Implementing fertility care: Insights from a participatory workshop in The Gambia.

INTRODUCTION: The Gambia, West Africa, has made recent progress on infertility, a component of sexual and reproductive health that is lagging behind others. Since 2016, there is favourable policy environment stemming from infertility research and partnership building with national stakeholders and local civil society organisations focussing on infertility. Here, we report outcomes from a participatory workshop on infertility policy implementation in The Gambia and provide insights on setting national priorities for fertility care in resource-limited settings. METHODS: We conducted a participatory workshop involving 29 participants from Gambia's public and private health sectors. Using selected participatory group work tools, stakeholders identified and prioritised key activities within the framework of five pre-defined areas of action, including (i) creating guidelines/regulations; (ii) recording/reporting data; (iii) building public-private partnership; (iv) training health providers; and (v) raising awareness and health-seeking. RESULTS: 17 prioritised activities were proposed across the five action areas, according to short- medium- and long-term timeframes. Three were further prioritised from the overall pool, through group consensus. A Group Model Building activity helped to envision the complexity through elucidating links, loops, and connections between each activity and their expected outcomes. CONCLUSIONS: The participatory workshop identified actionable interventions for fertility care in The Gambia, with stakeholders setting a clear path ahead. Despite challenges, the continued engagement of Gambian policymakers, practitioners, researchers, and activists in efforts to move beyond policy creation to its implementation is essential. Improving fertility care in The Gambia and other LMICs is feasible with effective collaboration and financial support.

Introducing assisted reproductive technologies in The Gambia, a survey on the perspectives of Gambian healthcare professionals and medical students.

BACKGROUND: Infertility remains a global reproductive health burden with the highest prevalence in low and middle-income countries. In sub-Saharan Africa, the ability to procreate holds great societal importance. Couples, and particularly women, with infertility can face devastating challenges, leading to social stigma, isolation and/or divorce. However, attention to addressing infertility is lacking in sub-Saharan Africa. In The Gambia, where this study is based, little is known about the potential for introduction of assisted reproductive technologies (ART) in the public health sector. METHODS: A quantitative survey was conducted using detailed questionnaires on infertility services available, staff knowledge, perceived barriers, and personal motivation to support assisted reproductive technologies. Data was collected electronically between April and June 2021 from healthcare providers (n = 70) in eleven health facilities throughout the country, as well as from medical students (n = 55) enrolled at The University of The Gambia. RESULTS: Basic infertility services were found to be lacking in the rural areas. Furthermore, 39% of staff (n = 27) providing fertility care had not receive any formal training on the topic. However, 91% of staff (n = 64) showed interest in acquiring additional knowledge and had a positive attitude towards supporting the introduction of ART. Perceived challenges of doing so included: (i) the competing importance of other health priorities; and (ii) religious and cultural barriers. CONCLUSION: This survey highlights that expansion of infertility services is needed, especially in rural areas. Staff perceived the introduction of ART as important, but this should be coupled with specialized training, as most medical staff had not received any formal infertility training. Future care providers (current medical students) showed both interest in ART and reported having received some basic training in infertility management. Given the reported lack of infrastructure and services, additional targeted investment in infertility care, including ART, will be needed to improve reproductive health for all, countrywide.

In Sub-Saharan Africa, the prevalence of involuntary childlessness (infertility) is high. However, services to help address this problem are inconsistent or lacking ­ including in the West African country of The Gambia, where this study was conducted. There is currently limited information on the infrastructure available and the level of knowledge and training among healthcare providers in the country to help address this issue. To address this gap in knowledge, we conducted a survey with health staff from different hospitals and with medical students at the University of The Gambia. The survey focused on the reported availability of services as well as participants' knowledge and training in both basic and advanced treatments for infertility. We found a major lack of infertility care services in rural areas. Furthermore, staff knowledge about infertility was minimal, and there was little knowledge about more advanced infertility care services, such as in vitro fertilization (IVF). The survey also found that staff and students perceived other health priorities and religion as major barriers for ART introduction. Staff noted that government funding for infertility treatment is minimal. In conclusion, this survey found a lack of reported infrastructure for infertility in rural areas of The Gambia, as well as a lack of formal training by staff. However, both staff and students showed interest in the potential introduction of ART. Overall, this survey highlights that more investment and training is needed to implement changes in order to modernize reproductive healthcare in The Gambia, in particular for those who face infertility.

Dry season prevalence of Plasmodium falciparum in asymptomatic gambian children, with a comparative evaluation of diagnostic methods.

