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Most African countries have recorded relatively lower COVID-19 burdens than Western countries. This has been attributed to early and strong political commitment and robust implementation of public health measures, such as nationwide lockdowns, travel restrictions, face mask wearing, testing, contact tracing, and isolation, along with community education and engagement. Other factors include the younger population age strata and hypothesized but yet-to-be confirmed partially protective cross-immunity from parasitic diseases and/or other circulating coronaviruses. However, the true burden may also be underestimated due to operational and resource issues for COVID-19 case identification and reporting. In this perspective article, we discuss selected best practices and challenges with COVID-19 contact tracing in Nigeria, Rwanda, South Africa, and Uganda. Best practices from these country case studies include sustained, multi-platform public communications; leveraging of technology innovations; applied public health expertise; deployment of community health workers; and robust community engagement. Challenges include an overwhelming workload of contact tracing and case detection for healthcare workers, misinformation and stigma, and poorly sustained adherence to isolation and quarantine. Important lessons learned include the need for decentralization of contact tracing to the lowest geographic levels of surveillance, rigorous use of data and technology to improve decision-making, and sustainment of both community sensitization and political commitment. Further research is needed to understand the role and importance of contact tracing in controlling community transmission dynamics in African countries, including among children. Also, implementation science will be critically needed to evaluate innovative, accessible, and cost-effective digital solutions to accommodate the contact tracing workload.

Objective The COVID-19 pandemic is a biosecurity threat, and many resource-rich countries are stockpiling and/or making plans to secure supplies of vaccine, therapeutics, and diagnostics for their citizens. We review the products that are being investigated for the prevention, diagnosis, and treatment of COVID-19; discuss the challenges that countries in sub-Saharan Africa may face with access to COVID-19 vaccine, therapeutics, and diagnostics due to the limited capacity to manufacture them in Africa; and make recommendations on actions to mitigate these challenges and ensure health security in sub-Saharan Africa during this unprecedented pandemic and future public-health crises. Main body Sub-Saharan Africa will not be self-reliant for COVID-19 vaccines when they are developed. It can, however, take advantage of existing initiatives aimed at supporting COVID-19 vaccine access to resource-limited settings such as partnership with AstraZeneca, the Coalition for Epidemic Preparedness and Innovation, the Global Alliance for Vaccine and Immunisation, the Serum Institute of India, and the World Health Organization’s COVID-19 Technology Access Pool. Accessing effective COVID-19 therapeutics will also be a major challenge for countries in sub-Saharan Africa, as production of therapeutics is frequently geared towards profitable Western markets and is ill-adapted to sub-Saharan Africa realities. The region can benefit from pooled procurement of COVID-19 therapy by the Africa Centres for Disease Control and Prevention in partnership with the African Union. If the use of convalescent plasma for the treatment of patients who are severely ill is found to be effective, access to the product will be minimally challenging since the region has a pool of recovered patients and human resources that can man supportive laboratories. The region also needs to drive the local development of rapid-test kits and other diagnostics for COVID-19. Conclusion Access to vaccines, therapeutics, and diagnostics for COVID-19 will be a challenge for sub-Saharan Africans. This challenge should be confronted by collaborating with vaccine developers; pooled procurement of COVID-19 therapeutics; and local development of testing and diagnostic materials. The COVID-19 pandemic should be a wake-up call for sub-Saharan Africa to build vaccines, therapeutics, and diagnostics manufacturing capacity as one of the resources needed to address public-health crises.

Globally, there are prevailing knowledge gaps in the epidemiology, clinical manifestations, and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children and adolescents; and these gaps are especially wide in African countries. The availability of robust age-disaggregated data is a critical first step in improving knowledge on disease burden and manifestations of coronavirus disease 2019 (COVID-19) among children. Furthermore, it is essential to improve understanding of SARS-CoV-2 interactions with comorbidities and coinfections such as human immunodeficiency virus (HIV), tuberculosis, malaria, sickle cell disease, and malnutrition, which are highly prevalent among children in sub-Saharan Africa. The African Forum for Research and Education in Health (AFREhealth) COVID-19 Research Collaboration on Children and Adolescents is conducting studies across Western, Central, Eastern, and Southern Africa to address existing knowledge gaps. This consortium is expected to generate key evidence to inform clinical practice and public health policy-making for COVID-19 while concurrently addressing other major diseases affecting children in African countries.

Little is known about the clinical features and outcomes of SARS-CoV-2 infection in Africa. We conducted a retrospective cohort study of patients hospitalized for COVID-19 between March 10, 2020 and July 31, 2020 at seven hospitals in Kinshasa, Democratic Republic of the Congo (DRC). Outcomes included clinical improvement within 30 days (primary) and in-hospital mortality (secondary). Of 766 confirmed COVID-19 cases, 500 (65.6%) were male, with a median (interquartile range [IQR]) age of 46 (34–58) years. One hundred ninety-one (25%) patients had severe/critical disease requiring admission in the intensive care unit (ICU). Six hundred twenty patients (80.9%) improved and were discharged within 30 days of admission. Overall in-hospital mortality was 13.2% (95% CI: 10.9–15.8), and almost 50% among those in the ICU. Independent risk factors for death were age < 20 years (adjusted hazard ratio [aHR] = 6.62, 95% CI: 1.85–23.64), 40–59 years (aHR = 4.45, 95% CI: 1.83–10.79), and ≥ 60 years (aHR = 13.63, 95% CI: 5.70–32.60) compared with those aged 20–39 years, with obesity (aHR = 2.30, 95% CI: 1.24–4.27), and with chronic kidney disease (aHR = 5.33, 95% CI: 1.85–15.35). In marginal structural model analysis, there was no statistically significant difference in odds of clinical improvement (adjusted odds ratio [aOR] = 1.53, 95% CI: 0.88–2.67, P = 0.132) nor risk of death (aOR = 0.65, 95% CI: 0.35–1.20) when comparing the use of chloroquine/azithromycin versus other treatments. In this DRC study, the high mortality among patients aged < 20 years and with severe/critical disease is of great concern, and requires further research for confirmation and targeted interventions.

