Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies

Introduction
Cervical cancer (CC) is the leading cause of cancer-related death among women in sub-Saharan Africa. It occurs most frequently in women living with HIV (WLHIV) and is classified as an AIDS-defining illness. Recent World Health Organisation (WHO) recommendations provide guidance for CC prevention policies, with specifications for WLHIV. We systematically reviewed policies for CC prevention and control in sub-Saharan countries with the highest HIV prevalence.

Methods
We included countries with an HIV prevalence ≥ 10% in 2018 and policies published between January 1st 2010 and March 31st 2022. We searched Medline via PubMed, the international cancer control partnership website and national governmental websites of included countries for relevant policy documents. The online document search was supplemented with expert consultation for each included country. We synthesised aspects defined in policies for HPV vaccination, sex education, condom use, tobacco control, male circumcision,cervical screening, diagnosis and treatment of cervical pre-cancerous lesions and cancer, monitoring mechanisms and cost of services to women while highlighting specificities for WLHIV.

Results
We reviewed 33 policy documents from nine countries. All included countries had policies on CC prevention and control either as a standalone policy (77.8%), or as part of a cancer or non-communicable diseases policy (22.2%) or both (66.7%). Aspects of HPV vaccination were reported in 7 (77.8%) of the 9 countries. All countries (100%) planned to develop or review Information, Education and Communication (IEC) materials for CC prevention including condom use and tobacco control. Age at screening commencement and screening intervals for WLHIV varied across countries. The most common recommended screening and treatment methods were visual inspection with acetic acid (VIA) (88.9%), Pap smear (77.8%); cryotherapy (100%) and loop electrosurgical procedure (LEEP) (88.9%) respectively. Global indicators disaggregated by HIV status for monitoring CC programs were rarely reported. CC prevention and care policies included service costs at various stages in three countries (33.3%).

Conclusion
Considerable progress has been made in policy development for CC prevention and control in sub Saharan Africa. However, in countries with a high HIV burden, there is need to tailor these policies to respond to the specific needs of WLHIV. Countries may consider updating policies using the recent WHO guidelines for CC prevention, while adapting them to context realities.

The magnitude and perceived reasons for childhood cancer treatment abandonment in Ethiopia: from health care providers’ perspective

Background
Treatment abandonment is one of major reasons for childhood cancer treatment failure and low survival rate in low- and middle-income countries. Ethiopia plans to reduce abandonment rate by 60% (2019–2023), but baseline data and information about the contextual risk factors that influence treatment abandonment are scarce.

Methods
This cross-sectional study was conducted from September 5 to 22, 2021, on the three major pediatric oncology centers in Ethiopia. Data on the incidence and reasons for treatment abandonment were obtained from healthcare professionals. We were unable to obtain data about the patients’ or guardians’ perspective because the information available in the cancer registry was incomplete to contact adequate number of respondents. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group. We included all (N = 38) health care professionals (physicians, nurses, and social workers) working at these centers who had more than one year of experience in childhood cancer service provision (a universal sampling and 100% response rate).

Results
The perceived mean abandonment rate in Ethiopia is 34% (SE 2.5%). The risk of treatment abandonment is dependent on the type of cancer (high for bone sarcoma and brain tumor), the phase of treatment and treatment outcome. The highest risk is during maintenance and treatment failure or relapse for acute lymphoblastic leukemia, and during pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia includes high cost of care, low economic status, long travel time to treatment centers, long waiting time, belief in the incurability of cancer and poor public awareness about childhood cancer.

Conclusions
The perceived abandonment rate in Ethiopia is high, and the risk of abandonment varies according to the type of cancer, phase of treatment or treatment outcome. Therefore, mitigation strategies to reduce the abandonment rate should include identifying specific risk factors and prioritizing strategies based on their level of influence, effectiveness, feasibility, and affordability.

Exposure to family planning messages and contraceptive use among women of reproductive age in Sub-Saharan Africa: A crosssectional program impact evaluation study

Many women of reproductive age in sub Saharan Africa are not utilizing any contraceptive method which is contributing to the high burden of maternal mortality. This study determined the prevalence, trends, and the impact of exposure to family planning messages (FPM) on contraceptive use (CU) among women of reproductive age in sub-Saharan Africa (SSA). We utilized the most recent data from demographic and health surveys across 26 SSA countries between 2013 and 2019. We assessed the prevalence and trends and quantified the impact of exposure to FPM on contraceptive use using augmented inverse probability weighting with regression adjustment. Sensitivity analysis of the impact estimate was conducted using endogenous treatment effect models, inverse probability weighting, and propensity score with nearest-neighbor matching techniques. The study involved 328,386 women of reproductive age. The overall prevalence of CU and the percentage of women of reproductive age in SSA exposed to FPM were 31.1% [95% CI: 30.6–31.5] and 38.9% [95% CI: 38.8–39.4] respectively. Exposure to FPM increased CU by 7.1 percentage points (pp) [95% CI = 6.7, 7.4] among women of reproductive age in SSA. The impact of FPM on CU was highest in Central Africa [6.7 pp; 95% CI: [5.7–7.7] and lowest in Southern Africa [2.2 pp; 95% CI: [1.3-3.0]. There was a marginal decline in the impact estimate among adolescents (estimate = 6.0 pp [95% CI = 5.0, 8.0]). Exposure to FPM has contributed to an increase in CU among women of reproductive age. Programs that are geared towards intensifying exposure to FPM through traditional media in addition to exploring avenues for appropriate use of electronic media remain critical.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

Purpose of Review
Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model.

