Over the past two decades, significant progress has been made in the global response to HIV/AIDS, driven by innovations such as expanding access to Antiretroviral Therapy (ART), enhancing prevention efforts, and promoting behavioral change strategies [1]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) established the 95-95-95 targets with the objective that by 2030, 95% of all people living with HIV (PLHIV) will be diagnosed, 95% of those diagnosed will be on ART, and 95% of those on ART will achieve viral suppression [1]. Achieving these ambitious goals is pivotal for controlling the HIV epidemic.

The World Health Organization (WHO) endorsed the “test-and-treat” strategy in 2016, recommending immediate ART initiation upon HIV diagnosis, regardless of CD4 count [2]. This approach has shown promise in reducing HIV transmission, improving health outcomes, and streamlining service delivery [2][3]. Many countries, including Cameroon, incorporated this strategy into national guidelines in 2016 to accelerate progress towards epidemic control [4]. Cameroon, with an estimated HIV prevalence of approximately 3.7% among adults aged 15 - 49 [4], adopted the test-and-treat policy to rapidly expand ART coverage, especially in high-burden regions like the South West. Despite policy adoption, challenges such as health system limitations, socio-cultural barriers, and issues related to adherence threaten to impede progress [5][6]. For instance, delays in ART initiation, inadequate infrastructure, stockouts of medicines, stigma, and misinformation have been reported [3][5][7]. Recent studies, such as Bekolo et al. (2023), have highlighted the implementation challenges of universal test-and-treat (UTT) strategies across West and Central Africa, emphasizing issues related to health system capacity, stigma, and adherence [5].

Adherence to ART remains a cornerstone for achieving viral suppression, as suboptimal adherence increases the risks of virologic failure, drug resistance, and ongoing HIV transmission [3]. Understanding adherence patterns and their determinants within the context of the test-and-treat strategy is crucial for developing effective interventions. Recent studies, such as Bekolo et al. (2023), highlight how the uptake of UTT policies influences clinical outcomes, including CD4, viral load, testing rates, and opportunistic infections. Incorporating these insights underscores the importance of evaluating ART initiation, adherence levels, and the various individual, sociocultural, and health system factors that influence adherence in the Southwest Region (SWR) of Cameroon. This study aims to assess these parameters and treatment outcomes among PLHIV, providing evidence to inform targeted interventions, optimize HIV service delivery, and advance progress toward the 95-95-95 targets.

This study highlights several important gaps and challenges in the implementation of the test-and-treat strategy within the South West Region of Cameroon. The notably low proportion (22.4%) of newly diagnosed patients initiating ART on the same day underscores delays in immediate treatment initiation, which can undermine the benefits of early ART, such as rapid viral suppression and reduced transmission [3][4]. These delays have resulted in 76.1% of persons initiating within 6 months and a few cases being initiated after a year from test dates. The fact that more than two-thirds (67.1%) of patients commenced treatment within six months indicates that systemic and patient-related barriers still impede prompt initiation [6]. Such delays can compromise the advantages of early ART, including rapid viral suppression and decreased transmission risk [2].

Adherence remains a critical determinant of treatment success. Although self-reported adherence was relatively high, with 79.8% indicating good adherence, the adherence levels measured by the Visual Analogue Scale (VAS) revealed that only 56.8% of patients maintained adherence above 90%. Furthermore, a significant association between adherence and viral suppression was observed, emphasizing the importance of consistent medication intake for achieving optimal clinical outcomes [5][11]. The high viral suppression rate (87.7%) during follow-up confirms that adherence directly influences virological success [12].

While adherence levels were relatively high, they remain influenced by socio-economic factors (income level, financial stability, employment status, and level of education), psychosocial (mental health condition, social support, cultural beliefs, stress, and stigma) challenges, and health system limitations such as poor provider-patient communication, lack of trust in the system, stockout of commodities, and long wait times. Older patients demonstrated better adherence. The demonstrated better adherence in older patients is consistent with existing evidence suggesting increased health literacy and stability among this age group [12][13]. Conversely, younger individuals faced barriers such as stigma and treatment fatigue, underscoring the need for tailored, youth-friendly interventions to enhance adherence [14].

The study also identified marital status as significantly associated with adherence, with married individuals more likely to adhere well compared to singles or widows [13]. No significant associations were found between adherence and other demographic variables such as gender, education level, or religion (Table 2 and Table3).

The strong association between adherence and viral suppression reaffirms that consistent medication intake is essential for optimal treatment outcomes [3]. Addressing social determinants, particularly stigma and concerns about confidentiality, is also very crucial. The misconception among many patients that ART can be discontinued emphasizes the importance of ongoing education to reinforce the understanding that lifelong adherence is necessary for sustained viral suppression [15].

