosocial Support of PLHIV

One of CIACP's core activities was to reach PLHIV through their associations to provide psychosocial support, consistent with global findings that such support improves emotional wellbeing and ART adherence [9]. Testimonies from support group members across divisions confirmed meaningful psychosocial gains, including strengthened confidence, peer solidarity, and openness about HIV status.

"We also learnt how to bring members together. In the group we have made our members busy. Many members did not want to be identified as belonging to the group before the CIACP program. During those days, the group was stigmatized in the community... Conference for people living with HIV was organized which was a forum for people to interact and share experiences with new friends, co-workers, relatives and even neighbours; which was quite relieving. Many are now courageous and can openly declare their status; sensitize others."

Support group president, female, age 42

Peer counseling also extended to discordant couples, addressing adherence challenges arising from relationship dynamics:

"We talk to members, counsel some of the spouses who were not open to each other thus, making adherence difficult. We also talk about the importance of taking ARVs to discordant couples to minimize the risk of infection."

Support group member, Tiko

Income-generating activities (IGAs) were a prominent feature of support group programming. Members received training in nutritional food production moringa, coconut oil, soya bean milk — some of which were consumed within groups and the surplus sold commercially. This mirrors interventions shown to economically empower PLHIV and support long-term integration [7].

"The trainings we obtained in Mutengene have helped us a lot. I and other group members now produce cocosoap and omo for sale. I cannot lack money now in my hand because the business is moving. I used to live in debts when I was depending on the meagre salary paid to me as a general labourer."

Support group president, Tiko

Groups that received donated chairs and canopies leveraged these assets to generate rental income, with funds used collectively to purchase food items and incentivize member attendance. The most enterprising groups, such as the one in Mutengene, extended into livestock farming piggery and poultry. Support groups located in health facilities benefited from staff involvement, while community-based groups depended heavily on the commitment of their presidents.

5.2 Integration of PLHIV Across Divisions

Integration outcomes varied considerably across the six divisions, reflecting differences in sensitization intensity, health infrastructure, and cultural context.

5.2.1 Divisions with Strong Integration

In Lebialem, Ekondo Titi (Ndian), Muyuka, and Tiko (Fako), PLHIV reported full participation in community, occupational, and social activities without fear of discrimination. In Ekondo Titi, the community chief contributed two hectares of land for a support group cassava farm, and the mayor reduced local taxes on PLHIV demonstrating institutional commitment to integration. Known HIV-positive persons operated food stalls and domestic services without social repercussions.

"It is very difficult now to know who has HIV or not. There is 100% integration to me. Many people feel free even to do their HIV test, know their status."

Resource person, Muyuka

"Most people do not know our status and most who know our status are also positive because we meet at the treatment centre. The fact that we are in the same situation, no one will reject the other."

Support group leader, Tiko

5.2.2 Divisions with Persistent Stigma

In Kupe Muanenguba particularly Bangem and Tombel stigma and discrimination remained high. Cultural taboos around HIV, high illiteracy, limited health infrastructure (one medical doctor, no specialists), and low awareness of ART continued to fuel social exclusion. Male informants in this division unanimously reported that PLHIV were not integrated:

"No, when people are HIV positive, they are stigmatized so they prefer not to make people know."

Male informant, KupeMuanenguba

This persistent stigma in conservative rural settings is consistent with literature documenting that stigma reduction is uneven in regions with poorer health literacy and higher cultural conservatism ([13]; [17]).

5.3 Support Group Dynamics

All nine support groups working with CIACP pre-existed the project. Membership trends showed general growth from initial numbers, though fluctuations occurred during project implementation particularly when incentives such as on-site ART dispensing were discontinued, reducing motivation for some members. Table 1 presents the membership dynamics across nine groups.

Community awareness of support groups varied by division. In Fako, all key informants (predominantly support group leaders and CIACP coordination staff) acknowledged group presence. In Kupe Muanenguba and Manyu, resource persons reported no support groups. Limited awareness in some divisions reduced help-seeking among PLHIV, reflecting documented links between community information availability and HIV care engagement (WHO, 2017).

Integration within communities was strongest where groups engaged in visible IGAs, collaborated with local authorities, and held regular sensitization events. In Lebialem, members worked with Peace Corps volunteers and designed income-generating projects. In Ekondo Titi, the group operated a cassava farm, garri production machine, and benefited from land grants and tax exemptions from local leaders. Support group fluctuations aligned with documented challenges of donor-dependent groups [14], but overall psychosocial benefits were consistent with global evidence ([9]; [3]).