Recent Findings
A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda.

Summary
Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.

Development of the anaesthesia workforce and organisation of the speciality in Uganda: a mixed-methods case study

Background: The development of modern anaesthesia practice in many low-income countries has lagged behind that of highincome countries despite early reports. Detailed descriptions of ‘surgery under anaesthesia’ in Uganda are available through Robert W. Felkin’s elaborate accounts of caesarean sections done in the Bunyoro-Kitara Kingdom. However, the earliest documented ‘modern’ surgical and anaesthesia procedures were performed by Sir Albert Cook and his brother Dr Jack Cook in 1897 at Mengo Hospital. Since then, anaesthesia has developed into an independent speciality with workforce development, professional bodies and a recognised practice. This study aimed to describe the development of the anaesthesia workforce and speciality since independence while sharing our experiences to benefit those countries on a similar journey.

Methods: We employed a mixed-methods approach, including surveys among anaesthesia providers, as well as key informant interviews and a workforce database review. Whenever possible, information was corroborated with written literature.

Results: There are three levels of training of anaesthesia providers in Uganda, including a Master of Medicine in anaesthesia for specialist physician providers, a Bachelor of Science in anaesthesia and a Higher Diploma in anaesthesia for non-physician providers. There are two Master of Medicine programmes, two Bachelor of Science in anaesthesia programmes and seven Higher Diploma programmes. The existing workforce consists of 68 specialists and more than 600 non-physician providers. The anaesthesia providers are organised under professional associations, namely the Association of Anesthesiologists of Uganda and the Uganda Anaesthetic Officers Association. International and regional collaborations have been critical in the development of anaesthesia in Uganda.

Conclusion: Uganda still has a low density of anaesthesia providers both in number and distribution but has established critical steps to substantially increase the workforce. These steps include three levels of training with numerous training programmes, professional bodies and partnerships. We present our experiences with different strategies, highlighting those that have failed, and suggest further recommendations on developing anaesthesia in Uganda.

The impact of the Fundamental Critical Course on knowledge acquisition in Rwanda

Background. Emerging critical care systems have gained little attention in low- and middle-income countries. In sub-Saharan Africa, only 4% of the healthcare workforce is trained in critical care, and mortality rates are unacceptably high in this patient population.
Aim. We sought to retrospectively describe the knowledge acquisition and confidence improvement of practitioners who attend the Fundamental Critical Care Support (FCCS) course in Rwanda.
Methods. We conducted a retrospective study in which we assessed survey data and multiple-choice question data that were collected before and after course delivery. The purpose of these assessments at the time of delivery was to evaluate participants’ perception and acquisition of critical care knowledge.
Results. Thirty-six interprofessional clinicians completed the training. Performance on the multiple-choice questions improved overall after the course (mean score pre-course of 56.5% to mean score post-course of 65.8%,p-value <0.001) and improved in all content areas with the exception of diagnosis and management of acute coronary syndrome and acute respiratory failure/mechanical ventilation. Both physicians and nurses improved their scores significantly (68.9% to 75.6%,p-value = 0.031 and 52.0% to 63.5%,p-value <0.001, respectively). Self-reported
confidence in level of knowledge also increased in all areas. Survey respondents indicated on open-answer questions that they would like the course offerings at least annually, and that further dissemination of the course in Rwanda was warranted.
Conclusion. Deploying the established FCCS course improved Rwandan healthcare provider knowledge and confidence across most critical care content areas. Therefore, this course represents a good first step in bridging the gaps noted in emerging critical care systems.

Essential Emergency and Critical Care as a health system response to critical illness and the COVID19 pandemic: What does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, low-cost care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in low resource settings with Kenya and Tanzania as case studies.

The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.

The costs per patient day of EECC is estimated to be 1.01 USD, 10.83 USD and 32.84 USD in Tanzania and 1.76 USD, 14.86 USD and 37.43 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13.11 USD and 17.33 USD for severe and 297.30 USD and 369.64 USD for critical COVID-19 patients in Tanzania and Kenya, respectively.

EECC, an approach of providing the essential care to all critically ill patients, is low-cost. The components of EECC are basic and universal and, when assessed against the existing gaps in critical care coverage and costs of advanced critical care, suggest that it should be a priority area of investment for health systems around the globe.

