Human immunodeficiency virus care and management in incarcerated populations in Sub-Saharan Africa between 2010 and 2022: A narrative review.

BACKGROUND: Different countries in sub-Saharan Africa (SSA) have established guidelines to reduce HIV transmission and improve its management in prisons. This narrative review aimed to examine established literature on HIV care and management among incarcerated persons in SSA to identify successful interventions that could inform improved guidelines, policies, and practices related to the clinical care of this population. METHODS: We searched PubMed, Scopus, Web of Science, Embase, and TRIP Medical Databases in August 2022 for articles published between 1st January 2010 and 30th June 2022. We identified 27 eligible articles based on the Population/Concept/Context framework. RESULTS: HIV screening primarily involved mass campaigns rather than formal prison programmes, with limited implementation of universal testing and treatment. Although a few studies reported on access to antiretrovirals (ARVs), prisoners in urban areas and females had disproportionate access. Barriers identified include poor living conditions, high levels of stigma, and resource constraints. Inter-prison transfers, release from prison, and lack of established programmes hindered follow-up and linkage to care. CONCLUSIONS: The implementation of strategies such as universal testing and treatment, human resource strengthening, financing plans for testing, ARV care, and frequent assessment of risk could improve HIV care and management in prisons in SSA.

Carbapenem-Resistant Acinetobacter baumannii Bloodstream Infection in a Ghanaian Patient with Unilateral Diaphragmatic Eventration and HIV Type 1 Infection.

Carbapenem-resistant Acinetobacter baumannii infection is a critically prioritized pathogen by the World Health Organization and a cause for growing concern due to increased mortality among hospitalised patients. Phrenic nerve palsy is a rare complication of herpes zoster infection of the C3, C4, and C5 nerve roots. We present a case of bloodstream carbapenem-resistant A. baumannii infection in a Ghanaian patient with HIV type 1 infection and multiple risk factors, including unilateral diaphragmatic eventration with compression atelectasis likely secondary to phrenic nerve palsy due to herpes zoster infection, consequently leading to recurrent hospital and ICU admission. In this case, we emphasize the need for clinicians in LMICs to be aware of CRAB, in order to advocate for the availability of evidence-based medicines in resource-limited settings for appropriate treatment. In addition, we illustrate the importance of a high index of suspicion for infection with carbapenem-resistant organisms such as A. baumannii and highlight a rare and severe complication of herpes zoster infection in the form of phrenic nerve palsy and consequent diaphragmatic eventration.

Hepatitis C virus seroprevalence, testing, and treatment capacity in public health facilities in Ghana, 2016-2021; A multi-centre cross-sectional study.

The current burden of Hepatitis C virus infection and the availability of HCV-related services in Ghana are not well described. Previous estimates on HCV seroprevalence in the country are outdated. This study investigated the HCV seroprevalence and testing and treatment capacity in Ghana. A multi-centre cross-sectional study was conducted in which laboratory and blood bank registers from 17 public healthcare institutions in Ghana were reviewed. A survey on cost and availability of HCV-related testing and treatment was also performed. Crude and pooled estimates of HCV seroprevalence, frequency and median cost of available diagnostic tests and medicines were described. The crude HCV seroprevalence was 2.62% (95% CI 2.53-2.72) and the pooled estimate was 4.58% (95% CI 4.06-5.11) among 103,609 persons tested in laboratories. Age (OR 1.02 95% CI 1.01-1.02) and male sex (OR 1.26 95% CI 1.08-1.48) were predictors of a positive anti-HCV RDT test. Northern administrative regions in Ghana had the highest HCV seroprevalence ranging from 8.3-14.4%. Among 55, 458 potential blood donors, crude HCV seroprevalence was 3.57% (95% CI 3.42-3.72). Testing was through Rapid Diagnostic Test (RDT) kits in most facilities, and only 2 of 17 centres were performing HCV RNA testing. The median cost of an anti-HCV RDT test was $0.97 (0-1.61) and $3.23 (1.61-7.58) for persons with and without government health insurance respectively. The median cost of a 12-week course of the pan-genotypic direct-acting antiviral therapy sofosbuvir-daclatasvir was $887.70. In conclusion, there are significant regional differences in HCV burden across Ghana. Limited access to and cost of HCV RNA and DAA therapy hinders testing and treatment capability, and consequently HCV elimination efforts. A national HCV program supported with a sustainable financing plan is required to accelerate HCV elimination in Ghana.

Global burden of liver disease: 2023 update.

Liver disease accounts for two million deaths annually and is responsible for 4% of all deaths (1 out of every 25 deaths worldwide); approximately two-thirds of all liver-related deaths occur in men. Deaths are largely attributable to complications of cirrhosis and hepatocellular carcinoma, with acute hepatitis accounting for a smaller proportion of deaths. The most common causes of cirrhosis worldwide are related to viral hepatitis, alcohol, and non-alcoholic fatty liver disease. Hepatotropic viruses are the aetiological factor in most cases of acute hepatitis, but drug-induced liver injury increasingly accounts for a significant proportion of cases. This iteration of the global burden of liver disease is an update of the 2019 version and focuses mainly on areas where significant new information is available like alcohol-associated liver disease, non-alcoholic fatty liver disease, viral hepatitis, and hepatocellular carcinoma. We also devote a separate section to the burden of liver disease in Africa, an area of the world typically neglected in such documents.

A nationwide cross-sectional review of in-hospital hepatitis B virus testing and disease burden estimation in Ghana, 2016 - 2021.