5.4 Sensitization Package Design and Community Outreach

CIACP deployed a diverse range of sensitization materials adapted to target audiences: PowerPoint presentations, banners, placards, posters, badges, T-shirts, calendars, and pens bearing HIV and abstinence messages. Materials were displayed and distributed during national events (Youth Week, Labour Day, Women's Day, World AIDS Day) and disseminated through schools, churches, and community gatherings. Drama, roleplay, and sketches were used for youth engagement. Radio broadcasts in Pidgin English and French extended reach into rural and illiterate populations.

Resource persons generally commended the design of packages as appropriate to their communities. However, feedback consistently pointed to unmet needs: more video and audio-visual materials, smaller portable booklets by topic, written materials for literate audiences, and microphones for open-air sensitizations. The CIACP Schools Coordinator noted that educational materials were tiered by level but remained insufficient in supply.

"We need to have written materials for literate people."

School head, Kumba

These gaps align with literature recommending context-relevant communication tools for diverse community groups [16] and the documented benefits of visual learning in low-literacy settings [13].

5.5 Male Involvement in ANC and PMTCT

Male partner participation in ANC/PMTCT was a core program objective that was partially attained. Table 2 presents the trend in Male as Partners (MAP) uptake across program years.

MAP uptake increased from 9% in 2013 to 14% in 2014 following intensified community messaging, then stabilized at 13% in 2015. This modest but consistent improvement was driven largely by radio and community sensitization, consistent with evidence on media effectiveness in male partner mobilization ([6]; [1]).

However, barriers remained substantial. Of 13 men with young children interviewed, only 3 had accompanied their spouses to ANC. Reasons cited included: cultural perception of pregnancy as a women-only concern; fear of being diagnosed with HIV or other STIs; shyness about attending a predominantly female health setting; lack of formal invitation from health facilities; work commitments; and in some cases, affective disconnection within the couple. These barriers are well-documented in PMTCT literature ([12]; [6]).

"I think I am safe because I don't have any woman outside and it is needless to go for ANC with her."

Male informant, KupeMuanenguba

"It's not necessary to me because I'm busy. I can't waste my time because it's a woman's affair."

Male informant, age 42, Tiko

Men who did participate or expressed openness to participation cited advantages of joint health monitoring, ensuring the wife followed medical advice, and the benefit of knowing both partners' HIV status. Suggested strategies for increasing male involvement included: formal written invitations from health facilities; church-based sensitization (given widespread church attendance in the region); door-to-door community education; female partner encouragement; and financial compensation for time spent at ANC. Some informants proposed conditional service protocols such as withholding immediate admission until the husband presents though these raised ethical concerns about patient welfare.

5.6 Stigma and Discrimination

CIACP's sustained community sensitization produced marked stigma reductions across most divisions. The program team reported that HIV has progressively been demystified from a social taboo associated with death, social exclusion, and divorce to a manageable chronic condition. Key indicators of reduced stigma included: open VCT attendance and ART collection without concealment; social integration in workplaces, markets, and churches; willingness of community members to eat, work, and socialize with known PLHIV; and greatly reduced incidence of family abandonment

"At first HIV positive clients were being isolated, insulted and it has drastically reduced up to the extent that we work together with support groups of people who openly identify themselves as HIV positive people."

Resource person, Lebialem.

"Some People detected with HIV almost committed suicide but after meeting with CIACP team were reassured and are alive today."

CIACP team member

The training of pastors as community resource persons was highlighted as a particularly effective mechanism for combating religious stigma. Several pastors now proactively request CIACP team visits for HIV sensitization.

Despite these gains, Kupe Muanenguba particularly Bangem remained an outlier. High illiteracy, cultural taboos, limited health workforce, and low community trust in health facilities perpetuated fear and discrimination. PLHIV in this division reported concealing their status rather than risking social exclusion, even though treatment was available free of charge. This finding is consistent with literature documenting that stigma persists longest in rural settings with limited health resources and high cultural conservatism ([13]; [10]).

6. Discussion

The findings of this evaluation demonstrate that the CIACP program achieved substantial progress across its primary objectives, while revealing important geographic and cultural heterogeneities that limit the generalizability of its successes within the Southwest Region.

Psychosocial support through CIACP-linked support groups produced outcomes consistent with global evidence on peer-led HIV interventions. The combination of counseling, peer solidarity, and income-generating activities mirrors models shown to improve ART adherence, reduce internalized stigma, and build economic resilience ([9]; [7]; [3]). The economic empowerment dimension coconut oil production, cocosoap, piggery, poultry, cassava farming was particularly impactful, addressing the financial stress that often drives treatment discontinuation. Support group membership generally grew or stabilized across the nine groups (total 224 members), though the documented decline in motivation following the cessation of on-site ART supply confirms findings that donor-dependent benefits undermine long-term sustainability when withdrawn [14].