Health system factors played a pivotal role in influencing adherence. Patients who paid more for HIV services were less adherent, whereas those receiving free services showed better adherence levels [7]. Concerns about confidentiality and privacy at health facilities also negatively impacted adherence, highlighting the need to strengthen health system policies that ensure privacy and stigma reduction [16][17]. Additionally, patients who were not asked to perform mandatory tests before starting ART were more likely to adhere well, suggesting that overly burdensome pre-treatment procedures may hinder initiation and adherence [18]. The association between paid services and adherence underscores the potential impact of financial barriers on treatment outcomes [15]. The COVID-19 pandemic further highlighted the need for resilient health systems and innovative approaches such as multi-month dispensing and community ART groups, which can reduce access barriers and ensure continuity of care [19].

Moreover, the study found that patients who doubted the information received from health facilities were significantly less likely to achieve viral suppression. Food insecurity also emerged as a significant barrier to adherence, with patients experiencing food shortages showing lower adherence levels, which consequently affected viral suppression rates [18].

Regarding viral load suppression, religion emerged as a significant factor, with variations observed across different faith groups. Patients who were not asked to undertake compulsory tests before treatment initiation were more likely to achieve viral suppression and adhere to ART, indicating that reducing procedural barriers may facilitate better treatment outcomes [7].

As recorded, delays in ART initiation, socioeconomic barriers, psychosocial challenges, and health system limitations collectively hinder optimal HIV care. Addressing these issues through targeted interventions, such as decentralizing services, improving confidentiality, reducing costs, and enhancing patient education, will be essential to improving adherence, timely initiation, and viral suppression in this setting. Strengthening the health system’s capacity to deliver patient-centered care and fostering community engagement can further support the successful implementation of the test-and-treat strategy [2][3].

In summary, our study confirms that delays in ART initiation, suboptimal adherence, and misconceptions about lifelong treatment persist despite policy shifts. Addressing these barriers requires strengthening health system capacity, community engagement, and targeted education initiatives.

The study’s strengths include its diverse and adequate sample size, encompassing participants from various demographic backgrounds such as age, gender, education, and religion, which enhances the representativeness of the findings. It employs a comprehensive approach by assessing multiple socio-demographic factors to understand their influence on adherence. The use of the Visual Analog Scale (VAS) offers a standardized, quantitative measure of adherence levels, enabling precise comparisons among participants. Additionally, appropriate statistical analyses, such as chi-square tests with p-values, ensure reliable evaluation of associations between variables and adherence. These strengths contribute to the validity, reliability, and practical applicability of the findings, making the study a valuable resource for informing healthcare strategies aimed at improving patient adherence through tailored approaches based on identified demographic factors.

Limitations of this study include its cross-sectional design, which restricts causal interpretations, and reliance on self-reported data, which may be subject to bias. Nonetheless, the findings provide valuable insights for policymakers and program managers aiming to optimize HIV care delivery and improve treatment outcomes in the region.

While the universal test-and-treat strategy shows promise, this study highlights significant challenges in implementing it in the South West Region of Cameroon. A low proportion of newly diagnosed patients initiated ART on the same day, with a high proportion starting within the first two weeks to six months and others after a year or more, reflecting systemic delays that weaken early treatment benefits. While adherence was relatively good, a substantial number of patients achieved viral suppression, though factors such as age, stigma, and misconceptions impacted outcomes. Notably, a large majority of patients believed they might stop treatment, underscoring misconceptions about lifelong ART. Based on these findings, we recommend enhancing the HIV service delivery cascade, policy implementation, reducing costs associated with HIV services, and improving patient education as vital steps. Additionally, addressing social and systemic barriers can improve ART uptake and viral suppression, supporting progress toward HIV epidemic control in the region. Specific strategies include establishing more peer support groups, safeguarding confidentiality, and providing counseling to foster trust, disclosure, and adherence. Collaborating with other social services to mitigate poverty and food insecurity is also essential in improving adherence.

This study was approved by the Ethics Committee of the University of Bamenda and given approval No: 2022/0779H/Uba/IRB. Administrative clearance was granted by the South West Regional Delegation of Public Health Ref. No: R11/MINSANTE/SWR/RDPH/PS/988/81. The respondents were adequately informed about all the relevant aspects of the study using the participant’s information sheet. The respondents were further informed that participation in the study was entirely voluntary and their consent and assent were sought and obtained. They were also informed that they had the right to do the interview, to abstain from participation, and to terminate their participation at any time, whenever they wanted to. Participants were assured of confidentiality, and data collection tools were coded to avoid participant identification. Consent for publication was not applicable.

The dataset that supports the findings of this study is accessible from the corresponding author upon reasonable request.

Tankoh Marceline Fegen conceptualized and designed the study, conducted the research, and drafted the manuscript. Niba Loveline Lum participated in the remodeling of the study, data analysis, review of the manuscript, and co-supervised the study. Tendongfor Nicholas provided overall supervision, a critical review of the manuscript, and contributed to the study design and interpretation. All authors read and approved the final version of the manuscript.

We would like to express our sincere gratitude to everyone who contributed to the success of this study, especially the participants for their cooperation and willingness to take part in this study.

HIV—Human Immunodeficiency Virus

AIDS—Acquired Immunodeficiency Syndrome

PLHIV—People Living with HIV

VAS—Visual Analog Scale

ART—Antiretroviral Therapy

WHO—World Health Organization

UNAIDS—Joint United Nations Programme on HIV/AIDS