Lessons from the pandemic: new best practices in selecting molecular diagnostics for point-of-care testing of infectious diseases in sub-Saharan Africa

INTRODUCTION

Point-of-care molecular diagnostics offer solutions to the limited diagnostic availability and accessibility in resource-limited settings. During the COVID-19 pandemic, molecular diagnostics became essential tools for accurate detection and monitoring of SARS-CoV-2. The unprecedented demand for molecular diagnostics presented challenges and catalyzed innovations which may provide lessons for the future selection of point-of-care molecular diagnostics.

AREAS COVERED

We searched PubMed from January 2020 to August 2023 to identify lessons learned from the COVID-19 pandemic which may impact the selection of point-of-care molecular diagnostics for future use in sub-Saharan Africa. We evaluated this in the context of REASSURED criteria (Real-time connectivity; Ease of specimen collection; Affordable; Sensitive; Specific; User-friendly; Rapid and robust; Equipment free; and Deliverable to users at the point of need) for point-of-care diagnostics for resource-limited settings.

EXPERT OPINION

The diagnostic challenges and successes during the COVID-19 pandemic affirmed the importance of the REASSURED criteria but demonstrated that these are not sufficient to ensure new diagnostics will be appropriate for public health emergencies. Capacity for rapid scale-up of diagnostic testing and transferability of assays, data, and technology are also important, resulting in updated REST-ASSURED criteria. Few diagnostics will meet all criteria, and trade-offs between criteria will need to be context-specific.

Perinatal HIV exposure and infection and caregiver depressive symptoms

Survival is possible for children perinatally exposed to or infected by HIV in the post-combined antiretroviral therapy era and identifying factors affecting children's ability to thrive has public health significance. Caregiver mental health is one such factor to consider given its impact on child development, but previous work has not included a full complement of HIV exposure/infection groups within HIV-endemic settings. We compared depressive symptoms among caregivers of 3 groups of 6-10-year-olds in Uganda: children with perinatally acquired HIV infection (CPHIV, n = 102), children with perinatal HIV exposure, but no infection (CPHEU, n = 101), and children without perinatal HIV exposure or infection (CHUU, n = 103). The Hopkins Symptom Checklist was used to assess caregiver depressive symptoms. Generalized linear models were used to estimate group mean differences. Adjusted models included caregiver demographics, social support, and lifetime trauma. Depression symptoms were higher among CPHEU compared to CPHIV caregivers (model coefficient [B] = -3.5, 95%CI -5.3, -1.8). This finding was minimally attenuated following adjustment for covariates (B = -2.2, 95%CI -4.1, -0.4) and among biological mothers. At lower levels of social support and wealth, CPHEU caregivers reported higher levels of depression symptoms than CPHIV caregivers. Our findings point to unmet mental health needs among CPHEU caregivers.

Acceptability of the dapivirine vaginal ring for HIV-1 prevention among women reporting engagement in transactional sex

We assessed if acceptability of the dapivirine vaginal ring for HIV prevention differed among the subgroup of women who reported engaging in transactional sex prior to enrollment in MTN-020/ASPIRE (phase III trial in Malawi, South Africa, Uganda, and Zimbabwe, 2012-2015; n = 2629). Transactional sex was defined as receipt of money, goods, gifts, drugs, or shelter in exchange for sex in the past year. Dimensions of acceptability included: ease of use and physical sensation in situ, impacts on sex, partner's opinion, and likelihood of future use. We used Poisson regression models with robust standard errors to compare risk of acceptability challenges by baseline history of transactional sex. At product discontinuation, women exchanging sex found the ring comfortable (90%), easy to insert (92%) and nearly all (96%) were likely to use the ring in the future. Women who had exchanged sex were more likely to report feeling the ring during sex (ARR 1.43, 95% CI: 1.09, 1.89; p = 0.01) and slightly more likely to mind wearing the ring during menses (ARR 1.22, 95% CI: 1.01, 1,46; p = 0.04) and during sex (ARR 1.22, 95% CI: 1.02, 1.45; p = 0.03). Messaging and counseling should include enhanced support for use during sex and menses to support optimal use.

Patient and caregiver experiences of living with dementia in Tanzania

Introduction: Tanzania is a low-income country with an increasing prevalence of dementia, which provides challenges for the existing healthcare system. People with dementia often don't receive a formal diagnosis, and with a lack of formal healthcare, are often predominantly supported by family relatives. There are very few published data relating to lived experiences of people with dementia in Tanzania. This study aimed to understand people with dementia, and their caregivers' experiences of living with dementia in Tanzania and the perceived needs of people with dementia.Methods: Qualitative, semi-structured interviews were conducted with 14 people with dementia and 12 caregivers in Moshi, Tanzania. Interviews were audio-recorded, translated, transcribed and analysed using a Framework Analysis approach.Results: Three sub-themes were identified within data describing the experience of 'Living with Dementia in Tanzania': 'Deteriorations in Health', 'Challenges to living with Dementia in Tanzanian Culture', and 'Lack of Support': people with dementia faced challenges due to social isolation, stigmatisation, and lack of caregiver knowledge on how best to provide support. Collectively, these impacted on both the physical and mental health of people with dementia. Misconceptions about dementia aetiology related to age, stresses of daily life and other co-morbidities. People with dementia were motivated to access treatment, exhibiting pluralistic health-seeking behaviours. There was an overall preference for non-pharmacological interventions over medication, with high levels of trust in medical professional opinions.Conclusions: Living with dementia in Tanzania is influenced by both cultural and religious factors. More work is needed to target supplementary healthcare (with efforts to promote accessibility), support for caregivers and public health education about dementia to overcome existent misconceptions and stigma.