Objective Uptake of permanent contraception among women remains low in sub-Saharan Africa compared to other regions. We aimed to synthesize available evidence on barriers to, and facilitators of permanent contraception with regards to tubal ligation among women in sub-Saharan Africa. Study Design We reviewed literature on tubal ligation among African women published between January 1, 2000 and October 30, 2017. We searched PubMed, Global health, EMBASE, Web of science, and Google scholar for quantitative, qualitative, and mixed methods studies which reported on barriers and/or facilitators to uptake of tubal ligation in sub-Saharan Africa. Finally, we conducted a narrative synthesis and categorized our findings using a framework based on the social ecological model. Results We included 48 articles in the review. Identified barriers to tubal ligation among women included individual-level (myths and misconceptions, fear of surgery, irreversibility of procedure, religious beliefs), interpersonal-level (male partner disapproval), and organizational-level (lack of healthcare worker expertise and equipment) factors. Facilitating factors included achievement of desired family size and perceived effectiveness (individual-level), supportive male partners and knowing other women with permanent contraception experience (interpersonal-level), and finally, subsidized cost of the procedure and task-sharing with lower cadre healthcare workers (organizational-level). Conclusions Barriers to, and facilitators of permanent contraception among women in sub-Saharan Africa are multilevel in nature. Strategies countering these barriers should be prioritized, as effective contraception can promote women’s health and economic development in sub-Saharan Africa. In addition to these strategies, more quantitative research is needed to further understand patient-level factors associated with uptake of permanent contraception among women.

Background Multidrug-resistant tuberculosis (MDR-TB) jeopardizes global TB control. The prevalence and predictors of Rifampicin-resistant (RR) TB, a proxy for MDR-TB, and the treatment outcomes with standard and shortened regimens have not been assessed in post-conflict regions, such as the South Kivu province in the eastern Democratic Republic of the Congo (DRC). We aimed to fill this knowledge gap and to inform the DRC National TB Program. Methods of adults and children evaluated for pulmonary TB by sputum smear microscopy and Xpert MTB/RIF (Xpert) from February 2012 to June 2017. Multivariable logistic regression, Kaplan–Meier estimates, and multivariable Cox regression were used to assess independent predictors of RR-TB and treatment failure/death. Results Of 1535 patients Xpert-positive for TB, 11% had RR-TB. Independent predictors of RR-TB were a positive sputum smear (adjusted odds ratio [aOR] 2.42, 95% confidence interval [CI] 1.63–3.59), retreatment of TB (aOR 4.92, 95% CI 2.31–10.45), and one or more prior TB episodes (aOR 1.77 per episode, 95% CI 1.01–3.10). Over 45% of RR-TB patients had no prior TB history or treatment. The median time from Xpert diagnosis to RR-TB treatment initiation was 12 days (interquartile range 3–60.2). Cures were achieved in 30/36 (83%) and 84/114 (74%) of patients on 9- vs 20/24-month MDR-TB regimens, respectively (P = .06). Predictors of treatment failure/death were the absence of directly observed therapy (DOT; adjusted hazard ratio [aHR] 2.77, 95% CI 1.2–6.66) and any serious adverse drug event (aHR 4.28, 95% CI 1.88–9.71). Conclusions Favorable RR-TB cure rates are achievable in this post-conflict setting with a high RR-TB prevalence. An expanded Xpert scale-up; the prompt initiation of shorter, safer, highly effective MDR-TB regimens; and treatment adherence support are critically needed to optimize outcomes., In tuberculosis (TB) patients from post-conflict eastern Democratic Republic of the Congo, 11.1% had rifampicin-resistant TB, of whom 46.5% had no prior TB. Cures were achieved in 83% and 74% of patients on 9- and 20/24-month multidrug-resistant TB regimens, respectively.

Background Nigeria has an annual population of ~ 200,000 women who are both pregnant and HIV-positive. High unmet need for family planning in this population could lead to unintended pregnancies, along with the increased risk of mother-to-child transmission of HIV (MTCT). To identify modifiable barriers and facilitators in effective family planning, we examined correlates of modern contraceptive use among HIV-positive women enrolled in the MoMent prevention of MTCT (PMTCT) implementation research study in rural North-Central Nigeria. Methods In this prospective cohort study, HIV-positive pregnant women were enrolled at 20 Primary Healthcare Centers and followed up to 12 months postpartum. Baseline socio-demographic, clinical and obstetric data were collected at enrollment. Participants were to receive routine family planning counselling from healthcare workers during postnatal visits. Analysis utilized baseline data linked to available family planning information collected from each woman at the first postpartum visit. Multivariate logistic regression was performed to determine factors associated with modern contraceptive use. Results Out of 497 women enrolled, family planning data was available for 399 (80.3%) women, of whom 349 (87.5%) received family planning counselling, and 321 (80.5%) were 30 years old or less. Two-thirds (268, 67.2%) of the cohort analyzed had 1–2 children at baseline; 24.8% (n = 99) had 3–4 children, and 8.0% (n = 32) had > 4 children. Approximately half (199, 49.9%) of the women reported no modern contraceptive use in the postpartum period. Male condoms (116, 29.1%) were the most reported method of contraception; other methods reported included oral hormones (71, 17.8%) and intrauterine devices (13, 3.2%). Only disclosure of HIV status to male partner or relative (aOR = 2.0, 95% CI: 1.2–3.3; p = 0.01) and receipt of family planning counselling (aOR = 2.3, 95% CI: 1.1–4.8; p = 0.03) were positively associated with reported modern contraceptive use. Age, marital or educational status, religious affiliation, employment status, gravidity and parity were non-correlates. Conclusions Family planning counselling and disclosure of HIV status are modifiable positive predictors of contraceptive use among our cohort of postpartum HIV-positive women in rural Nigeria. Rates of unintended pregnancy and concomitant risk of MTCT could be significantly reduced through strategies that facilitate these correlates. Clinical trials registration Clinicaltrials.gov registration number: NCT 01936753; registered September 3, 2013.