Stigma reduction was the program's most visible success in five of six divisions, driven by sustained sensitization, pastoral training, test-and-treat scale-up, and visible peer role models. This aligns with Mahajan et al.'s (2008) framework for community-level stigma reduction and with Turan et al.'s (2017) evidence that ART normalization improves social acceptance of PLHIV. However, the persistent stigma in Kupe Muanenguba underscores the finding of Parker and Aggleton (2013) that cultural conservatism, health illiteracy, and infrastructural deficits create enclaves where standard sensitization approaches are insufficient. Tailored, intensive, and long-term engagement strategies are required in such settings.

Male involvement in ANC/PMTCT improved modestly from 9% in 2013 to a peak of 14% in 2014 but remained far below the program's aspirational targets. The barriers identified (cultural norms, fear of testing, shyness, lack of invitations, time constraints) are precisely those documented across sub-Saharan African PMTCT literature ([12]; [6]). The moderate progress achieved reflects the effectiveness of radio messaging and community mobilization but also highlights that male engagement requires deeper structural interventions: formal institutional protocols for male invitation, couple-centered counseling models, and community norm-change initiatives that reframe male ANC attendance as a masculine responsibility rather than a concession.

Program coverage was uneven. Activities were concentrated in divisional capitals and health facility catchment areas, leaving sub-divisional communities; especially in Mamfe, Bangem, and rural Ndian inadequately served. Limited transport infrastructure and insufficient resource person density compounded this. The solution proposed in the field; training resource persons at sub-divisional level to eliminate travel dependency, is well-supported by community health literature [4].

Sustainability emerged as a crosscutting concern. CIACP's integration into the CBCHS structure provided institutional anchorage, and collaborations with local councils and government delegations enhanced legitimacy. However, meaningful long-term sustainability requires budgetary commitments from local councils, formal recognition of resource persons in community governance, and expanded institutional HIV and AIDS committees across all CBCHS facilities. The model of integrating HIV programming into existing health infrastructure rather than operating as a vertical program is endorsed by global health evidence as the most durable approach ([14]; WHO, 2017).

Small declines in HIV positivity rates (from 3.9% to 3.4% among newly diagnosed pregnant women between 2014 and 2015; from 2.8% to 2.7% among community VCT participants) are encouraging but must be interpreted with caution given the absence of more recent population-based survey data. These trends are consistent with the program's contribution to the UNAIDS 90-90-90 goal, particularly the first 90 (diagnosis). Continued investment in VCT, counseling, and community mobilization remains essential to sustain these gains.

7. Conclusion And Recommendations

The CIACP program has meaningfully advanced the integration of People Living with HIV in the Southwest Region of Cameroon. Through psychosocial support groups, community sensitization, pastoral training, media engagement, and income-generating activities, the program contributed to reduced stigma and discrimination, improved treatment adherence, and modest gains in male ANC involvement achievements grounded in and consistent with global community-based HIV evidence.

Nevertheless, three critical gaps demand attention in the program's next phase. First, geographic coverage remains insufficient: rural and peri-urban communities across all six divisions particularly those in Kupe Muanenguba, Manyu, and sub-divisional areas of Fako and Meme require intensified, culturally adapted interventions. Second, support group sustainability depends on reducing donor dependency through deeper integration with local governance structures, health system budgeting, and diversified income strategies. Third, male involvement in PMTCT requires a strategic shift from awareness campaigns to structural and relational interventions that normalize male reproductive health participation.

Based on the findings, the following recommendations are advanced:

• Expand training of sub-divisional resource persons to improve geographic reach without dependency on transport infrastructure.

• Institutionalize formal male invitation protocols in all ANC facilities within the Southwest Region, accompanied by targeted community norm-change campaigns.

• Establish dedicated budget lines for HIV interventions in local council budgets through sustained CBCHS advocacy and formal Memoranda of Understanding with municipal governments.

• Develop culturally tailored sensitization packages for conservative rural communities in Kupe Muanenguba, incorporating local language materials, visual media, and community elder/traditional authority engagement.

• Strengthen the sustainability of support groups by linking them formally with government livelihood programs, cooperatives, and microfinance institutions to reduce reliance on project funding.

• Enhance sensitization materials with audio-visual content (videos, portable topic-specific booklets) and ensure adequate supply in all intervention areas, including schools.

• Continue VCT expansion as a frontline strategy toward achieving UNAIDS 90-90-90 targets, with improved community mobilization protocols and counseling for HIV-negative individuals.

Ultimately, community-based HIV programs such as CIACP demonstrate that participatory, multisectoral, and economically empowering interventions can effectively reduce fear, normalize HIV, and promote integration. Sustaining and scaling these gains in Cameroon will require adaptive programming, locally owned leadership, and sustained political commitment to health equity.