A systematic review (2020-2022)

There has been significant progress with regards to winning the fight against HIV globally, particularly due to the introduction of antiretroviral therapy (ART). COVID-19 threatened to derail gains in the fight against HIV. As we have started to see with studies on COVID-19 and HIV, there is a need to 'provide an in-depth view' in understanding the dynamics between the two epidemics, especially in sub-Saharan Africa. We, therefore, undertook a systemic review of existing literature to synthesize the effects of COVID-19 on the utilization of HIV services in sub-Saharan Africa, the literature on the risks associated with HIV during the COVID-19 pandemic, and lastly, the innovations and strategies adopted to continue receiving treatment in sub-Saharan Africa. We conducted a systematic review of studies published between 2020 and April 2022. We searched for relevant sub-Saharan studies in the following databases: PubMed, Google Scholar, J-STOR, and Science Direct. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search identified 647 papers, and after screening, 41 were in line with the inclusion criteria and were included in the review. There was evidence of the negative effects of COVID-19 on reducing HIV testing, ART treatment, and HIV prevention services. There is evidence pointing to the need for people living with HIV to be prioritized for COVID-19 vaccinations. Innovations and strategies implemented to mitigate the effects of COVID-19 on HIV services include community-based ART distribution, multi-month ART dispensing, the use of digital technologies, and the use of the already existing HIV infrastructure to fight COVID-19. It is still imperative that future studies explore the predictors of utilization of HIV services in the advent of COVID-19.

Perinatal palliative care in sub-Saharan Africa: recommendations for practice, future research, and guideline development

Worldwide, sub-Saharan Africa has the highest burden of global neonatal mortality (43%) and neonatal mortality rate (NMR): 27 deaths per 1,000 live births. The WHO recognizes palliative care (PC) as an integral, yet underutilized, component of perinatal care for pregnancies at risk of stillbirth or early neonatal death, and for neonates with severe prematurity, birth trauma or congenital anomalies. Despite bearing a disproportionate burden of neonatal mortality, many strategies to care for dying newborns and support their families employed in high-income countries (HICs) are not available in low-and-middle-income countries (LMICs). Many institutions and professional societies in LMICs lack guidelines or recommendations to standardize care, and existing guidelines may have limited adherence due to lack of space, equipment, supplies, trained professionals, and high patient load. In this narrative review, we compare perinatal/neonatal PC in HICs and LMICs in sub-Saharan Africa to identify key areas for future, research-informed, interventions that might be tailored to the local sociocultural contexts and propose actionable recommendations for these resource-deprived environments that may support clinical care and inform future professional guideline development.

Patient Care and Treatment Strategies for Skin Diseases in Sub-Saharan Africa: Role of Traditional and Western Medicines

The perspective of the people of Sub-Saharan Africa (SSA) toward both traditional and western healthcare systems varies. The goal of the current study is to examine the SSA's unique skin disease health care system. This study comprises numerous research that sought to examine how the general public feels about the SSA's current healthcare system. In this review, common skin conditions, such as atopic dermatitis, buruli ulcers, dermatophytosis, and scabies, are addressed. According to this report, government agencies must pay particular attention to skin illnesses in SSA and raise public awareness. Availability of medical care, socioeconomic factors, degree of education, and other factors influence patients' attitudes toward traditional and western health care differently in different geographic areas. Facts suggest that self-medication is the preference of the majority of patients before seeking dermatological care. The present study concludes that the magnitude of skin diseases is neglected or underestimated in many regions of SSA. Also, western healthcare facilities of many regions of SSA are not up to the mark. The present study recommends that proper access to the health care system and awareness about skin diseases through various government programs can be helpful in the regulation of skin disorders among people of SSA.

The burden of malaria in sub-Saharan Africa and its association with development assistance for health and governance: An exploration of the GBD 2019 study