Introduction Adolescent HIV prevention and treatment is a high priority for youth healthcare in sub-Saharan Africa. Methods This study employed concept mapping to identify factors that impact the implementation of HIV prevention and intervention programs for adolescents in sub-Saharan Africa. Key stakeholders including researchers, policymakers, and non-governmental organization (NGO) personnel constituting membership of the NIH-sponsored Adolescent HIV Prevention and Treatment Implementation Science Alliance responded to the question: “In your experience, what factors have facilitated or hindered implementation of evidence-based HIV prevention or treatment for adolescents in sub-Saharan Africa?” Participants generated statements in response to the focus question, sorted them into thematically relevant groups, and rated each statement on its importance and changeability. Results Through data analyses and participant feedback, 15 distinct themes were derived. “Workforce/Workflow” and “HIV Stigma and Adolescent Development” were rated highest for importance, and “Threshold Conditions for Treatment” and “Structure of Implementation Efforts” were rated most changeable. Conclusions Understanding implementation science determinants and mechanisms can facilitate the uptake of successful implementation and sustainment strategies for the prevention and treatment of HIV in a given context. We placed determinants and mechanisms within the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to provide greater contextual integration with broader theories in implementation science. Implementers across multiple disciplines can use these findings to improve the scale-up of evidence-based practices for adolescent HIV prevention and treatment in sub-Saharan Africa. Implementation approaches that consider the determinants and mechanisms identified in this study and integrated in implementation frameworks will likely have utility for other health conditions and contexts.

Summary box In the early phase of the COVID-19 pandemic, Ghana’s response was hailed as one of the best in Africa. The country’s ‘whole-of-government’ approach was structured around five objectives: to curtail the importation of cases; identify and contain them; care for the sick; cushion the impact of COVID-19 on Ghana’s economic and social life; and boost domestic production as a means of deepening self-reliance.1 The government’s perspective on the COVID-19 response was captured by the president in March 2020: ‘We know how to bring the economy back to life. What we do not know is how to bring people back to life.’2 However, nearly a year on, Ghana is contending with gaps between rhetoric and reality. In Accra, the capital city, the B.1.1.7 variant first identified in the UK now constitutes up to 88% of all infections,3 and it is driving an ongoing surge in hospitalisations and deaths. These realities merit a review of Ghana’s COVID-19 response so far, and a broader thinking about practical measures to contain …

Background In much of sub-Saharan Africa, male partners play influential roles in women's access to maternal-child healthcare, including prevention of mother-to-child transmission of HIV services. We explored male partner perspectives on women’s access to maternal-child healthcare in North-Central Nigeria. Methods Three focus groups were conducted with 30 men, purposefully-selected on the basis of being married, and rural or urban residence. Major themes explored were men’s maternal-child health knowledge, gender power dynamics in women’s access to healthcare, and peer support for pregnant and postpartum women. Data were manually analyzed using Grounded Theory, which involves constructing theories out of data collected, rather than applying pre-formed theories. Results Mean participant age was 48.3 years, with 36.7% aged Conclusions Strategic engagement of community leaders, including traditional and religious leaders, is needed to address harmful norms and practices underlying gender inequity in health decision-making. Gender mainstreaming, where the needs and concerns of both men and women are considered, should be applied in maternal-child healthcare education and delivery. Clinic fee reductions or elimination can facilitate service access. Finally, professional organizations can do more to reinforce respectful maternity care among healthcare workers.

Objectives Tuberculosis (TB) is a leading infectious cause of death globally. Of the estimated 10 million people who developed active TB in 2019, 1.8 million (18%) were adolescents and young adults aged 15–24 years. Adolescents have poorer rates of TB screening, treatment initiation and completion compared to adults. Unfortunately, there is relatively less programme, research and policy focus on TB for adolescents aged 10–19 years. This article reviews the scope of health services and the relevant policy landscape for TB case notification and care/treatment, TB/HIV management, and latent TB infection for adolescents in Nigeria. Additionally, it discusses considerations for TB vaccines in this population. Content All Nigeria Federal Ministry of Health policy documents relevant to adolescent health services and TB, and published between 2000 and 2020 underwent narrative review. Findings were reported according to the service areas outlined in the Objectives. Summary and Outlook Nine policy documents were identified and reviewed. While multiple policies acknowledge the needs of adolescents in public health and specifically in TB programming, these needs are often not addressed in policy, nor in program integration and implementation. The lack of age-specific epidemiologic and clinical outcomes data for adolescents contributes to these policy gaps. Poor outcomes are driven by factors such as HIV co-infection, lack of youth-friendly health services, and stigma and discrimination. Policy guidelines and innovations should include adaptations tailored to adolescent needs. However, these adaptations cannot be developed without robust epidemiological data on adolescents at risk of, and living with TB. Gaps in TB care integration into primary reproductive, maternal-child health and nutrition services should be addressed across multiple policies, and mechanisms for supervision, and monitoring and evaluation of integration be developed to guide comprehensive implementation. Youth-friendly TB services are recommended to improve access to quality care delivered in a patient-centered approach.

Background Rifampicin (RIF) resistance is highly correlated with isoniazid (INH) resistance and used as proxy for multidrug-resistant tuberculosis (MDR-TB). Using MTBDRplus as a comparator, we evaluated the predictive value of Xpert MTB/RIF (Xpert)–detected RIF resistance for MDR-TB in eastern Democratic Republic of the Congo (DRC). Methods We conducted a cross-sectional study involving data from new or retreatment pulmonary adult TB cases evaluated between July 2013 and December 2016. Separate, paired sputa for smear microscopy and MTBDRplus were collected. Xpert testing was performed subject to the availability of Xpert cartridges on sample remnants after microscopy. Results Among 353 patients, 193 (54.7%) were previously treated and 224 (63.5%) were MTBDRplus TB positive. Of the 224, 43 (19.2%) were RIF monoresistant, 11 (4.9%) were INH monoresistant, 53 (23.7%) had MDR-TB, and 117 (52.2%) were RIF and INH susceptible. Overall, among the 96 samples detected by MTBDRplus as RIF resistant, 53 (55.2%) had MDR-TB. Xpert testing was performed in 179 (50.7%) specimens; among these, 163 (91.1%) were TB positive and 73 (44.8%) RIF resistant. Only 45/73 (61.6%) Xpert-identified RIF-resistant isolates had concomitant MTBDRplus-detected INH resistance. Xpert had a sensitivity of 100.0% (95% CI, 92.1–100.0) for detecting RIF resistance but a positive-predictive value of only 61.6% (95% CI, 49.5–72.8) for MDR-TB. The most frequent mutations associated with RIF and INH resistance were S531L and S315T1, respectively. Conclusions In this high-risk MDR-TB study population, Xpert had low positive-predictive value for the presence of MDR-TB. Comprehensive resistance testing for both INH and RIF should be performed in this setting.