BACKGROUND: Subclinical infection with Plasmodium falciparum remains highly prevalent, yet diagnosing these often low-density infections remains a challenge. Infections can be subpatent, falling below the limit of detection for conventional thick-film microscopy and rapid diagnostic testing (RDT). In this study, the prevalence of subclinical P. falciparum infections in school-aged children was characterised at the start of the dry season in the Upper River Region of The Gambia in 2017/2018, with a goal to also compare the utility of different diagnostic tools. METHODS: In a cross-sectional survey of children living in 29 villages on the south bank of the Gambia river (median age of 10 years), matched microscopy, rapid diagnostic test (RDT, detecting histidine-rich protein 2) and polymerase chain reaction (PCR, targeting either 18S rRNA or var gene acidic terminal sequence) were used to determine the prevalence of patent and subpatent infections and to compare the performance of the different diagnostic methods. RESULTS: The prevalence of var gene acidic terminal sequence (varATS) qPCR-detectable infections was 10.2% (141/1381) with a median density of 3.12 parasites/µL. Malaria prevalence was highly heterogeneous across the region, ranging from < 1% to ~ 40% prevalence in different village clusters. Compared to varATS, 18S rRNA PCR detected fewer low-density infections, with an assay sensitivity of 50% and specificity of 98.8%. Parasite prevalence in the cohort was 2.9% by microscopy and 1.5% by RDT. Compared to varATS qPCR, microscopy and RDT had sensitivities of 11.5% and 9.2%, respectively, although both methods were highly specific (> 98%). Samples that were positive by all three tests (varATS qPCR, RDT and microscopy) had significantly higher parasite densities (median = 1705 parasites/µL) than samples that were positive by varATS qPCR only (median = 2.4 parasites/µL). CONCLUSIONS: The majority of subclinical malaria infections in school-aged children were of extremely low parasite density and detectable only by ultra-sensitive PCR analysis. Understanding the duration of these low density infections, their physiological impact and their contribution to sustained parasite transmission is necessary to inform malaria elimination strategies.

'Bouncing Back' From Subclinical Malaria: Inflammation and Erythrocytosis After Resolution of P. falciparum Infection in Gambian Children.

Recent malaria is associated with an increased risk of systemic bacterial infection. The aetiology of this association is unclear but malaria-related haemolysis may be one contributory factor. To characterise the physiological consequences of persistent and recently resolved malaria infections and associated haemolysis, 1650 healthy Gambian children aged 8-15 years were screened for P. falciparum infection (by 18sRNA PCR) and/or anaemia (by haematocrit) at the end of the annual malaria transmission season (t1). P. falciparum-infected children and children with moderate or severe anaemia (haemoglobin concentration < 11g/dl) were age matched to healthy, uninfected, non-anaemic controls and screened again 2 months later (t2). Persistently infected children (PCR positive at t1 and t2) had stable parasite burdens and did not differ significantly haematologically or in terms of proinflammatory markers from healthy, uninfected children. However, among persistently infected children, IL-10 concentrations were positively correlated with parasite density suggesting a tolerogenic response to persistent infection. By contrast, children who naturally resolved their infections (positive at t1 and negative at t2) exhibited mild erythrocytosis and concentrations of pro-inflammatory markers were raised compared to other groups of children. These findings shed light on a 'resetting' and potential overshoot of the homeostatic haematological response following resolution of malaria infection. Interestingly, the majority of parameters tested were highly heterogeneous in uninfected children, suggesting that some may be harbouring cryptic malaria or other infections.

Infectivity of patent Plasmodium falciparum gametocyte carriers to mosquitoes: establishing capacity to investigate the infectious reservoir of malaria in a low-transmission setting in The Gambia.

BACKGROUND: Understanding the human malaria infectious reservoir is important for elimination initiatives. Here, we implemented mosquito membrane feeding experiments to prepare for larger studies to quantify the transmission potential and relative contribution of the human infectious reservoir. METHODS: Patients with clinical malaria attending four health facilities with at least 16 Plasmodium falciparum gametocytes per µL were recruited during the 2018 transmission season. Infectiousness to mosquitoes was assessed by direct membrane feeding assay (DMFA). We compared our results with a Bayesian predictive model to investigate the relationship between infectiousness and gametocyte density and explore the impact of fever on gametocyte infectivity. RESULTS: A total of 3177 suspected malaria cases were screened; 43.3% (1376) had microscopically patent P. falciparum parasites and 3.6% (114) of them had gametocytes. Out of 68 DMFAs, 38 (55.9%) resulted in at least one infected mosquito, with a total of 15.4% (1178/7667) of mosquitoes infected with 1-475 oocysts per gut. The relationship between mosquito infection prevalence and gametocytaemia was similar to other African settings and negatively associated with fever (OR: 0.188, 95% CI 0.0603 to 0.585, p=0.0039). CONCLUSIONS: Among symptomatic malaria patients, fever is strongly associated with transmission failure. Future studies can use DMFA to better understand the human malaria reservoir in settings of low endemicity in The Gambia and inform malaria elimination initiatives.