Creating a Sustainable Foundation for Interventional Radiology Services and Training in Sub-Saharan Africa: Five-Year Update on the Road2IR Initiative

PURPOSE

To evaluate the growth and quality of an IR training model designed for resource-constrained settings and implemented in Tanzania, as well as its overall potential to increase access to minimally invasive procedures across the region.

MATERIALS AND METHODS

IR training in Tanzania began in 10/2018 through monthly deployment of visiting teaching teams for hands-on training combined with in-person and remote lectures. A competency-based two-year Master of Science (MSc) in IR curriculum was inaugurated at the nation's main teaching hospital in 10/2019, graduating its first two classes in 2021 and 2022. Procedural data, demographics, and clinical outcomes were collected and analyzed throughout the duration of this program.

RESULTS

From 10/2018 to 7/2022, 1,595 procedures were performed in Tanzania: 1,236 non-vascular and 359 vascular, all with local fellows as primary operators. 97.2% were technically successful, 95.2% were without complication, and 28.9% were performed independently by Tanzanian fellows and faculty with no difference in complication and technical success rates (p=0.63 and 0.90, respectively), irrespective of procedural class. Ten IR physicians graduated from this program during the study period, followed by another three per year going forward. Partner training programs in Uganda and Rwanda mirroring this model commenced in 2023 and 2024, respectively.

CONCLUSION

The reported training model offers a practical and effective solution to meet many of the challenges associated with the lack of access to IR in sub-Saharan Africa.

Making the Case for Joint Decision-Making in Future Multipurpose Prevention Technology (MPT) Choice: Qualitative Findings on MPT Attribute Preferences from the CUPID Study (MTN-045)

Introduction

Young women in sub‐Saharan Africa account for two‐thirds of all new HIV infections and face high rates of unintended pregnancy. Multipurpose prevention technologies (MPTs) are promising products under development that are designed to simultaneously prevent HIV and unintended pregnancy. Since MPTs will be used in the context of sexual relationships, ensuring acceptability and use requires understanding the role of male partners in MPT use decision‐making.

Methods

This paper draws on qualitative data from 39 couples enrolled in the Microbicide Trials Network (MTN) 045 study, conducted in 2019–2020. Partners completed a discrete choice experiment (DCE), first separately and then jointly, to measure preferences for future MPT attributes and then completed a qualitative interview. We also draw on quantitative data from interviewer observation about who dominated the decision‐making process during the joint DCE. Content analysis was used to examine (1) how couples made decisions on existing non‐MPT HIV and pregnancy prevention products; (2) how couples made decisions on future ideal‐MPT product during the DCE; and (3) how these decision‐making processes varied by decision‐making dominance (10 male, 10 female and 19 equal) and interview type (19 joint and 20 separate).

Results

Existing non‐MPT product decisions focused on trust between partners and product attributes, while future ideal‐MPT product decisions exclusively focused on product attributes. Across existing and future products, preferences for product attributes varied by gender. Male partners were most concerned with limiting side effects impacting sexual pleasure, female partners were most concerned with limiting side effects causing physical symptoms and both were concerned with the return to fertility. Across all dominance and interview types, couples reported making decisions together and female partners were often able to negotiate with male partners for their preferred product or set of product attributes.

Conclusions

Research activities in this study provided an opportunity for couples to openly present their product attribute preferences to their partner, learn about their partner's attribute preferences, negotiate for their ideal set of attributes and ultimately choose attributes that benefited the couple without disempowering the female partner. Future research should focus on the utility of couple‐based decision‐making aids or similar tools for facilitating joint MPT decision‐making.

Establishment of a Percutaneous Nephrostomy Service to Treat Obstructive Uropathy Secondary to Cervical Cancer in Tanzania

Background Cervical cancer is the fourth most common cancer among women globally. Age-standardized cervical cancer mortality is higher in East Africa than anywhere else in the world. Prior to October 2018, patients presenting with obstructive uropathy secondary to late-stage cervical cancer in Tanzania who were no longer eligible for palliative chemoradiation therapy were discharged home without intervention. The purpose of this study was to evaluate whether the establishment of a percutaneous nephrostomy service in a quaternary hospital in Dar es Salaam, Tanzania, a resource-limited country, benefits patients who have late-stage cancer induced obstructive uropathy.