The novel severe acute respiratory syndrome-coronavirus-2 pandemic has spread to Africa, where nearly all countries have reported laboratory-confirmed cases of novel coronavirus disease (COVID-19). Although there are ongoing clinical trials of repurposed and investigational antiviral and immune-based therapies, there are as yet no scientifically proven, clinically effective pharmacological treatments for COVID-19. Among the repurposed drugs, the commonly used antimalarials chloroquine (CQ) and hydroxychloroquine (HCQ) have become the focus of global scientific, media, and political attention despite a lack of randomized clinical trials supporting their efficacy. Chloroquine has been used worldwide for about 75 years and is listed by the WHO as an essential medicine to treat malaria. Hydroxychloroquine is mainly used as a therapy for autoimmune diseases. However, the efficacy and safety of CQ/HCQ for the treatment of COVID-19 remains to be defined. Indiscriminate promotion and widespread use of CQ/HCQ have led to extensive shortages, self-treatment, and fatal overdoses. Shortages and increased market prices leave all countries vulnerable to substandard and falsified medical products, and safety issues are especially concerning for Africa because of its healthcare system limitations. Much needed in Africa is a cross-continental collaborative network for coordinated production, distribution, and post-marketing surveillance aligned to low-cost distribution of any approved COVID-19 drug; this would ideally be piggybacked on existing global aid efforts. Meanwhile, African countries should strongly consider implementing prescription monitoring schemes to ensure that any off-label CQ/HCQ use is appropriate and beneficial during this pandemic.

Background Tuberculosis is a main cause of death in people living with HIV and results in around 39 000 deaths every year in Nigeria. Isoniazid preventive therapy (IPT), the standard tuberculosis preventive therapy used in Nigeria, has been shown to significantly reduce mortality and prevent tuberculosis in people with HIV. Despite efforts and strategies to scale up this treatment in Nigeria, the process has remained very slow. Here we describe a programme to increase IPT uptake in health facilities in four states in northern Nigeria, while also monitoring trends in IPT use with the aim of increasing access for people with HIV. Methods Data were collected at 90 health facilities in Nasarawa, Kano, and Katsina states and the Federal Capital Territory (FCT), Nigeria, between Oct 1, 2017, and March 31, 2019. A monitoring tool was used to track clinic attendance, IPT eligibility status, and percentage uptake of isoniazid (the proportion of people with HIV starting a 6 month course of isoniazid) in patients with HIV at these health facilities. Baseline data were collected between Oct 1, 2017, and Feb 28, 2018, and identified reasons for low IPT uptake included: stockout of isoniazid, documentation gaps, improper filling of the relevant source documents, and poor clinician awareness of use of IPT. In response to these barriers to uptake, interventions such as folder tagging and electronic prompts of eligible clients prior to clinic visits, clinician sensitisations through training and retraining to raise the awareness of IPT, and active tracking of eligible clients were implemented. We collected post-intervention data from March 1, 2018, to March 31, 2019. Analysis was done using Excel and STATA. Findings During the 6 month pre-intervention period, 3659 (14%) patients were commenced on isoniazid out of 26 136 eligible patients. In the initial 6 months post-intervention, 18 367 (80%) patients were started on isoniazid out of 22 020 eligible patients. Uptake dropped suddenly in October, 2018, due to stockout of isoniazid. Remedial stock redistribution resulted in a steady increase of isoniazid uptake and a total number of 43 075 patients out of 50 050 patients (86%) commenced isoniazid within the 12 month review period. Interpretation Capacity building of health-care workers on isoniazid through training and retraining resulted in marked improvements in IPT uptake through: increased health-care worker knowledge about IPT; proper documentation on the relevant source documents and the electronic medical records; and availability, and use of, isoniazid electronic prompts to highlight clients who were eligible for IPT. However, there is a need to strengthen drug logistics, especially in guaranteeing a consistent and adequate supply of isoniazid in all facilities to avoid stockouts, thus ensuring optimum IPT uptake or access for people living with HIV in Nigeria. Funding Institute of Human Virology, Nigeria

Background Peer support provided by experienced and/or trained “expert” women living with HIV has been adopted by prevention of mother-to-child transmission of HIV (PMTCT) programs across sub-Saharan Africa. While there is ample data on HIV status disclosure among non-expert women, there is little data on disclosure among such expert women, who support other women living with HIV. Objective This study compared HIV disclosure rates between expert and non-expert mothers living with HIV, and contextualized quantitative findings with qualitative data from expert women. Methods We compared survey data on HIV disclosure to male partners and family/friends from 37 expert and 100 non-expert mothers living with HIV in rural North-Central Nigeria. Four focus group discussions with expert mothers provided further context on disclosure to male partners, extended family and peers. Chi square and Fisher’s exact tests were applied to quantitative data. Qualitative data were manually analyzed using a Grounded Theory approach. Results Two-thirds of the 137 participants were 21–30 years old; 89.8% were married, and 52.3% had secondary-level education. Disclosure to male partners was higher among expert (100.0%) versus non-expert mothers (85.0%), p = 0.035. Disclosure to anyone (93.1% vs 80.8%, p = 0.156), and knowledge of male partners’ HIV status were similar (75.7% versus 66.7%, p = 0.324) between expert and non-expert mothers, respectively. With respect to male partners, HIV serodiscordance rates were also similar (46.4% vs 55.6%, p = 0.433). Group discussions indicated that expert mothers did not consistently disclose to their mentored clients, with community-level stigma and discrimination stated as major reasons for this non-disclosure. Conclusions Expert mothers experience similar disclosure barriers as their non-expert peers, especially regarding disclosure outside of intimate relationships. Thus, attention to expert mothers’ coping skills and disclosure status, particularly to mentored clients is important to maximize the impact of peer support in PMTCT. Clinical trials registration Clinicaltrials.gov registration number NCT 01936753 (retrospective), September 3, 2013.

