Cancer control collaborations between China and African countries.

Over the past decade, China has emerged as Africa's largest trade partner and source of foreign direct investment, with public health ranked as a top priority in China-Africa collaborations. During the same period, cancer has emerged as a leading cause of death in Africa, with more than 700 000 deaths per year and projections of more than 1 million deaths per year by 2030. In this Review, we explore the effects of increasing China-Africa collaborations on cancer control in Africa. We review the published literature on health-care assistance, research, education and training, and infrastructure and present the results of an institutional review board-approved survey of African oncology health-care professionals and institutional leaders that assessed their perception of the effects of China-Africa collaborations. From peer-reviewed articles and grey literature, we found that the number of China-Africa collaborations have grown substantially over the past decade in different areas, especially in patient care and infrastructure. Research publications have also surged in quantity in the past decade compared with previous years. However, the survey results suggest research collaborations remain infrequent and that medical professionals in African cancer centres rarely participate in direct research collaborations with Chinese institutions. The Review also highlights the challenges and benefits of increasing China-Africa collaborations. Challenges include insufficient monitoring and evaluation of the projects in Africa and poor coordination and alignment of the various initiatives. The benefits of these collaborations for Africa include improved health outcomes, strengthened health systems, and socioeconomic development. Benefits are also apparent for China, such as securing energy and resource supplies, expanded trade and investment opportunities, and improved diplomatic relations. Overall, China-Africa collaborations are increasing and having a substantial effect in both China and the African continent. Recommendations to minimise the challenges and maximise the benefits for more positive consequences on cancer control in Africa are discussed.

Heterosexual Oral and Anal Sex: Perceptions, Terminologies, and Attitudes of Younger and Older Adults in Ibadan, Nigeria.

Although heterosexual oral and anal sexual behaviors have been reported in sub-Saharan Africa, little is known about how they are understood and perceived, particularly, in West Africa. We undertook a qualitative exploration of local terminologies and sexual scripts associated with heterosexual oral and anal sex in preparation for a quantitative survey. We held focus group discussions (18) and interviews (44) with younger and middle-aged men and women from the general population and female sex workers (FSWs) in selected communities in Ibadan. Most participants had heard of oral and anal sex. Younger adults aged 18-25 years, particularly male participants and FSWs, appeared more informed than older adults in the general population. Sexually explicit movies were the most cited source of information. Oral and anal sexual behaviors were considered sensitive, with different local names, meanings, and interpretations. Participants advised against the use of slang terms in research. We identified six different scripts employed by participants in discussing oral and anal sex practices: protecting sexual relationship, financial reward, an alternative to vaginal sex, pleasure, male dominance and control, and risk, stigma, and disgust.

Cancer in sub-Saharan Africa: a Lancet Oncology Commission.

In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.

Association between HIV-1 subtype and drug resistance in Nigerian infants.

Background: Many lines of evidence point to HIV-1 subtype-specific differences in the development of drug resistance mutations. While variation between subtype C and others has been extensively explored, there has been less emphasis on subtypes common to West Africa. We examined a previously described national survey of pretreatment drug resistance in HIV-1-infected Nigerian children aged <18 months, to explore the association between subtypes and patterns of resistance. Methods: Five hundred and forty-nine dried blood spots, from 15 early infant diagnostic facilities in Nigeria, were amplified and HIV-1 polymerase was sequenced. Four hundred and twenty-four were analysed for surveillance drug resistance mutations (SDRMs). Associations between subtype and SDRMs were evaluated by Fisher's exact test and logistic regression analysis, controlling for geographical region and exposure. Results: Using the sub-subtypes of HIV-1 G defined by Delatorre et al. (PLoS One 2014. 9: e98908) the most common subtypes were CRF02_AG (174, 41.0%), GWA-I (128, 30.2%), GWA-II (24, 5.7%), GCA (11, 2.6%), A (21, 5.0%) and CRF06_cpx (18, 4.2%). One hundred and ninety infants (44.8%) had ≥1 NNRTI mutation, 92 infants (21.7%) had ≥1 NRTI mutation and 6 infants (1.4%) had ≥1 PI mutation. By logistic regression, 67N was more common in GWA-II/GCA than CRF02_AG (OR 12.0, P = 0.006), as was 70R (OR 23.1, P = 0.007), 184I/V (OR 2.92, P = 0.020), the presence of ≥1 thymidine analogue mutation (TAM) (OR 3.87, P = 0.014), ≥1 type 2 TAM (OR 7.61, P = 0.001) and ≥1 NRTI mutation (OR 3.26, P = 0.005). Conclusions: This dataset reveals differences among SDRMs by subtype; in particular, between the GWA-II and GCA subclades, compared with CRF02_AG and GWA-I.

