The bottleneck is the programme: "when, not whom" in the retrospective acceptability of community-based ART initiation among criminalised key populations living with HIV in Cameroon

Abstract Background. Key populations (KP) — including men who have sex with men (MSM) and female sex workers (FSW) — carry a disproportionate HIV burden yet remain underserved, especially where their identities and practices are criminalised. Community-based ART initiation (CBARTI) delivered by KP-serving community-based organisations (CBOs) could reach them, but whether they find it acceptable, and what drives that acceptability, is poorly documented. Methods. Analytical cross-sectional study with an embedded qualitative component among MSM and FSW living with HIV who initiated ART during the first ten months (February–November 2024) of Cameroon's national community-based ART initiation programme. We evaluated its entire pilot — the three KP-serving CBOs then implementing the modality, in two cities — and interviewed participants after at least twelve months on treatment. Acceptability was operationalised as uptake of community versus facility initiation and as free-text reasons mapped to the Theoretical Framework of Acceptability (TFA). Associations were examined with a Firth-penalised modified Poisson model with small-sample-corrected robust variance. Results. Of 135 participants, 116 (85.9%; 95% CI 78.9–91.3) initiated in the community, with no difference between MSM and FSW. Uptake was governed by when initiation occurred, not whom it involved: it rose from 33.3% in February to 100% from July onward (adjusted prevalence ratio 1.065 per month, 1.029–1.102; p < 0.001), while no individual characteristic was associated with it, and all 19 facility initiations occurred at a single site in the opening months. Reasons clustered into four TFA constructs — affective attitude (belonging), opportunity cost (proximity) and ethicality (confidentiality, discretion, safety), with burden — whereas intervention coherence, perceived effectiveness and self-efficacy never arose; the few facility initiators cited only logistics. Conclusion. Among criminalised key populations in urban Cameroon, community-based ART initiation was highly and almost uniformly acceptable, valued for belonging, privacy and proximity. What limited was the time the programme and its users took to trust a new modality, not any reluctance of the patient: even the few who chose a facility did so for convenience, not because they rejected community care. Programme should scale community initiation while preserving its discreet, peer-led character and domestic funding so that it endures beyond a single donor.