Zero to 19 year-old children in sub-Saharan Africa bear a disproportionate proportion of the global burden of communicable and non-communicable diseases. Significant public health gains have been made in the fight against these diseases, however, factors such as underequipped health systems, disease outbreaks, conflict, and political instability continue to challenge prevention and control. The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) introduces new challenges to public health programs in sub-Saharan Africa. Of particular concern are programs targeting major conditions among children, such as undernutrition, vaccine-preventable pneumonia and diarrhea, malaria, tuberculosis, HIV, and sickle cell disease. This article focuses on the impact of the COVID-19 pandemic on child health in sub-Saharan Africa. We review the epidemiology of major pediatric diseases and, referencing modeling projections, discuss the short- and long-term impact of the pandemic on major disease control. We deliberate on potential complications of SARS-CoV-2 co-infections/co-morbidities and identify critical social and ethical issues. Furthermore, we highlight the paucity of COVID-19 data and clinical trials in this region and the lack of child participants in ongoing studies. Lastly, approaches and interventions to mitigate the pandemic’s impact on child health outcomes are discussed.ImpactChildren in sub-Saharan Africa bear a disproportionate burden of communicable and non-communicable diseases globally; this remains true even as the COVID-19 pandemic persists.Amidst the fast-expanding COVID-19 literature, there is little comprehensive coverage of the pandemic’s indirect impact on child health in sub-Saharan Africa.This article comprehensively outlines the threat that the pandemic poses to major disease prevention and control for children in sub-Saharan Africa. It discusses the potential impact of SARS-CoV-2 co-infections/co-morbidities, highlights research gaps, and advocates for data and action to mitigate the ripple effects of the pandemic on this population.

The acceptability of lifelong antiretroviral therapy (ART) among HIV-positive women in highburden Nigeria, is not well-known. We explored readiness of users and providers of prevention of mother-to-child transmission of HIV (PMTCT) services to accept lifelong ART -before Option B plus was implemented in Nigeria. We conducted 142 key informant interviews among 100 PMTCT users (25 pregnant-newly-diagnosed, 26 pregnant-in-care, 28 lost-to-follow-up (LTFU) and 21 postpartum women living with HIV) and 42 PMTCT providers in rural North-Central Nigeria. Qualitative data were manually analyzed via Grounded Theory. PMTCT users had mixed views about lifelong ART, strongly influenced by motivation to prevent infant HIV and by presence or absence of maternal illness. Newly-diagnosed women were most enthusiastic about lifelong ART, however postpartum and LTFU women expressed conditionalities for acceptance and adherence, including minimal ART side effects and potentially serious maternal illness. Providers corroborated user findings, identifying the postpartum period as problematic for lifelong ART acceptability/adherence. Option B plus scale-up in Nigeria will require proactively addressing PMTCT user fears about ART side effects, and continuous education on long-term maternal and infant benefits. Structural barriers such as the availability of trained providers, long clinic wait times and patient access to ART should also be addressed.Keywords: Nigeria; HIV; adherence; Option B plus; PMTCT; rural

Background Adolescents living with HIV (ALHIV) have worse health outcomes than other populations of people living with HIV. Contributing factors include lack of standard and comprehensive procedures for ALHIV transitioning from pediatric to adult care. This has contributed to poor retention at, and following transition, which is problematic especially in high ALHIV-burden, resource-limited settings like Nigeria. Methods Using a two-arm cluster randomized control design, the Adolescent Coordinated Transition (ACT) trial will measure the comparative effectiveness of a graduated transition and organized support group intervention against the usual practice of abrupt transfer of Nigerian ALHIV from pediatric to adult care. This study will be conducted at 12 secondary and tertiary healthcare facilities (six intervention, six control) across all six of Nigeria’s geopolitical zones. The study population is 13- to 17-year-old ALHIV (N = 216, n = 108 per study arm) on antiretroviral therapy. Study participants will be followed through a 12-month pre-transfer/transition period and for an additional 24 months post transfer/transition. The primary outcome measure is the proportion of ALHIV retained in care at 12 and 24 months post transfer. Secondary outcome measures are proportions of ALHIV achieving viral suppression and demonstrating increased psychosocial wellbeing and self-efficacy measured by psychometric tests including health locus of control, functional social support, perceived mental health, and sexual risk and behavior. Discussion We hypothesize that the ACT intervention will significantly increase psychosocial wellbeing, retention in care and ultimately viral suppression among ALHIV. ACT’s findings have the potential to facilitate the development of standard guidelines for transitioning ALHIV and improving health outcomes in this population. The engagement of a consortium of local implementing partners under the Nigeria Implementation Science Alliance allows for nationwide study implementation and expedient results dissemination to program managers and policy-makers. Ultimately, ACT may also provide evidence to inform transitioning guidelines not only for ALHIV but for adolescents living with other chronic diseases in resource-limited settings. Trial registration ClinicalTrials.gov, ID: NCT03152006. Registered on May 12, 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2347-z) contains supplementary material, which is available to authorized users.

Supplemental Digital Content is Available in the Text., Background: Six implementation research studies in Malawi, Nigeria, and Zimbabwe tested approaches for improving retention in care among women living with HIV. We simulated the impact of their interventions on the probability of HIV transmission during pregnancy and breastfeeding. Methods: A computer-based state-transition model was developed to estimate the impact of the retention interventions. Patient-level data from the 6 studies were aggregated and analyzed, and weighted averages of mother-to-child transmission (MTCT) of HIV probabilities were presented. The average MTCT probability of the more successful interventions was applied to national estimates to calculate potential infections averted if these interventions were taken to scale. Results: Among the total cohort of 5742 HIV-positive women, almost 80% of all infant infections are attributed to the roughly 20% of HIV-positive pregnant and breastfeeding women not retained on antiretroviral therapy. Higher retention in the arms receiving interventions resulted in an overall lower estimated MTCT probability of 9.9% compared with 12.3% in the control arms. In the 2 studies that showed a statistically significant effect, Prevention of MTCT Uptake and Retention (PURE) and Mother Mentor (MoMent), the difference in transmission rates between intervention and control arms was 4.1% and 7.3%, respectively. Scaling up retention interventions nationally in the 3 countries could avert an average of almost 3000 infant infections annually. Conclusions: Linking HIV-positive pregnant women to antiretroviral therapy and retaining them is essential for addressing the remaining gaps and challenges in HIV/AIDS care and the elimination of MTCT. At national level, even modest improvements in retention translates into large numbers of infant infections averted.