Current prevalence pattern of tobacco smoking in Nigeria: a systematic review and meta-analysis.

BACKGROUND: National smoking cessation strategies in Nigeria are hindered by lack of up-to-date epidemiologic data. We aimed to estimate prevalence of tobacco smoking in Nigeria to guide relevant interventions. METHODS: We conducted systematic search of publicly available evidence from 1990 through 2018. A random-effects meta-analysis and meta-regression epidemiologic model were employed to determine prevalence and number of smokers in Nigeria in 1995 and 2015. RESULTS: Across 64 studies (n = 54,755), the pooled crude prevalence of current smokers in Nigeria was 10.4% (9.0-11.7) and 17.7% (15.2-20.2) for ever smokers. This was higher among men compared to women in both groups. There was considerable variation across geopolitical zones, ranging from 5.4% (North-west) to 32.1% (North-east) for current smokers, and 10.5% (South-east) to 43.6% (North-east) for ever smokers. Urban and rural dwellers had relatively similar rates of current smokers (10.7 and 9.1%), and ever smokers (18.1 and 17.0%). Estimated median age at initiation of smoking was 16.8 years (IQR: 13.5-18.0). From 1995 to 2015, we estimated an increase in number of current smokers from 8 to 11 million (or a decline from 13 to 10.6% of the population). The pooled mean cigarettes consumption per person per day was 10.1 (6.1-14.2), accounting for 110 million cigarettes per day and over 40 billion cigarettes consumed in Nigeria in 2015. CONCLUSIONS: While the prevalence of smokers may be declining in Nigeria, one out of ten Nigerians still smokes daily. There is need for comprehensive measures and strict anti-tobacco laws targeting tobacco production and marketing.

Epidemiology of harmful use of alcohol in Nigeria: a systematic review and meta-analysis.

Background: Nigeria, the most populous country in Africa, has reported relatively high levels of alcohol misuse, yet limited resources to guide effective population-wide response. There is a need to integrate existing empirical information in order to increase the power and precision of estimating epidemiological evidence necessary for informing policies and developing prevention programs. Objectives: We aimed to estimate nationwide and zonal prevalence of harmful use of alcohol in Nigeria to inform public health policy and planning. Methods: Epidemiologic reports on alcohol use in Nigeria from 1990 through 2018 were systematically searched and abstracted. We employed random-effects meta-analysis and meta-regression model to determine the number of harmful alcohol users. Results: 35 studies (n = 37,576 Nigerians) were identified. Pooled crude prevalence of harmful use of alcohol was 34.3% (95% CI: 28.6-40.1); twice as high among men (43.9%, 31.1-56.8) compared to women (23.9%, 16.4-31.4). Harmful alcohol use was higher in rural settings (40.1%, 24.2-56.1) compared to urban settings (31.2%, 22.9-39.6). The number of harmful alcohol users aged ≥15 years increased from 24 to 34 million from 1995 to 2015. However, actual age-adjusted prevalence of harmful use of alcohol in Nigeria decreased from 38.5% to 32.6% over the twenty-year period. Conclusions: While the prevalence of the total population that drinks harmfully appears to be dropping, absolute number of individuals that would be classified as harmful drinkers is increasing. This finding highlights the complexity of identifying and advocating for substance abuse policies in rapidly changing demographic settings common in Africa, Asia, and other developing countries.

Association between patient-reported HIV status and provider recommendation for screening in an opportunistic cervical Cancer screening setting in Jos, Nigeria.

BACKGROUND: Cervical cancer screening (CCS) is an important health service intervention for prevention of morbidity and mortality from invasive cervical cancer. The role of provider recommendation and referral is critical in utilization of this services particularly in settings where screening is largely opportunistic. We sought to understand how patient-reported human immunodeficiency virus (HIV) infection status is associated with provider referral in an opportunistic screening setting. METHODS: We performed a cross-sectional analysis of data on a sample of women who had received a CCS at the "Operation Stop" cervical cancer (OSCC) screening service in Jos, Nigeria over a 10-year time period (2006-2016). We used the de-identified records of women who had their first CCS to analyze the association between patient-reported HIV and likelihood of provider-referral at first CCS. We performed descriptive statistics with relevant test of association using Student t-test (t-test) for continuous variables and Pearson chi square or Fisher exact test where applicable for categorical variables. We also used a bivariable and multivariable logistic regression models to estimate the independent association of patient-reported HIV on provider referral. All statistical tests were performed using STATA version 14.1, College Station, Texas, USA. Level of statistical significance was set at 0.05. RESULTS: During the 10-year period, 14,088 women had their first CCS. The reported HIV prevalence in the population was 5.0%; 95% CI: 4.6, 5.4 (703/14,088). The median age of women who were screened was 37 years (IQR; 30-45). Women who were HIV infected received more referrals from providers compared to women who were HIV uninfected (68.7% versus 49.2%), p-value < 0.001. Similarly, we found an independent effect of patient-reported HIV infection on the likelihood for provider-referral in the screened sample (aOR = 2.35; 95% CI: 1.95, 2.82). CONCLUSION: Our analysis supports the design of health systems that facilitates providers' engagement and provision of necessary counseling for CCS in the course of routine clinical care. The practice of offering recommendation and referrals for CCS to women at high risk of cervical cancer, such as HIV infected women should be supported.