Even with a reduced burden of malaria in sub-Saharan Africa (SSA), differences remain in the rate of change among countries and sub-regions. We used data from the Global Burden of Disease Study 2019 to establish the relationship between Development Assistance for Health (DAH) and governance and trends in malaria burden in SSA. The trend was estimated using the Joinpoint regression program and the Institute of Health Metrics and Evaluation's DAH database, and World Bank Governance Indicators to analyze the DAH and governance respectively from 2000 to 2017 and used two-way fixed effects to establish their association with the trend in the period. The findings showed decreases in SSA's age-standardised rates for disability-adjusted life years (ASDR) (-47% (95% uncertainty interval (UI) -69% to -14%)), deaths (-38% (95% UI -65% to -3%)), incidence (-35% (95% UI -44% to -25%)), and prevalence (-34% (95% UI -43% to -24%)). Decreases in ASDR were associated with increases in DAH (β -134.18, standard error (SE) 27.26) and governance scores (β -246.19, SE 39.13). The association between reductions in malaria burden and increases in DAH and in governance scores shows the need for accelerated funding of malaria programs and advocacy for better disease governance in malaria-endemic countries.Abbreviations: APC: Annual percentage change; ASDR: Age-standardised disability-adjusted life-year rate; ASIR: Age-standardised incidence rate; ASIR: Age-standardised incidence rate; ASMR: Age-standardised mortality rate; CSSA: Central sub-Saharan Africa; DAH: Development Assistance for Health; DALYs: Disability-adjusted life years; ESSA: Eastern sub-Saharan Africa; GBD: Global burden of disease; GHDx Global Health Data Exchange; IHME: Institute of Health Metrics and Evaluation; SDGs: Sustainable Development Goals; SSA: Sub-Saharan Africa; SSSA: Southern sub-Saharan Africa; UNSD: United Nations Statistics Division; USD: United States dollars; WGI: World Bank Governance Indicators; WHO: World Health Organization; WSSA: Western sub-Saharan Africa.

Systematic review of psychosocial interventions for adult cancer patients and their family caregivers in Sub-Saharan Africa

Cancer is becoming a public health issue in the Sub-Saharan Africa (SSA). This systematic review aims to synthesise psychosocial interventions and their effects on the health outcomes of adult cancer patients and their family caregivers in SSA. We identified eligible publications in English language from PubMed, Cumulative Index of Nursing and Allied Health Literature Plus with Full Text, Embase, APA PsycInfo, Scopus, and African Index Medicus databases. We included psychosocial interventions targeted adult cancer patients/survivors or their family caregivers in SSA. This review identified five psychosocial interventions from six studies that support adult cancer patients and their family caregivers in SSA. The interventions focused on providing informational, psycho-cognitive, and social support. Three interventions significantly improved quality of life outcomes for cancer patients and their caregivers. Significant gaps exist between the rapidly increasing cancer burdens and the limited psychosocial educational interventions supporting adult cancer patients and their families in SSA. The reviewed studies provide preliminary evidence on development and testing interventions that aim to improve patients' and caregivers' quality of life.

Increasing health system synergies in low-income settings: Lessons learned from a qualitative case study of Rwanda

Building synergies is seen as an effective strategy to address and decrease existing fragmentation in health systems of low-and middle-income countries (LMICs). To that end, different programmes, such as the Sector Wide Approach, have been adopted to increase health system synergies. Despite these efforts, fragmentation remains an enduring problem, hampering health system performance in LMICs. This study is part of the Lancet Commission on synergies between Universal Health Coverage, Health Security, and Health Promotion; we aimed to document synergising strategies adopted by Rwanda. Data for this paper came from a qualitative study including in-depth interviews of 15 key informants and a document review. A thematic analysis embracing deductive and inductive approaches was used to analyse the data. We found that Rwanda adopted three main strategies to increase health system synergies: (1) alignment of health programmes with national health policies and strategies, (2) increased coordination across national health institutions, and (3) effective monitoring and evaluation frameworks. Achieving synergies in a low-resource country is challenging but not impossible. To meet the target of global health agendas such as the Sustainable Development Goals and the prevention of future global pandemics, efforts to increase health system synergies in LMICs need to be strengthened.

Gender relations and the utilization of contraceptives and antenatal care services in Kenya, Namibia and Nigeria

The impacts of gender relations (GR) on reproductive health in sub-Saharan Africa (SSA) have received little attention. Virtually non-existent are studies that take cognizance of the socio-cultural diversity of SSA countries in assessing the impacts. Using Demographic and Health Survey data from Namibia, Kenya and Nigeria, this study investigated whether feminine gender relations (FGR) predict higher uptake of contraceptives and antenatal care services (ANC) in SSA. Results from univariate, bivariate and multivariate analyses showed that Namibia had the highest prevalence of FGR (20.0%) and contraceptive use (57.8%) while Nigeria had the lowest FGR (5.7%) but highest ANC utilization (42.1%). At the unadjusted levels, FGR predicted higher contraceptive use in Namibia and Nigeria but became insignificant when sociodemographic confounders were controlled for. Masculine gender relations (MGR) however predicted increased contraceptive and ANC utilization in the three countries at the unadjusted levels and contraceptive use in Kenya and Nigeria when adjusted. That MGR predicted higher odds of using contraceptives in a largely gender egalitarian Kenya and patriarchal Nigeria while FGR was insignificant even in the largely feministic Namibia, suggests that promoting equality in GR, rather than emphasizing female autonomy, possesses greater capacity for improving reproductive health outcomes in SSA.