BACKGROUND Peer support (PS) has reportedly improved Prevention of mother-to-child transmission (PMTCT) outcomes in high HIV-burden settings; however, evidence of impact on retention in care is limited. Retention in care implies consistent engagement and treatment adherence. The MoMent study evaluated the impact of structured vs unstructured PS on postpartum retention and viral load suppression among rural Nigerian women. METHODS A total of 497 HIV-positive pregnant women were consecutively enrolled at 10 primary health care centers with structured mentor mother (MM) support, and at 10 pair-matched primary health care centers with routine, ad hoc PS. The structured MM intervention comprised an outcome-specific scope of work, close MM supervision, standardized documentation, performance evaluations, and retraining as appropriate. Retention was defined by clinic attendance during the first 6-month postpartum. Participants with ≥3 of 6 expected monthly visits were considered retained. Women with a 6-month postpartum plasma viral load of

BACKGROUND Early infant diagnosis (EID) by 2 months of age is an important prevention of mother-to-child cascade step that serves as an early postpartum indicator of program success. Uptake and timely presentation for infant HIV diagnosis are significant challenges in resource-limited settings. Few studies on maternal peer support (PS) have demonstrated impact on EID. The MoMent study evaluated the impact of structured PS on timely presentation for EID testing in rural North-Central Nigeria. METHODS A total of 497 HIV-positive pregnant women were consecutively recruited at 10 primary health care centers with structured, closely supervised Mentor Mother (MM) support, and 10 pair-matched primary health care centers with routine but ad hoc PS. EID was assessed among HIV-exposed infants delivered to recruited women, and was defined by presentation for DNA polymerase chain reaction testing between 35 and 62 days of life. A logistic regression model with generalized estimating equation to account for clustering was used to assess the effect of MMs on EID presentation. RESULTS Data from 408 live-born infants were available for analysis. Exposure to MM support was associated with higher odds of timely EID presentation among infants, compared with routine PS (adjusted odds ratios = 3.7, 95% confidence interval: 2.8 to 5.0). CONCLUSIONS Closely supervised, organized MM support significantly improved presentation for EID among HIV-exposed infants in a rural Nigerian setting. Structured PS can improve rates of timely EID presentation and potentially the uptake of EID testing in resource-limited settings.

The World Health Organization (WHO) recommends exclusive breast-feeding (EBF) for HIV exposed infants for six months; this is considered best practice for reducing mother-to-child transmission of HIV in the postpartum period. This is a scoping review of the barriers affecting women's decision-making and choice to sustain the practice of EBF in sub-Saharan Africa (SSA). An online literature search via PubMed, Science Direct, Google Scholar, WHO and Joint United Nations Programme on HIV and AIDS (UNAIDS) websites identified research studies and reports that explored socio-economic, cultural and infant feeding counselling-related barriers to EBF among HIV-positive mothers in SSA. A total of 341 relevant articles were identified only 35 (23 qualitative, 3 quantitative and 9 mixed methods) met the inclusion criteria. Findings reveal that key barriers to choice and sustained practice of EBF are healthcare workers’ personal biases, inadequate counselling skills and guideline knowledge, a culture of mixed feeding norms, and maternal lack of decision-making power and fear of vertical transmission. Transmission of HIV programs in countries where major challenges persist should evaluate and address the identified healthcare worker and community-level factors impeding EBF. Key words: Africa South of the Sahara, breastfeeding, counselling, cultural norms, socioeconomic, HIV seropositivity, mothers.

Background HIV status disclosure to male partners is important for optimal outcomes in the prevention of mother-to-child transmission of HIV (PMTCT). Depending on timing of HIV diagnosis or pregnancy status, readiness to disclose and disclosure rates may differ among HIV-positive women. We sought to determine rates, patterns, and experiences of disclosure among Nigerian women along the PMTCT cascade. Methods HIV-positive women in rural North-Central Nigeria were purposively recruited according to their PMTCT cascade status: pregnant-newly HIV-diagnosed, pregnant-in care, postpartum, and lost-to-follow-up (LTFU). Participants were surveyed to determine rates of disclosure to male partners and others; in-depth interviews evaluated disclosure patterns and experiences. Tests of association were applied to quantitative data. Qualitative data were manually analysed by theme and content using the constant comparative method in a Grounded Theory approach. Results We interviewed 100 women; 69% were 21–30 years old, and 86% were married. There were 25, 26, 28 and 21 women in the newly-diagnosed, in-care, postpartum, and LTFU groups, respectively. Approximately 81% of all participants reported disclosing to anyone; however, family members were typically disclosed to first. Ultimately, more women had disclosed to male partners (85%) than to family members (55%). Rates of disclosure to anyone varied between groups: newly-diagnosed and LTFU women had the lowest (56%) and highest (100%) rates, respectively (p = 0.001). However, family (p = 0.402) and male partner (p = 0.218) disclosure rates were similar between cascade groups. Across all cascade groups, fear of divorce and intimate partner violence deterred women from disclosing to male partners. However, participants reported that with assistance from healthcare workers, disclosure and post-disclosure experiences were mostly positive. Conclusion In our study cohort, although disclosure to male partners was overall higher, family members appeared more approachable for initial disclosure. Across cascade groups, male partners were ultimately disclosed to at rates > 75%, with no significant inter-group differences. Fear appears to be a major reason for non-disclosure or delayed disclosure by women to male partners. Augmentation of healthcare workers’ skills and involvement can mediate gender power differentials, minimize fear and shorten time to male partner disclosure among women living with HIV, regardless of their PMTCT cascade status. Trial registration Clinicaltrials.gov registration number NCT 01936753, September 3, 2013 (retrospectively registered).