Estimating the Risk of Maternal Death at Admission: A Predictive Model from a 5-Year Case Reference Study in Northern Uganda

Background. Uganda is one of the countries in the Sub-Saharan Africa with a very high maternal mortality ratio estimated at 336 deaths per 100,000 live births. We aimed at exploring the main factors affecting maternal death and designing a predictive model for estimation of the risk of dying at admission at a major referral hospital in northern Uganda. Methods. This was a retrospective matched case-control study, carried out at Lacor Hospital in northern Uganda, including 130 cases and 336 controls, from January 2015 to December 2019. Multivariate logistic regression was used to estimate the net effect of the associated factors. A cumulative risk score for each woman based on the unstandardised canonical coefficients was obtained by the discriminant equation. Results. The average maternal mortality ratio was 328 per 100,000 live births. Direct obstetric causes contributed to 73.8% of maternal deaths; the most common were haemorrhage (42.7%), sepsis (24.0%), hypertensive disorders (18.7%) and complications of abortion (2.1%), whereas malaria (23.5%) and HIV/AIDS (20.6%) were the leading indirect causes. The odds of dying were higher among women who were aged 30 years or more (OR 1.12; 95% CI, 1.04–1.19), did not attend antenatal care (OR 3.11; 95% CI, 1.36–7.09), were HIV positive (OR 3.13; 95% CI, 1.41–6.95), had a caesarean delivery (OR 2.22; 95% CI 1.13–4.37), and were referred from other facilities (OR 5.57; 95% CI 2.83–10.99). Conclusion. Mortality is high among mothers referred late from other facilities who are HIV positive, aged more than 30 years, lack antenatal care attendance, and are delivered by caesarean section. This calls for prompt and better assessment of referred mothers and specific attention to antibiotic therapy before and after caesarean section, especially among HIV-positive women.

A systematic review of randomized control trials of HPV self-collection studies among women in sub-Saharan Africa using the RE-AIM framework

Introduction
Self-collection of samples for HPV testing may increase women’s access to cervical cancer screening in low- and middle-income settings. However, implementation remains poor in many regions. The purpose of this systematic review was to examine implementation data from randomized controlled trials evaluating human papillomavirus (HPV) self-collection testing among women in sub-Saharan Africa using the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework.

Methods
We searched four electronic databases (PubMed, CINAHL, Web of Science, and Global Health) for pragmatic randomized controlled trials that promote HPV self-collection among women in sub-Saharan Africa. Study selection and data extraction were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist. Two researchers independently extracted information from each article using a RE-AIM data extraction tool. The reporting of RE-AIM dimensions was summarized and synthesized across included interventions.

Results
We identified 2008 citations, and eight studies were included. These reported on five unique interventions. The five interventions were conducted in five countries: Cameroon, Ethiopia, Kenya, Nigeria, and Uganda. Intervention reach (80%) was the most commonly reported RE-AIM dimension, followed by adoption (56%), efficacy/effectiveness (52%), implementation (47%), and maintenance (0%). All the interventions described increased uptake of HPV testing among study participants (effectiveness). However, the majority of the studies focused on reporting internal validity indicators such as inclusion criteria (100%) and exclusion criteria (100%), and few reported on external validity indicators such as participation rate (40%), intervention cost (40%), staff selection (20%), and cost of maintenance (0%).

Conclusions
Our review highlights the under-reporting of external validity indicators such as participation rate, intervention, and maintenance costs in studies of self-collection for HPV testing among women in SSA. Future research should focus on including factors that highlight internal validity factors and external validity factors to develop a greater understanding of ways to increase not only reach but also implementation and long-term maintenance of these interventions. Such data may advance the translation of HPV interventions into practice and reduce health disparities in SSA. Findings highlight the need for innovative tools such as participatory learning approaches or open challenges to expand knowledge and assessment of external validity indicators to ultimately increase the uptake of HPV testing among women in SSA.

High HIV Detection in a Tertiary Facility in Liberia: Implications and Opportunities

Background: HIV/AIDS remains one of the world’s most significant public health challenges; sub-Saharan Africa accounts for 71% of the global burden of HIV. Testing for HIV is pivotal to achieving UNAIDS 95-95-95 target towards bringing an end to the epidemic.

Objective: The study assessed five-year HIV testing data from the largest tertiary hospital in Monrovia, Liberia and highlights risk groups that would benefit from targeted testing and prevention interventions.

Methods: This was a single-center academic hospital-based retrospective analysis of HIV testing data from January 2014 to December 2018 obtained from all testing sites at John F. Kennedy Medical Center in Monrovia, Liberia. Pooled HIV testing data during the study period were analyzed using descriptive statistics and stratified by age, gender and pregnancy status. Annual diagnoses rates were reported as proportion of individuals tested within a specified category (age [=25 years], gender, and pregnancy status) that had a positive HIV test. Five-year trends were analyzed.

Results: Over the study period, 41,343 non-pregnant individuals were screened for HIV. In addition, the antenatal clinic performed 24,913 tests. Of non-pregnant individuals tested, 4,066 (10%) were diagnosed with HIV ranging from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15–24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018 respectively. Annually, 2–3% of all pregnant women tested were diagnosed with HIV. While HIV detection rates decreased over time overall, children less than 15 years of age showed an annual increase from 6.7% in 2014 to 12.3% in 2018.

Conclusion: A large five-year dataset from the largest tertiary facility in Liberia shows broad HIV detection rates that are much higher than national prevalence estimates. Ramping up HIV testing and prevention interventions including pre-exposure prophylaxis are sorely needed.