Sex-ratio at birth in Nigeria: A demographic perspective

The study attempts at estimating the sex-ratio at birth in Nigeria. The study focuses on demographic surveys with complete maternity histories, including some 0.50 million births. It compares results with published estimates from births in health facilities and a few data from vital registration, including some 1.13 million births. Results from demographic surveys give an estimate of about 106 boys for 100 girls. There were no significant variations by large region in the country, and no significant trend over the years (1990-2018). Published estimates provided a similar value (106.2), with somewhat lower value in health facilities (105.3), and somewhat higher values in local vital registration (106.8), and major variations among available studies. Despite uncertainty, Nigeria appears to have higher sex-ratios than most African countries, with the exception of Ethiopia, and higher values than its five neighboring countries. Reasons for these high values of the secondary sex-ratio are discussed.

Epidemiology of tungiasis in sub-saharan Africa: a systematic review and meta-analysis

Tungiasis is a public health disease in many rural and urban slums in sub-Saharan Africa (SSA), primarily affecting children and the elderly. Yet, this disease has received little attention in many sub-Saharan African countries. We conducted a systematic review and meta-analysis to estimate the pooled prevalence of tungiasis and associated risk factors in SSA. We searched AJOL, Google Scholar, Web of Science, and PubMed for population-based studies that reported the prevalence of tungiasis and risk factors in SSA between January 1980 and July 2020. The study employed a random-effects model and heterogeneity to estimate the pooled prevalence and evaluate the Cochran's Q-test respectively across studies that met the inclusion criteria. We screened 104 articles and retrieved 42 full-text articles to evaluate for inclusion in the review. Twenty-seven studies involving 16,303 individuals in seven SSA countries were analyzed. The pooled prevalence of tungiasis in SSA was 33.4% (95% CI: 27.6-39.8), while tungiasis prevalence was 46.5%, 44.9%, 42.0%, 37.2%, 28.1%, 22.7% and 20.1% for Ethiopia, Cameroon, Tanzania, Kenya, Nigeria, Rwanda, and Uganda, respectively. The risk of tungiasis was associated with gender, participants' age groups (4-15 years and ≥60 years), earthen floor, non-regular use of footwear, contact with animals, and residence in rural areas. An integrated approach addressing significant factors in tungiasis prevalence in SSA needs to be designed and implemented by a trans-disciplinary composition of community leaders, health professionals, non-governmental institutions, and policymakers.

What Motivates People With (Pre)Diabetes to Move? Testing Self-Determination Theory in Rural Uganda

Introduction

Sub-Saharan Africa is experiencing a rapid growth of type 2 diabetes (T2D) and its related burden. Regular physical activity (PA) is a successful prevention strategy but is challenging to maintain. Self-determination theory (SDT) posits that more autonomous forms of motivation are associated with more sustainable behavior change. Evidence to support this claim is lacking in sub-Saharan Africa. This study aims to explore the relationships between latent constructs of autonomous and controlled motivation, perceived competence, perceived relatedness, PA behavior, and glycemic biomarkers.

Methods

Structural equation modeling was applied to cross-sectional data from a rural Ugandan population (N = 712, pre-diabetes = 329, diabetes = 383). Outcome measures included self-reported moderate and vigorous PA, pedometer counts, and fasting plasma glucose (FPG) and glycated hemoglobin (HbA1C).

Results

Our findings support SDT, but also suggest that different types of motivation regulate different domains and intensities of PA. Higher frequency of vigorous PA – which was linked to a lower HbA1C and FPG – was predicted by autonomous motivation (β = 0.24) but not by controlled motivation (β = −0.05). However, we found no association with moderate PA frequency nor with pedometer counts. Perceived competence and perceived relatedness predicted autonomous motivation. Autonomous motivation functioned as a mediator between those needs and PA behavior.

Conclusion

This is the first study providing evidence for a SDT model explaining PA among people at risk of, or living with, T2D in a rural sub-Saharan African setting. Our findings suggest that individuals who experience genuine support from friends or family and who feel competent in doing vigorous PA can become motivated through identification of health benefits of PA as their own goals. This type of motivation resulted in a higher frequency of vigorous PA and better glycemic biomarkers. On the other hand, people who felt more motivated through pressure from others or through feelings of guilt or shame were not more engaged in PA.

Clinical Trial Registration

ISRCTN 11913581. Registered January 10, 2017.

How the Cervical Microbiota Contributes to Cervical Cancer Risk in Sub-Saharan Africa

Despite ongoing efforts, sub-Saharan Africa faces a higher cervical cancer burden than anywhere else in the world. Besides HPV infection, definitive factors of cervical cancer are still unclear. Particular states of the cervicovaginal microbiota and viral infections are associated with increased cervical cancer risk. Notably, HIV infection, which is prevalent in sub-Saharan Africa, greatly increases risk of cervicovaginal dysbiosis and cervical cancer. To better understand and address cervical cancer in sub-Saharan Africa, a better knowledge of the regional cervicovaginal microbiome is required This review establishes current knowledge of HPV, HIV, cervicovaginal infections, and the cervicovaginal microbiota in sub-Saharan Africa. Because population statistics are not available for the region, estimates are derived from smaller cohort studies. Microbiota associated with cervical inflammation have been found to be especially prevalent in sub-Saharan Africa, and to associate with increased cervical cancer risk. In addition to high prevalence and diversity of HIV and HPV, intracellular bacterial infections such as Chlamydia, Gonorrhea, and Mycoplasma hominis are much more common than in regions with a low burden of cervical cancer. This suggests the prevalence of cervical cancer in sub-Saharan Africa may be partially attributed to increased cervical inflammation resulting from higher likelihood of cervical infection and/or microbial dysbiosis.