Mobile phone use for a social strategy to improve antiretroviral refill experience at a low-resource HIV clinic: patient responses from Nigeria.

In sub-Saharan African areas where antiretroviral (ARV) drugs are not available through community pharmacies, clinic-based pharmacies are often the primary source of ARV drug refills. Social pressure is mounting on treatment providers to adjust ARV refill services towards user-friendly approaches which prioritize patients' convenience and engage their resourcefulness. By this demand, patients may be signalling dissatisfaction with the current provider-led model of monthly visits to facility-based pharmacies for ARV refill. Mobile phones are increasingly popular in sub-Saharan Africa, and have been used to support ARV treatment goals in this setting. A patient-centred response to on-going social pressure requires treatment providers to view ARV refill activities through the eyes of patients who are negotiating the challenges of day-to-day life while contemplating their next refill appointment. Using focus groups of five categories of adult patients receiving combination ARV therapy, we conducted this cross-sectional qualitative study to provide insight into modifiable gaps between patients' expectations and experiences of the use of mobile phones in facility-based ARV refill service at a public HIV clinic in Nigeria. A notable finding was patients' preference for harnessing informal social support (through intermediaries with mobile phones) to maintain adherence to ARV refill appointments when they could not present in person. This evolving social support strategy also has the potential to enhance defaulter tracking. Our study findings may inform the development of ARV refill strategies and the design of future qualitative studies on client-provider communication by mobile phones in under-resourced HIV treatment programmes.

Artemether-Lumefantrine Exposure in HIV-Infected Nigerian Subjects on Nevirapine-Containing Antiretroviral Therapy.

Coadministration of nevirapine-based antiretroviral therapy (ART) and artemether-lumefantrine is reported to result in variable changes in lumefantrine exposure. We conducted an intensive pharmacokinetic study with 11 HIV-infected adults who were receiving artemether-lumefantrine plus nevirapine-based ART, and we compared the results with those for 16 HIV-negative adult historical controls. Exposure to artemether and lumefantrine was significantly lower and dihydroartemisinin exposure was unchanged in subjects receiving nevirapine-based ART, compared with controls. Nevirapine exposure was unchanged before and after artemether-lumefantrine administration.

Willingness of reproductive-aged women in a Nigerian community to accept human papillomavirus vaccination for their children.

AIM: The aim of this study was to determine the willingness of reproductive-aged women in a Nigerian community to allow human papillomavirus (HPV) vaccination in their children and the associated factors with this decision. MATERIAL AND METHODS: A multistage household survey of 1002 women who participated in the HPV Vaccine and Cervical Cancer Prevention Survey from 26 August to 29 September 2012 at Ibadan North Local Government Area, Mokola Ibadan, Nigeria. Descriptive, bivariate and multivariable analyses were performed, and statistical significance was set at 95% confidence level (CI). RESULTS: There was high willingness (88.6%) to vaccinate, and this attitude was associated with previous history of genital discharge or sores (adjusted odds ratio, 1.91; 95%CI, 1.05-3.45), and knowledge that cervical cancer is preventable (adjusted odds ratio, 1.67; 95%CI, 1.07-2.59). On the likely acceptability of Nigerian HPV vaccine policy, about two-thirds strongly agreed to its incorporation into the routine immunization program (66.9%), it being free (66.7%) and mandatory (64.3%), amongst other factors. The commonest concerns raised were cost/expenses (10.2%), that it might encourage promiscuity (9.9%), or stimulate early sexual debut (6.7%), and fear of infertility (6.3%). CONCLUSION: This study found that the majority of Nigerian women are willing to vaccinate their children against HPV infection and would prefer free universal HPV vaccination with regulation to ensure better uptake. The concerns expressed would need to be addressed by policy-makers to increase its acceptability.

Maternal Near-Miss Due to Unsafe Abortion and Associated Short-Term Health and Socio-Economic Consequences in Nigeria.