Materials and Methods A retrospective study was performed on patients who presented with obstructive uropathy secondary to late-stage cervical cancer and have undergone percutaneous nephrostomy at Muhimbili National Hospital and Ocean Road Cancer Institute from October 2018 to May 2021. Twenty-one interventional radiology (IR) teaching teams consisting of IR attendings, IR technologists, and nurses travelled to Tanzania from North America on monthly 2-week trips during that period. A review of preprocedural, procedural, and follow-up data was performed using Research Electronic Data Capture. Statistical analysis and comparison were performed on patients' creatinine levels preprocedure, 7 days and 30 days postprocedure.

Results Sixty-two patients qualified to be included in this study. In addition to the initial 62 nephrostomy placements, 14 follow-up procedures were performed either under visiting faculty supervision or independently by the Tanzanian IR fellows. Technical success rate was 98.7%. Complications (SIR Class A and B) occurred in eight cases. The average preprocedure creatinine (1051.48 ± 704.08µmol/L) decreased by 59% 7 days postprocedure and by 77% 30 days postintervention. Postprocedural clinical information was obtained for 28 (45.2%) patients and 18 were able to restart chemotherapy following nephrostomy.

Conclusion Prior to 2018, percutaneous nephrostomy placement was not available in Tanzania. This study presented the initial safety, technical feasibility, and clinical benefit of establishing a percutaneous nephrostomy service in such a resource-limited setting.

Safety and Effectiveness of Transthoracic Core Needle Biopsy in a Newly Established Interventional Radiology Program in Tanzania

Background Transthoracic core needle biopsy (TTCNB) became a routinely offered procedure in Tanzania in October 2018. This study evaluates the safety and effectiveness of establishing a TTCNB program in a resource-limited setting.

Methodology A single center, prospective, observational cohort study was conducted at Muhimbili National Hospital on 90 patients who underwent computed tomography-guided TTCNB from October 2018 to May 2021. Patient and procedural data, including demographic information, complications, pathology results, and clinical outcomes, were stored in a Research Electronic Data Capture (REDCap) database. Follow-up was conducted at 4 weeks postprocedure by phone. Descriptive analysis was performed using Statistical Package for Social Sciences.

Results A total of 90 patients underwent TTCNB. Seven samples were lost or never processed. In total, 68/83 (81.9%) of processed samples were diagnostic, with 89.7% (n = 61) classified as malignant and 10.3% (n = 7) classified as benign. Overall, 82.4% (n = 56) were classified as primary malignancies, 7.4% (n = 5) as metastatic malignancies, 5.9% (n = 4) as benign tumors, and 4.4% (n = 3) as infectious. Reasons for nondiagnostic samples were crashed/insufficient samples in 53.3% (n = 8) and nonspecific chronic inflammation in 46.7% (n = 7). Minor (Society of Interventional Radiology [SIR] class A and B) complications occurred in 8 cases (8.9%), while there was 1 (1.1%) major complication (SIR class F). A total of 44/90 (48.9%) patients could be reached for follow-up at 4 weeks postprocedure. In addition, 31/44 (70.5%) of these patients had a diagnosis of malignancy. Of these, 20 received chemotherapy, 8 died prior to receiving any treatment, 2 declined any further medical or surgical intervention, and 1 was treated with surgical excision and adjuvant chemotherapy.

Conclusion Although recently introduced in Tanzania, TTCNB has been performed with 81.9% diagnostic accuracy and a complication rate comparable to existing literature.

State of Cancer Control in Rwanda: Past, Present, and Future Opportunities

Rwanda is a densely populated low-income country in East Africa. Previously considered a failed state after the genocide against the Tutsi in 1994, Rwanda has seen remarkable growth over the past 2 decades. Health care in Rwanda is predominantly delivered through public hospitals and is emerging in the private sector. More than 80% of patients are covered by community-based health insurance (Mutuelle de Santé). The cancer unit at the Rwanda Biomedical Center (a branch of the Ministry of Health) is responsible for setting and implementing cancer care policy. Rwanda has made progress with human papillomavirus (HPV) and hepatitis B vaccination. Recently, the cancer unit at the Rwanda Biomedical Center launched the country’s 5-year National Cancer Control Plan. Over the past decade, patients with cancer have been able to receive chemotherapy at Butaro Cancer Center, and recently, the Rwanda Cancer Center was launched with 2 linear accelerator radiotherapy machines, which greatly reduced the number of referrals for treatment abroad. Palliative care services are increasing in Rwanda. A cancer registry has now been strengthened, and more clinicians are becoming active in cancer research. Despite these advances, there is still substantial work to be done and there are many outstanding challenges, including the need to build capacity in cancer awareness among the general population (and shift toward earlier diagnosis), cancer care workforce (more in-country training programs are needed), and research.