Unexpected low frequency of respiratory symptoms in an HIV-positive urban sub-Saharan population compared to an HIV-negative control group

Background

Chronic respiratory illnesses and respiratory infections are common in HIV-positive populations. It seems reasonable that HIV-positive people experience more respiratory symptoms, such as coughing and breathlessness, than those who are HIV-negative.

Objectives

This study aims to determine the frequency of respiratory symptoms in an urban African HIV-positive population.

Method

A cross-sectional study was conducted in Johannesburg, South Africa, in 2016–2017. Four groups of participants were included: HIV-positive participants (1) not yet on antiretroviral therapy (ART), (2) on first-line ART, (3) on second-line ART and (4) age- and sex-matched HIV-negative controls. Data were collected on socio-demographics, respiratory risk factors and respiratory symptoms. A logistic regression analysis was performed to determine if respiratory symptoms differed between groups and to identify determinants associated with symptoms.

Results

Overall, 547 participants were included, of whom 62% were women, with a median age of 37 years. Of these patients, 63% (347) were HIV-positive, 26% were ART-naïve, 24% were on first-line ART and 50% were on second-line ART. Cough and/or productive cough was reported by 27 (5%), wheezing by 9 (2%) and breathlessness by 118 (22%) of the participants. The frequency of these symptoms did not differ by HIV status after adjustment for age and sex. Breathlessness was associated with age, female sex, obesity, a history of respiratory infection and a history of airway hyper-reactivity.

Conclusion

The frequency of respiratory symptoms was low in our study population except for breathlessness. HIV-positive participants, whether or not on ART, did not experience more symptoms than HIV-negative participants.

Linkage to primary care after home-based blood pressure screening in rural KwaZulu-Natal, South Africa: a population-based cohort study

OBJECTIVES

The expanding burden of non-communicable diseases (NCDs) globally will require novel public health strategies. Community-based screening has been promoted to augment efficiency of diagnostic services, but few data are available on the downstream impact of such programmes. We sought to assess the impact of a home-based blood pressure screening programme on linkage to hypertension care in rural South Africa.

SETTING

We conducted home-based blood pressure screening withinin a population cohort in rural KwaZulu-Natal, using the WHO Stepwise Approach to Surveillance (STEPS) protocol.

PARTICIPANTS

Individuals meeting criteria for raised blood pressure (≥140 systolic or ≥90 diastolic averaged over two readings) were referred to local health clinics and included in this analysis. We defined linkage to care based on self-report of presentation to clinic for hypertension during the next 2 years of cohort observation. We estimated the population proportion of successful linkage to care with inverse probability sampling weights, and fit multivariable logistic regression models to identify predictors of linkage following a positive hypertension screen.

RESULTS

Of 11 694 individuals screened, 14.6% (n=1706) were newly diagnosed with elevated pressure. 26.9% (95% CI 24.5% to 29.4%) of those sought hypertension care in the following 2 years, and 38.1% (95% CI 35.6% to 40.7%) did so within 5 years. Women (adjusted OR (aOR) 2.41, 95% CI 1.68 to 3.45), those of older age (aOR 11.49, 95% CI 5.87 to 22.46, for 45-59 years vs <30) and those unemployed (aOR 1.71, 95% CI 1.10 to 2.65) were more likely to have linked to care.

CONCLUSIONS

Linkage to care after home-based identification of elevated blood pressure was rare in rural South Africa, particularly among younger individuals, men and the employed. Improved understanding of barriers and facilitators to NCD care is needed to enhance the effectiveness of blood pressure screening in the region.

Ameloblastic carcinoma: a clinicopathologic analysis of cases seen in a Nigerian Teaching Hospital and review of literature

Introduction

Ameloblastic carcinoma is a rare malignant odontogenic neoplasm that exhibits histological features of ameloblastoma in combination with cytological atypia. It may arise de novo or secondarily through malignant de-differentiation of pre-existing ameloblastoma or odontogenic cyst. Secondary ameloblastic carcinomas often results from repeated surgical intervention, which is a mainstay of odontogenic tumor management in resource limited settings. To date, relatively few cases of ameloblastic carcinomas have been reported and many cases have been misdiagnosed as ameloblastoma. This is due to its wide range of clinicopathological feature which range from indolent to aggressive. It may present as an aggressive ulcerated mass or as a simple cystic lesion; hence, it often challenging to delineate from its benign counterpart, ameloblastoma.

Methods

this study reviewed the clinicopathological data on 157 cases of odontogenic tumors diagnosed over a 10 years period from the pathology archive of the Oral Pathology Unit of Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife, Nigeria.