Little is known about maternal near-miss (MNM) due to unsafe abortion in Nigeria. We used the WHO criteria to identify near-miss events and the proportion due to unsafe abortion among women of childbearing age in eight large secondary and tertiary hospitals across the six geo-political zones. We also explored the characteristics of women with these events, delays in seeking care and the short-term socioeconomic and health impacts on women and their families. Between July 2011 and January 2012, 137 MNM cases were identified of which 13 or 9.5% were due to unsafe abortions. Severe bleeding, pain and fever were the most common immediate abortion complications. On average, treatment of MNM due to abortion costs six times more than induced abortion procedures. Unsafe abortion and delays in care seeking are important contributors to MNM. Programs to prevent unsafe abortion and delays in seeking postabortion care are urgently needed to reduce abortion related MNM in Nigeria.

Attitudes of women and men living with HIV and their healthcare providers towards pregnancy and abortion by HIV-positive women in Nigeria and Zambia.

Fertility decisions among people living with HIV/AIDS (PLWHA) are complicated by disease progression, the health of their existing children and possible antiretroviral therapy (ART) use, among other factors. Using a sample of HIV-positive women (n = 353) and men (n = 299) from Nigeria and Zambia and their healthcare providers (n = 179), we examined attitudes towards childbearing and abortion by HIV-positive women. To measure childbearing and abortion attitudes, we used individual indicators and a composite measure (an index). Support for an HIV-positive woman to have a child was greatest if she was nulliparous or if her desire to have a child was not conditioned on parity and lowest if she already had an HIV-positive child. Such support was found to be lower among HIV-positive women than among HIV-positive men, both of which were lower than reported support from their healthcare providers. There was wider variation in support for abortion depending on the measure than there was for support for childbearing. Half of all respondents indicated no or low support for abortion on the index measure while between 2 and 4 in 10 respondents were supportive of HIV-positive women being able to terminate a pregnancy. The overall low levels of support for abortion indicate that most respondents did not see HIV as a medical condition which justifies abortion. Respondents in Nigeria and those who live in urban areas were more likely to support HIV-positive women's childbearing. About a fifth of HIV-positive respondents reported being counselled to end childbearing after their diagnosis. In summary, respondents from both Nigeria and Zambia demonstrate tempered support of (continued) childbearing among HIV-positive women while anti-abortion attitudes remain strong. Access to ART did not impart a strong effect on these attitudes. Therefore, pronatalist attitudes remain in place in the face of HIV infection.

Temporal distribution of baseline characteristics and association with early mortality among HIV-positive patients at University College Hospital, Ibadan, Nigeria.

The first six months of HIV care and treatment are very important for long-term outcome. Early mortality (within 6 months of care initiation) undermines care and treatment goals. This study assessed the temporal distribution in baseline characteristics and early mortality among HIV patients at the University College Hospital, Ibadan, Nigeria from 2006-2013. Factors associated with early mortality were also investigated. This was a retrospective analysis of data from 14 857 patients enrolled for care and treatment at the adult antiretroviral clinic of the University College Hospital, Ibadan, Nigeria. Effects of factors associated with early mortality were summarised using a hazard ratio with a 95% confidence interval obtained from Cox proportional hazard regression models. The mean age of the subjects was 36.4 (SD=10.2) years with females being in the majority (68.1%). While patients' demographic characteristics remained virtually the same over time, there was significant decline in the prevalence of baseline opportunistic infections (2006-2007=55.2%; 2011-2013=38.0%). Overall, 460 (3.1%) patients were known to have died within 6 months of enrollment in care/treatment. There was no significant trend in incidence of early mortality. Factors associated with early mortality include: male sex, HIV encephalopathy, low CD4 count (< 50 cells), and anaemia. To reduce early mortality, community education should be promoted, timely access to care and treatment should be facilitated and the health system further strengthened to care for high risk patients.

Human papillomavirus prevalence and type distribution in invasive cervical cancer in sub-Saharan Africa.