Introduction The period of transition from pediatric to adult care has been associated with poor health outcomes among 10–19 year old adolescents living with HIV (ALHIV). This has prompted a focus on the quality of transition services, especially in high ALHIV-burden countries. Due to lack of guidelines, there are no healthcare transition standards for Nigeria’s estimated 240,000 ALHIV. We conducted a nationwide survey to characterize routine transition procedures for Nigerian ALHIV. Materials and methods This cross-sectional survey was conducted at public healthcare facilities supported by five local HIV service implementing partners. Comprehensive HIV treatment facilities with ≥1 year of HIV service provision and ≥20 ALHIVs enrolled were selected. A structured questionnaire assessed availability of treatment, care and transition services for ALHIV. Transition was defined as a preparatory process catering to the medical, psychosocial, and educational needs of adolescents moving from pediatric to adult care. Comprehensive transition services were defined by 6 core elements: policy, tracking and monitoring, readiness evaluation, planning, transfer of care, and follow-up. Results All 152 eligible facilities were surveyed and comprised 106 (69.7%) secondary and 46 (30.3%) tertiary centers at which 17,662 ALHIV were enrolled. The majority (73, 48.3%) of the 151 facilities responding to the “clinic type” question were family-centered and saw all clients together regardless of age. Only 42 (27.8%) facilities had an adolescent-specific HIV clinic; 53 (35.1%) had separate pediatric/adolescent and adult HIV clinics, of which 39 (73.6%) reported having a transfer/transition policy. Only 6 (15.4%) of these 39 facilities reported having a written protocol. There was a bimodal peak at 15 and 18 years for age of ALHIV transfer to adult care. No surveyed facility met the study definition for comprehensive transition services. Conclusions Facilities surveyed were more likely to have non-specialized HIV treatment services and had loosely-defined, abrupt transfer versus transition practices, which lacked the core transition elements. Evidence-based standards of transitional care tailored to non-specialized HIV treatment programs need to be established to optimize transition outcomes among ALHIV in Nigeria and in similar settings.

Background Low rates of maternal healthcare service utilization, including facility delivery, may impede progress in the prevention of mother-to-child transmission of HIV (PMTCT) and in reducing maternal and infant mortality. The MoMent (Mother Mentor) study investigated the impact of structured peer support on early infant diagnosis presentation and postpartum maternal retention in PMTCT care in rural Nigeria. This paper describes baseline characteristics and correlates of facility delivery among MoMent study participants. Methods HIV-positive pregnant women were recruited at 20 rural Primary Healthcare Centers matched by antenatal care clinic volume, client HIV prevalence, and PMTCT service staffing. Baseline and delivery data were collected by participant interviews and medical record abstraction. Multivariate logistic regression with generalized estimating equation analysis was used to evaluate for correlates of facility delivery including exposure to structured (closely supervised Mentor Mother, intervention) vs unstructured (routine, control) peer support. Results Of 497 women enrolled, 352 (71%) were between 21 and 30 years old, 319 (64%) were Christian, 245 (49%) had received secondary or higher education, 402 (81%) were multigravidae and 299 (60%) newly HIV-diagnosed. Delivery data was available for 445 (90%) participants, and 276 (62%) of these women delivered at a health facility. Facility delivery did not differ by type of peer support; however, it was positively associated with secondary or greater education (aOR 1.9, CI 1.1–3.2) and Christian affiliation (OR 1.4, CI 1.0–2.0) and negatively associated with primigravidity (OR 0.5; 0.3–0.9) and new HIV diagnosis (OR 0.6, CI 0.4–0.9). Conclusions Primary-level or lesser-educated HIV-infected pregnant women and those newly-diagnosed and primigravid should be prioritized for interventions to improve facility delivery rates and ultimately, healthy outcomes. Incremental gains in facility delivery from structured peer support appear limited, however the impact of duration of pre-delivery support needs further investigation. Religious influences on facility delivery and on general maternal healthcare service utilization need to be further explored. Trial Registration ClinicalTrials.gov number NCT01936753, registered September 2013. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1417-2) contains supplementary material, which is available to authorized users.

Background: Nigeria is a key target country in the global effort toward elimination of mother-to-child transmission of HIV. Low coverage of prevention of mother-to-child transmission (PMTCT) interventions, adherence, and retention-in-care rates in HIV-positive pregnant women are contributing factors to high mother-to-child transmission of HIV (MTCT) rates. In Nigeria, rural areas, served largely by primary health care facilities, have particularly poor indicators of PMTCT coverage. Mentor Mothers are HIV-positive women who serve as peer counselors for PMTCT clients, provide guidance, and support in keeping appointments and promoting antiretroviral adherence and retention-in-care. The Mother Mentor (MoMent) study aims to investigate the impact of structured Mentor Mother programs on PMTCT outcomes in rural Nigeria. Design and Methods: A prospective cohort study will compare rates of retention-in-care among PMTCT clients who are supported by formally-trained supervised Mentor Mothers versus clients who receive standard-of-care, informal peer support. Study sites are 20 primary health care centers (10 intervention, 10 control) in rural North-Central Nigeria. The study population is HIV-positive mothers and exposed infant pairs (MIPs) (N = 480; 240 MIPs per study arm). Primary outcome measures are the proportion of exposed infants receiving early HIV testing by age 2 months, and the proportion of MIPs retained in care at 6 months postpartum. Secondary outcome measures examine antiretroviral adherence, 12-month postpartum MIP retention, and MTCT rates. This article presents details of the study design, the structured Mentor Mother programs, and how their impact on PMTCT outcomes will be assessed.

Correction In the original publication [1] the figure captions of Figs. 2 and 3 were reversed. The correct version can be found in this Erratum.

Background: In 2014, Nigeria accounted for 33% of all new childhood HIV infections that occurred among the 22 Global Plan priority countries where 80% of HIV-infected women reside. Even with a vertical HIV transmission rate of 27%, only 6% of infants born to HIV-infected women in Nigeria receive early infant diagnosis (EID). This article reports rates of antiretroviral prophylaxis, EID, and mother-to-child transmission in a congregation-based Healthy Beginning Initiative (HBI) designed to increase HIV testing among pregnant women in southeast Nigeria. Methods: This is a nested cohort study of HIV-exposed infants (HEI) within the HBI trial originally designed as a 2-arm cluster randomized trial. HIV-infected mothers and infants were followed between January 2013 and August 2014. Results: Across both arms of the study, 72 HIV-infected women delivered 69 live infants (1 set of twins) and 4 had miscarriages. Of the 69 live-born HEI, HIV status was known for 71% (49/69), 16% (11/69) died before sample collection, and 13% (9/69) were lost to follow-up. Complete information was available for 84% of HEI (58/69), of which 64% (37/58) received antiretroviral prophylaxis. Among the 49 infants tested for HIV, 88% (43/49) received EID within 2 months and 12% (6/49) received antibody testing after 18 months. The mother-to-child transmission rate was 8.2% (4/49). Conclusions: EID was higher and HIV transmission rate was lower among the HBI participants compared to reported rates in 2014. However, further progress is needed to achieve goals of elimination of infant HIV infection.