Results

of all these cases, we identified that 64.9% were Ameloblastomas, while 8.3% were ameloblastic carcinomas. Primary subtypes of ameloblastic carcinoma constituted 23.08%, while 69.23% of the cases were of the secondary subtype. We also found that the secondary subtype of ameloblastic carcinomas showed a higher mean duration value of 7.7 years. Most lesions were found in posterior mandible and presented with ulceration, perforation and ill-defined borders radiographically.

Conclusion

this study is among the few that have documented higher frequency of secondary ameloblastic carcinoma in the scientific literature.

Implementing a mobile diagnostic unit to increase access to imaging and laboratory services in western Kenya

Access to basic imaging and laboratory services remains a major challenge in rural, resource-limited settings in sub-Saharan Africa. In 2016, the Academic Model Providing Access to Healthcare programme in western Kenya implemented a mobile diagnostic unit (MDU) outfitted with a generator-powered X-ray machine and basic laboratory tests to address the lack of these services at rural, low-resource, public health facilities. The objective of this paper is to describe the design, implementation, preliminary impact and operational challenges of the MDU in western Kenya. Since implementing the MDU at seven rural health facilities serving a catchment of over half a million people, over 4500 chest radiographs have been performed, with one or more abnormalities detected in approximately 30% of radiographs. We observed favorable feedback and uptake of MDU services by healthcare workers and patients. However, various operational challenges in the design and construction of the MDU and the transmission and reporting of radiographs in remote areas were encountered. Our experience supports the feasibility of deploying an MDU to increase access to basic radiology and laboratory services in rural, resource-limited settings.

Hazardous alcohol consumption and alcohol-related problems are associated with unknown and HIV-positive status in fishing communities in Uganda

In Uganda, alcohol consumption is associated with higher HIV prevalence. However, research is needed to better understand how different patterns of alcohol consumption and alcohol-related problems may drive this association. In this cross-sectional study, we examined how hazardous alcohol use and alcohol-related problems such as psychological, physical, and social harms are associated with HIV status in fishing communities in Uganda. 300 (132 male, 168 female) residents of fishing communities in Uganda (75 participants from each of the following occupational groups: fishmongers, alcohol sellers, commercial sex workers (CSW), and fishermen) completed an interviewer-assisted computerized interview. We captured information on sociodemographics and HIV testing history. Prior 12-month hazardous alcohol consumption patterns and alcohol-related problems were assessed with the AUDIT and AUDADIS. 19.7%, 58.0%, and 23.3% of the sample reported being HIV positive, being HIV negative from a test within the prior 12 months, and not knowing their HIV status respectively. 18.7% reported the co-occurrence of hazardous alcohol consumption patterns and alcohol-related problems. 7.7% reported either hazardous alcohol consumption patterns or alcohol-related problems. Compared to non-drinkers, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of being HIV positive (adjOR 2.75, 95% CI 1.17-6.43) and of unknown HIV status (adjOR 3.35, 95% CI 1.52-7.42). Reporting only hazardous consumption levels, only alcohol-related problems, or low-risk drinking, did not increase the odds of being HIV positive or of unknown status. Among those not HIV positive, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of never having had an HIV test (adjOR 3.78, 95% CI 1.63-8.68). The co-occurrence of hazardous alcohol use and alcohol related problems appears to be a prominent risk factor for HIV infection, not knowing one's HIV status, and never testing for HIV in this setting.

Individual, maternal and household risk factors for anaemia among young children in sub-Saharan Africa: a cross-sectional study

OBJECTIVE

Anaemia affects the majority of children in sub-Saharan Africa (SSA). Previous studies of risk factors for anaemia have been limited by sample size, geography and the association of many risk factors with poverty. In order to measure the relative impact of individual, maternal and household risk factors for anaemia in young children, we analysed data from all SSA countries that performed haemoglobin (Hb) testing in the Demographic and Health Surveys.

DESIGN AND SETTING

This cross-sectional study pooled household-level data from the most recent Demographic and Health Surveys conducted in 27 SSA between 2008 and 2014.

PARTICIPANTS

96 804 children age 6-59 months.

RESULTS

The prevalence of childhood anaemia (defined as Hb <11 g/dL) across the region was 59.9%, ranging from 23.7% in Rwanda to 87.9% in Burkina Faso. In multivariable regression models, older age, female sex, greater wealth, fewer household members, greater height-for-age, older maternal age, higher maternal body mass index, current maternal pregnancy and higher maternal Hb, and absence of recent fever were associated with higher Hb in tested children. Demographic, socioeconomic factors, family structure, water/sanitation, growth, maternal health and recent illnesses were significantly associated with the presence of childhood anaemia. These risk factor groups explain a significant fraction of anaemia (ranging from 1.0% to 16.7%) at the population level.

CONCLUSIONS

The findings from our analysis of risk factors for anaemia in SSA underscore the importance of family and socioeconomic context in childhood anaemia. These data highlight the need for integrated programmes that address the multifactorial nature of childhood anaemia.