In sub-Saharan Africa, invasive cervical cancer (ICC) incidence and mortality are among the highest in the world. This cross-sectional epidemiological study assessed human papillomavirus (HPV) prevalence and type distribution in women with ICC in Ghana, Nigeria, and South Africa. Cervical biopsy specimens were obtained from women aged ≥ 21 years with lesions clinically suggestive of ICC. Histopathological diagnosis of ICC was determined by light microscopy examination of hematoxylin and eosin stained sections of paraffin-embedded cervical specimens; samples with a confirmed histopathological diagnosis underwent HPV DNA testing by polymerase chain reaction. HPV-positive specimens were typed by reverse hybridization line probe assay. Between October 2007 and March 2010, cervical specimens from 659 women were collected (167 in Ghana, 192 in Nigeria and 300 in South Africa); 570 cases were histologically confirmed as ICC. The tumor type was identified in 551/570 women with ICC; squamous cell carcinoma was observed in 476/570 (83.5%) cases. The HPV-positivity rate in ICC cases was 90.4% (515/570). In ICC cases with single HPV infection (447/515 [86.8%]), the most commonly detected HPV types were HPV16 (51.2%), HPV18 (17.2%), HPV35 (8.7%), HPV45 (7.4%), HPV33 (4.0%) and HPV52 (2.2%). The prevalence of single and multiple HPV infections seemed higher among HIV-positive women and HPV type distribution appeared to differ according to tumor type and HIV status. In conclusion, HPV16, 18, 45 and 35 were the most common HPV types in sub-Saharan African women with ICC and HPV infections were more common in HIV-positive women.

Disposition of amodiaquine and desethylamodiaquine in HIV-infected Nigerian subjects on nevirapine-containing antiretroviral therapy.

OBJECTIVES: Artesunate plus amodiaquine is used for malaria treatment in regions with overlapping HIV endemicity. Co-administration of artesunate/amodiaquine with antiretroviral therapy (ART) may result in drug-drug interactions, but minimal data exist. This study evaluated the impact of nevirapine-based ART, containing a backbone of zidovudine and lamivudine, on the disposition of amodiaquine and its active metabolite, desethylamodiaquine (DEAQ). METHODS: This was an open-label, parallel-group pharmacokinetic comparison between HIV-infected, adult subjects receiving steady-state nevirapine-based ART (n = 10) and ART-naive subjects (control group, n = 11). All subjects received a loose formulation of artesunate/amodiaquine (200/600 mg) daily for 3 days, with serial pharmacokinetic sampling over 96 h following the final dose of artesunate/amodiaquine. Amodiaquine and DEAQ were quantified using a validated HPLC method with UV detection. Pharmacokinetic parameters were determined using standard non-compartmental methods. RESULTS: Exposures to both amodiaquine and DEAQ were significantly lower in the nevirapine-based ART group compared with the control group (amodiaquine AUC0₋24 145 versus 204 ng·h/mL, P = 0.02; DEAQ AUC0₋96 14,571 versus 21,648 ng·h/mL, P < 0.01). The AUCDEAQ/AUC(amodiaquine) ratio was not different between groups (ART group 116 versus control group 102, P = 0.67). CONCLUSIONS: Subjects on nevirapine-based ART had lower exposure to both amodiaquine and DEAQ (28.9% and 32.7%, respectively). Consequently, this may negatively impact the effectiveness of artesunate/amodiaquine in HIV-infected individuals on this ART combination.

Modeling optimal cervical cancer prevention strategies in Nigeria.

BACKGROUND: This study aims to assess the most efficient combinations of vaccination and screening coverage for the prevention of cervical cancer (CC) at different levels of expenditure in Nigeria. METHODS: An optimization procedure, using a linear programming approach and requiring the use of two models (an evaluation and an optimization model), was developed. The evaluation model, a Markov model, estimated the annual number of CC cases at steady state in a population of 100,000 women for four alternative strategies: screening only; vaccination only; screening and vaccination; and no prevention. The results of the Markov model for each scenario were used as inputs to the optimization model determining the optimal proportion of the population to receive screening and/or vaccination under different scenarios. The scenarios varied by available budget, maximum screening and vaccination coverage, and overall reachable population. RESULTS: In the base-case optimization model analyses, with a coverage constraint of 20% for one lifetime screening, 95% for vaccination and a budget constraint of $1 per woman per year to minimize CC incidence, the optimal mix of prevention strategies would result in a reduction of CC incidence of 31% (3-dose vaccination available) or 46% (2-dose vaccination available) compared with CC incidence pre-vaccination. With a 3-dose vaccination schedule, the optimal combination of the different strategies across the population would be 20% screening alone, 39% vaccination alone and 41% with no prevention, while with a 2-dose vaccination schedule the optimal combination would be 71% vaccination alone, and 29% with no prevention. Sensitivity analyses indicated that the results are sensitive to the constraints included in the optimization model as well as the cervical intraepithelial neoplasia (CIN) and CC treatment cost. CONCLUSIONS: The results of the optimization model indicate that, in Nigeria, the most efficient allocation of a limited budget would be to invest in both vaccination and screening with a 3-dose vaccination schedule, and in vaccination alone before implementing a screening program with a 2-dose vaccination schedule.