Improving TB detection among children in routine clinical care through intensified case finding in facility-based child health entry points and decentralized management: A before-and-after study in Nine Sub-Saharan African Countries.

In 2022, an estimated 1.25 million children <15 years of age developed tuberculosis (TB) worldwide, but >50% remained undiagnosed or unreported. WHO recently recommended integrated and decentralized models of care as an approach to improve access to TB services for children, but evidence remains limited. The Catalyzing Paediatric TB Innovation project (CaP-TB) implemented a multi-pronged intervention to improve TB case finding in children in nine sub-Saharan African countries. The intervention introduced systematic TB screening in different facility-based child-health entry-points, decentralisation of TB diagnosis and management, improved sample collection with access to Xpert® MTB/RIF or MTB/RIF Ultra testing, and implementation of contact investigation. Pre-intervention records were compared with those during intervention to assess effect on paediatric TB cascade of care. The intervention screened 1 991 401 children <15 years of age for TB across 144 health care facilities. The monthly paediatric TB case detection rate increased significantly during intervention versus pre-intervention (+46.0%, 95% CI 36.2-55.8%; p<0.0001), with variability across countries. The increase was greater in the <5 years old compared to the 5-14 years old (+53.4%, 95% CI 35.2-71.9%; p<0.0001 versus +39.9%, 95% CI 27.6-52.2%; p<0.0001). Relative contribution of lower-tier facilities to total case detection rate increased from 37% (71.8/191.8) pre-intervention to 50% (139.9/280.2) during intervention. The majority (89.5%) of children with TB were identified through facility-based intensified case-finding and primarily accessed care through outpatient and inpatient departments. In this multi-country study implemented under real-life conditions, the implementation of integrated and decentralized interventions increased paediatric TB case detection. The increase was driven by lower-tier facilities that serve as the primary point of healthcare contact for most patients. The effect was greater in children < 5 years compared to 5-14 years old, representing an important achievement as the TB detection gap is higher in this subpopulation. (Study number NCT03948698).

"The co-authors of pregnancy": leveraging men's sense of responsibility and other factors for male involvement in antenatal services in Kinshasa, DRC.

BACKGROUND: Despite efforts to improve male involvement (MI), few male partners typically attend antenatal care (ANC). MI in ANC and interventions to prevent mother-to-child HIV transmission have been demonstrated to be beneficial for the HIV-positive mother and her child. This study aimed to explore factors influencing partner attendance and highlight interventions with potential to improve MI within a Congolese context. METHODS: This was an exploratory, qualitative study conducted in two urban and two semi-urban catchment areas of Kinshasa, DRC in June-September 2016. Two women-only and two men-only focus group discussions (FGDs) were held; participants were recruited from ANC clinics and surrounding communities. Key informants purposively selected from health facility leadership and central government were also interviewed. Guide topics included MI barriers and facilitators, experiences with couples' ANC attendance and perceptions of MI interventions and how to improve them. Data from FGDs and interviews were analyzed to determine three interventions that best addressed the identified MI facilitators and barriers. These interventions were explored further through dialogues held with representatives from community organizations. RESULTS: This study included 17 female and 18 male FGD participants, 3 key informants and 21 community dialogue participants. Receipt of clinic staff advice was the most commonly-reported factor facilitating male attendance. No time off work was the most commonly-reported barrier. Only men identified responsibility, referring to themselves as "authors of the pregnancy," and wanting to be tested for HIV as facilitators. The most promising interventions perceived by FGD and interview participants were male partner invitation letters, couple- and male-friendly improvements to ANC, and expert peer-to-peer outreach. Community dialogue participants provided further detail on these approaches, such as invitation letter content and counseling messages targeting men attending ANC. CONCLUSIONS: Common themes regarding male involvement in ANC that emerged from this study included men's need to understand how the pregnancy is progressing and how best to care for their female partners and unborn children, and ANC settings that were misaligned to the needs of men and couples. Interventions at the individual, facility and community levels were discussed that could result in improvements to male attendance at pregnancy-related services.

Epidemic History and Iatrogenic Transmission of Blood-borne Viruses in Mid-20th Century Kinshasa.

BACKGROUND: The human immunodeficiency virus type 1 (HIV-1) pandemic was ignited in Léopoldville (now known as Kinshasa), in the former Belgian Congo. Factors that jump-started its early expansion remain unclear. Nonlethal hepatitis C virus (HCV) and human T-cell lymphotropic virus (HTLV-1) can be used to investigate past iatrogenic transmission. METHODS: We undertook a cross-sectional study of elderly inhabitants of Kinshasa, with serological assays, amplification, and sequencing. Risk factors were assessed through logistic regression. Phylogenetic methods reconstructed the genetic history of HCV. RESULTS: A total of 217 of 839 participants (25.9%) were HCV seropositive; 26 (3.1%) were HTLV-1-seropositive. Amplification products were obtained from 118 HCV-seropositive participants; subtypes 4k (in 47 participants) and 4r (in 38) were most common. Independent risk factors for HCV subtype 4r seropositivity were intramuscular tuberculosis therapy, intravenous injections at hospital A, intravenous injections before 1960, and injections at a colonial-era venereology clinic. Intravenous injections at hospital B and antimalarials were associated with HCV subtype 4k seropositivity. Risk factors for HTLV-1 seropositivity included intravenous injections at hospitals C or D and transfusions. Evolutionary analysis of viral sequences revealed independent exponential amplification of HCV subtypes 4r and 4k from the 1950s onward. CONCLUSIONS: Iatrogenic transmission of HCV and HTLV-1 occurred in mid-20th century Kinshasa, at the same time and place HIV-1 emerged. Iatrogenic routes may have contributed to the early establishment of the pandemic.

Engaging with research ethics in central Francophone Africa: reflections on a workshop about ancillary care.

Research ethics is predominantly taught and practiced in Anglophone countries, particularly those in North America and Western Europe. Initiatives to build research ethics capacity in developing countries must attempt to avoid imposing foreign frameworks and engage with ethical issues in research that are locally relevant. This article describes the process and outcomes of a capacity-building workshop that took place in Kinshasa, Democratic Republic of Congo in the summer of 2011. Although the workshop focused on a specific ethical theme - the responsibilities of researchers to provide health-related care to their research participants - we argue that the structure of the workshop offers a useful method for engaging with research ethics in general, and the theme of ancillary care encourages a broad perspective on research ethics that is highly pertinent in low-income countries. The workshop follows an interactive, locally driven model that could be fruitfully replicated in similar settings.