Prevalence and factors associated with medication adherence among patients with hypertension in sub-Saharan Africa: protocol for a systematic review and meta-analysis

INTRODUCTION

Hypertension is the leading cardiovascular risk factor globally, associated with a high morbidity and mortality. The high prevalence of hypertension in sub-Saharan Africa (SSA) is associated with contrastingly low awareness, treatment and control rates. Adherence to medication remains a major determinant of optimal blood pressure control. This systematic review aims to determine the prevalence, and factors associated with adherence to antihypertensive pharmacotherapy among patients with hypertension in SSA.

METHODS AND ANALYSIS

We will include studies published in Africa up to 31 December 2017. The following databases will be searched: PubMed, Embase, SCOPUS and Web of Science to identify potential studies without language restriction. To minimise chances of missing studies, resources specific to African literature such as WHO AFROLIB, African Index Medicus and African Journals Online will also be searched. Two reviewers will independently screen studies, extract data and critically appraise included studies for risk of bias, and a third reviewer will resolve discrepancies. A random-effects meta-analysis is planned to pool study-specific estimates to obtain a summary measure presented in Forest plots. Heterogeneity of included studies will be assessed using the χ² test on Cochrane's Q statistic and quantified using I². Publication bias will be assessed using the Egger's test and funnel plots. This protocol has been prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Protocols 2015 statement.

ETHICAL AND DISSEMINATION

An ethical approval is not required for the proposed study, as it will be based on already published data. The end report will be presented at conferences and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42017079838.

Thirty-year trends in the prevalence and severity of female genital mutilation: a comparison of 22 countries

Introduction

Female genital mutilation (FGM) harms women's health and well-being and is widely considered a violation of human rights. The United Nations has called for elimination of the practice by 2030.

Methods

We used household survey data to measure trends in the prevalence of FGM in 22 countries. We also examined trends in the severity of the practice by measuring changes in the prevalence of flesh removal, infibulation and symbolic 'nicking' of the genitals. We evaluated the extent to which measurement error may have influenced our estimates by observing the consistency of reports for the same birth cohorts over successive survey waves.

Results

The prevalence of all types of FGM fell in 17 of 22 countries we examined. The vast majority of women who undergo FGM have flesh removed from their genitals, likely corresponding to the partial or total removal of the clitoris and labia. Infibulation is still practised throughout much of sub-Saharan Africa. Its prevalence has declined in most countries, but in Chad, Mali and Sierra Leone the prevalence has increased by 2-8 percentage points over 30 years. Symbolic nicking of the genitals is relatively rare but becoming more common in Burkina Faso, Chad, Guinea and Mali.

Conclusion

FGM is becoming less common over time, but it remains a pervasive practice in some countries: more than half of women in 7 of the 22 countries we examined still experience FGM. The severity of the procedures has not changed substantially over time. Rigorous evaluation of interventions aimed at eliminating or reducing the harms associated with the practice is needed.

High prevalence of pain among adult HIV-infected patients at University of Gondar Hospital, Northwest Ethiopia

Background

HIV/AIDS are pressing global health problems. Pain is a common symptom reported by patients living with HIV/AIDS. The exact cause of pain in HIV patients has not been thoroughly described, but it may, due to a symptom of HIV itself, result from opportunistic infections, as a side effect of antiretroviral drugs, concurrent neoplasia or other causes. In addition, pain perception of HIV-infected patients is highly variable and may vary based on cultural context and patient demographics. In Ethiopia, there is insufficient evidence on the prevalence and factors associated with HIV-related pain.

Methods

A cross-sectional study was conducted among 422 adult HIV-infected patients at Gondar University Hospital antiretroviral care clinic from March 1 to May 1, 2016. Systematic random sampling was used to select study participants. A pretested interviewer-administered questionnaire and a standardized medical record data abstraction tool were used to collect data. A short form brief pain inventory tool was used to measure the outcome. Bivariate and multivariate logistic regression models were fitted to identify factors associated with pain among adult HIV patients.

Results

The prevalence of pain was found to be 51.2% (95% CI: 46.4%–55.9%). Headache (17.9%), abdominal pain (15.6%), and backache (13.3%) were the most common symptoms of study participants. Being female (adjusted odds ratio [aOR]=1.8, 95% CI: 1.1–2.9); regular alcohol intake (aOR=3.3, 95% CI: 1.5–7.2); baseline World Health Organization clinical disease stage: II (aOR=2.5, 95% CI: 1.2–4.9), III (aOR=2, 95%, CI: 1.1–3.6), and IV (aOR=2.4, 95% CI: 1.1–5.3); and the presence of a chronic comorbid condition (aOR=5.9, 95% CI: 2.1–16.7) were significantly associated with pain.

Conclusion

Adult HIV patients in this sample reported a high level of chronic pain. Healthcare providers should better implement a routine pain assessment among HIV-positive patients to alleviate their suffering.

The cost of accessing infant HIV medications and health services in Uganda

Patient costs are a critical barrier to the elimination of mother to child HIV transmission. Despite the Ugandan government providing free public HIV services, infant antiretroviral (ARV) prophylaxis coverage remains low (25%). To understand costs mothers incur in accessing ARV prophylaxis for their infants, we conducted a mixed methods study to quantify and identify their direct costs. We used cross-sectional survey data and focus group discussions from 49 HIV-positive mothers in Uganda. Means and standard deviations were calculated for the direct costs (e.g., transportation, caretaker, services/medications) involved in accessing infant HIV services. The direct cost of attending HIV clinic visits averaged $3.71 (SD = $3.52). Focus group discussions identified two costs hindering access to infant HIV services: transportation costs and informal service charges. All participants reported significant costs associated with accessing infant HIV services - the equivalent of 2-3 days' income. To address transportation costs, community and home care models should be explored. Additionally, stricter policies and oversight should be implemented to prevent informal HIV service charges.