Introduction. Uptake of antenatal services is low in Nigeria; however, indicators in the Christian-dominated South have been better than in the Muslim-dominated North. This study evaluated religious influences on utilization of general and HIV-related maternal health services among women in rural and periurban North-Central Nigeria.Materials and Methods. Targeted participants were HIV-positive, pregnant, or of reproductive age in the Federal Capital Territory and Nasarawa. Themes explored were utilization of facility-based services, provider gender preferences, and Mentor Mother acceptability. Thematic and content approaches were applied to manual data analysis.Results. Sixty-eight (68) women were recruited, 72% Christian and 28% Muslim. There were no significant religious influences identified among barriers to maternal service uptake. All participants stated preference for facility-based services. Uptake limitations were mainly distance from clinic and socioeconomic dependence on male partners rather than religious restrictions. Neither Muslim nor Christian women had provider gender preferences; competence and positive attitude were more important. All women found Mentor Mothers highly acceptable.Conclusion. Barriers to uptake of maternal health services appear to be minimally influenced by religion. ANC/PMTCT uptake interventions should target male partner buy-in and support, healthcare provider training to improve attitudes, and Mentor Mother program strengthening and impact assessment.

More than 80% of the HIV-infected adolescents live in sub-Saharan Africa. Acquired immune deficiency syndrome (AIDS)-related mortality has increased among adolescents 10-19 y old. The impact is highest in sub-Saharan Africa, where >80% of HIV-infected adolescents live. The World Health Organization has cited inadequate access to HIV testing and counseling (HTC) as a contributing factor to AIDS-related adolescent deaths, most of which occur in sub-Saharan Africa. This review focuses on studies conducted in high adolescent HIV-burden countries targeted by the "All In to End Adolescent AIDS" initiative, and describes barriers to adolescent HTC uptake and coverage. Fear of stigma and family reaction, fear of the impact of a positive diagnosis, perceived risk with respect to sexual exposure, poor attitudes of healthcare providers, and parental consent requirements are identified as major impediments. Most-at-risk adolescents for HIV infection and missed opportunities for testing include, those perinatally infected, those with early sexual debut, high mobility and multiple/older partners, and pregnant and nonpregnant females. Regional analyses show relatively low adolescent testing rates and more restrictive consent requirements for HTC in West and Central Africa as compared to East and southern Africa. Actionable recommendations for widening adolescent access to HTC and therefore timely care include minimizing legal consent barriers, healthcare provider training, parental education and involvement, and expanding testing beyond healthcare facilities.

Background: The prevalence of domestic violence among Nigerian women increased from 21% in 2011 to 30% in 2013, with an estimated two-thirds of these women experiencing violence from a male intimate partner. Previous studies have found a correlation between HIV-positive status and domestic violence in Nigerian women. In this study, we aimed to identify different forms of, and factors associated with, intimate partner violence (IPV) among women living with HIV in southwestern Nigeria. Methods: We conducted a cross-sectional survey at a tertiary health facility that cares for more than 1500 women living with HIV. The research team, including a facility-based counsellor, used a structured questionnaire to collect sociodemographic and intimate relationship data from participants. Information about IPV before and after women disclosed their HIV status to partners was collected. IPV forms were categorised as physical, sexual, and psychological according to WHO Domestic Violence definitions. Characteristics of respondents who reported IPV were compared with those for women who did not. We used Z tests and χ2 tests to compare dependent and independent samples, respectively, and we used multivariate logistic regression to identify factors independently associated with IPV. Findings: Between May 1 and May 30, 2013, we interviewed 328 women, which represents about 22% of HIV-positive women attending the facility. Mean age was 33·1 years (SD 0·73). Most women (226 [68·9%]) knew their partner's HIV status for the previous 12 months; 32·3% (106) had an HIV-positive partner, and 36·6% (120) had a partner who was HIV-negative. Over a third of women (115 [35·1%]) had experienced any form of IPV. Psychological violence (62/115 [53·9%]) was the most common type of violence reported by respondents, followed by physical violence (40/115 [34·8%]) and sexual violence (39 [33·9%]). There was a 62·8% (206/328) HIV disclosure rate to partners; of these women, 79 (38·3%) reported experiencing pre-disclosure IPV, with 40 (50·6%) experiencing physical violence, 39 (49·4%) sexual violence and 62 (78·5%) psychological violence. However, a higher proportion of women (115/206 [55·8%]) experienced IPV post-disclosure compared with pre-disclosure IPV (p=0·0004), with 58 (50·4%) of these women experiencing physical violence, 71 (61·7%) sexual violence, and 113 (98·2%) psychological violence. Correlates for post-disclosure IPV were having an HIV-positive partner (p

Background Acute illness and injury are major causes of child morbidity and mortality. Young children are prone to injury, and schools in developing countries are often not optimally child-proofed. In Nigeria, primary schoolteachers supervise students in an often injury-prone environment, with poor access to emergency services. First Aid (FA) can make a significant difference in outcome for a young child injured at school. This study was conducted to assess FA knowledge and skills in a cohort of primary school teachers and evaluate the effect of a training program on the cohort’s FA capacity. Methods We randomly selected 151 teachers from 16 primary schools in Ibadan. A 26-point survey and simulated scenarios graded on an 18-point scale assessed FA knowledge and skills, respectively. Based on identified gaps, a training program was developed and applied to a randomly selected subset of 70 of the 151 teachers, assigning them to intervention (N = 36) and control (N = 34). Controls were given an HIV education talk. FA knowledge and skills were measured immediately and 3 months post-intervention. FA knowledge was rated poor ( 17); skills were rated poor ( 11). Chi-square, t-test and ANOVA were used to compare means and to test for associations. Results Respondents’ mean age was 41.44 ± 9.90 years, and 95.4% had poor baseline knowledge. There was no difference in mean FA knowledge between intervention (7.69 ± 1.97) and control (7.29 ± 2.47) at baseline (p = 0.49). Mean baseline FA skills scores between intervention (0.5 ± 2.27) and control (0.65 ± 1.28) were similar (p = 0.59). Compared to baseline, there was a significant increase in mean FA knowledge immediately (20.83 ± 1.00, p Conclusions First aid knowledge and skills among primary school teachers in Ibadan was poor. The training program led to a significant and sustained improvement in teachers’ FA capacity. Primary school teachers can be trained and retrained to provide appropriate and timely basic care for students injured at school.