Cost-Effectiveness of Screening and Treatment for Cervical Cancer in Tanzania: Implications for other Sub-Saharan African Countries

OBJECTIVES

To compare the institutional cost per person of screening and treatment between two groups of patients-those screened and those not screened before treatment for cervical cancer at Ocean Road Cancer Institute (ORCI) in Dar es Salaam, Tanzania-and to perform a cost-effectiveness analysis of the ORCI cervical cancer screening program.

METHODS

The study included 721 screened and 333 unscreened patients treated at ORCI for cervical cancer from 2002 to 2011. We compared the cost of cervical cancer treatment per patient with life-years gained for patients screened at ORCI versus not screened.

RESULTS

Patients with cancer were diagnosed at an earlier stage after participating in screening compared with nonparticipants. For example, 14.0% of stage I cancer patients had received screening by ORCI compared with 7.8% of unscreened cases. For stage IV cancer, these percentages were 1.4% and 6.9%, respectively. Average screening and treatment cost for patients receiving cancer screening ($2526) was higher than that for unscreened patients ($2482). However, we calculated an incremental cost-effectiveness ratio of $219 per life-year gained from receiving cervical cancer screening compared with not being screened, and thus the ORCI screening program was highly cost-effective. Furthermore, the screening program was associated with averting 1.3 deaths from cervical cancer each year resulting from earlier diagnoses of cancer cases, with the incremental cost-effectiveness ratio of $4597 per life saved.

CONCLUSIONS

Although Sub-Saharan Africa faces substantial challenges in population health management, our study highlights the potential benefits from expanding access to regular cervical cancer screening for women in this region.

The inverse primary care law in sub-Saharan Africa: a qualitative study of the views of migrant health workers

BACKGROUND

Many low-income and middle-income countries globally are now pursuing ambitious plans for universal primary care, but are failing to deliver adequate care quality because of intractable human resource problems.

AIM

To understand why migrant nurses and doctors from sub-Saharan Africa did not wish to take up available posts in primary and first-contact care in their home countries.

DESIGN AND SETTING

Qualitative study of migrant health workers to Europe (UK, Belgium, and Austria) or southern Africa (Botswana and South Africa) from sub-Saharan Africa.

METHOD

Semi-structured interviews with 66 health workers (24 nurses and 42 doctors) from 18 countries between July 2011 and April 2012. Transcripts were analysed thematically using a framework approach.

RESULTS

The reasons given for choosing not to work in primary care were grouped into three main analytic streams: poor working environment, difficult living experiences, and poor career path. Responders described a lack of basic medicines and equipment, an unmanageable workload, and lack of professional support. Many had concerns about personal security, living conditions (such as education for children), and poor income. Primary care was seen as lower status than hospital medicine, with lack of specialist training opportunities and more exposure to corruption.

CONCLUSIONS

Clinicians are reluctant to work in the conditions they currently experience in primary care in sub-Saharan Africa and these conditions tend to get worse as poverty and need for primary care increases. This inverse primary care law undermines achievement of universal health coverage. Policy experience from countries outside Africa shows that it is not immutable.

Efficiency of an intervention package for arterial hypertension comprising telemanagement in a Cameroonian rural setting: The TELEMED-CAM study

Introduction

Sub-Saharan Africa has a disproportionate burden of disease and an extreme shortage of health workforce. Therefore, adequate care for emerging chronic diseases can be very challenging. We implemented and evaluated the effectiveness of an intervention package comprising telecare as a mean for improving the outcomes of care for hypertension in Rural Sub-Saharan Africa.

Methods

The study involved a telemedicine center based at the Yaounde General Hospital (5 cardiologists) in the Capital city of Cameroon, and 30 remote rural health centers within the vicinity of Yaoundé (20 centers (103 patients) in the usual care group, and 10 centers (165 patients) in the intervention groups). The total duration of the intervention was 24 weeks.

Results

Participants in the intervention group had higher baseline systolic (SBP) and diastolic (DBP) blood pressure, and included fewer individuals with diabetes than those in the usual care group (all p < 0.01). Otherwise, the baseline profile was mostly similar between the two groups. During follow-up, more participants in the intervention groups achieved optimal BP control, driven primarily by greater improvement of BP control among High risk participants (hypertension stage III) in the intervention group.

Conclusion

An intervention package comprising tele-support to general practitioners and nurses is effective in improving the management and outcome of care for hypertension in rural underserved populations. This can potentially help in addressing the shortage of trained health workforce for chronic disease management in some settings. However context-specific approaches and cost-effectiveness data are needed to improve the application of telemedicine for chronic disease management in resource-limited settings.