BACKGROUND AND AIMS: Data are needed to inform hepatitis B virus (HBV) testing and treatment policies in Ghana to make progress towards achieving the 2030 WHO elimination targets. This study investigated testing patterns for HBV and described the age, sex, and region-specific prevalence of HBV infection in Ghana using hospital data. METHODS: A nationwide multi-centre cross-sectional study was performed where hospital-based registers were reviewed. These included review of 139,966 laboratory, 169,048 blood bank, and 83,920 delivery register entries from 22 healthcare institutions in Ghana. Frequencies and proportions, and crude and pooled estimates reported. Chi squared test was used for tests of independence. Logistic regression was used to identify factors associated with a positive test result. RESULTS: The crude HBsAg seroprevalence was 8.48% (95%CI 8.25-8.57%) with pooled estimate of 11.40% (95%CI 10.44-12.35). HBsAg seroprevalence among children under 5 years was 1.87% (95%CI 1.07-3.27) and highest age-specific seroprevalence was in those 40-49 years. The highest region-specific seroprevalences was in the Savannah (22.7%). Predictors of a positive HBsAg RDT test included female sex (OR 0.81 95% CI 0.74-0.88), and age (OR 1.005 95%CI 1.002-1.007). The proportion of parturient women receiving HBsAg testing increased between 2017 (87.2%) and 2020 (94.3%) (p < 0.001). The crude HBsAg seroprevalence in parturient women was 6.14% (95% CI 5.97-6.31). Among blood donors the crude HBsAg seroprevalence was 5.69% (95%CI 5.58-5.80). Data from 2 teaching hospitals indicated that in 2020, although 1500 HBsAg positive tests were recorded only 746 serological profile and 804 HBV DNA tests were performed. HBV e antigen seroprevalence was 6.28% (95%CI 4.73-7.84). CONCLUSION AND RECOMMENDATIONS: Ghana remains a country with high HBV burden. There is an unequal distribution, with higher HBsAg seroprevalence in the north of the country. Furthermore, PCR testing is not widely available outside of large teaching hospitals, which limits diagnostic work-up. Hepatitis reporting systems and registers should be improved to facilitate data capture of indicators and standardised across the country to allow for comparability. Furthermore, where gains have been made in testing among pregnant women, there is a need for linkage to appropriate care.

Ambulatory end-stage liver disease in Ghana; patient profile and utility of alpha fetoprotein and aspartate aminotransferase: platelet ratio index.

BACKGROUND: End-stage liver disease (ESLD) is a major burden on public health, particularly in sub-Saharan Africa, where hepatitis B virus (HBV) is an important risk factor. We aimed to describe clinical characteristics of ESLD from cirrhosis or hepatocellular carcinoma (HCC) and the performance of aspartate aminotransferase (AST)-platelet ratio index (APRI) and alpha fetoprotein (AFP) in Ghana. METHODS: We performed an observational cross-sectional study in outpatient hepatology clinics at three teaching hospitals in Ghana, West Africa. One hundred and forty-one HCC, 216 cirrhosis and 218 chronic HBV patients were recruited by convenience sampling. Sociodemographic, history and examination, laboratory, and disease staging information were shown using descriptive statistics. Performance of the APRI score in diagnosis of cirrhosis and AFP in the diagnosis of HCC was determined using AUROC analysis. RESULTS: Median age at presentation was 44 years for HCC and 46 years for cirrhosis. HBV was found in 69.5% of HCC and 47.2% of cirrhosis cases, and HCV in 6.4% and 3.7% respectively. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in diagnosis of cirrhosis, and cut-off of 1 had sensitivity of 75.9% and specificity of 89%. AUC of AFP was 0.88 (95% CI 0.81-0.94) in diagnosis of HCC. Low monthly income was associated with lower odds of undertaking AFP. Thirty one percent of cirrhotic persons were Child-Pugh C, and 67.9% of HCC patients had advanced or terminal disease at presentation. CONCLUSIONS: Our findings emphasize the young age of ESLD patients in Ghana and the advanced nature at presentation. It highlights shortcomings in surveillance and the need for policies to address the burden and improve outcomes in Ghana.

The 6-star doctor? Physicians' communication of poor prognosis to patients and their families in Cape Coast, Ghana.

INTRODUCTION: Communication is considered a key skill for physicians globally and has formed a central part of medical curricula since the WHO identified it as a key attribute of the '5-star doctor'. Communication of poor prognosis to patients and caregivers is particularly challenging, yet an important example of physicians' clinical communication, and a priority within palliative care research. Knowledge is scarce regarding the different positions physicians adopt during poor prognosis communication, especially in sub-Saharan countries. METHODS: This qualitative study took place at the Cape Coast Teaching Hospital in Ghana's Central Region. Physicians in the internal medicine department, with experience in communicating poor prognosis to patients and families on a weekly basis were purposively sampled. Based on the concept of information power, a maximum variation of participants, in terms of age, sex, seniority and experience was achieved after conducting 10 semistructured interviews in March 2019. Positioning theory was used as a theoretical lens to inform study design. The data were analysed through a constructivist thematic analysis approach. RESULTS: Physicians adopted six positions, considered as six different themes, during their communication of poor prognosis: clinical expert, educator, counsellor, communicator, protector and mentor. Physicians' choice of position was fluid, guided by local context and wider health system factors. Physicians' desire to communicate with patients and families in a way that met their needs highlighted three key challenges for communication of poor prognosis: linguistic difficulties, pluralistic health beliefs and the role of family. These challenges presented ethical complexities in relation to autonomy and non-maleficence. CONCLUSION: Context is key to physicians' communication of poor prognosis. Communication of poor prognosis is multifaceted, complex and unpredictable. Physicians' communication training should be developed to emphasise contextual circumstances and physician support, and international policy models on physicians' roles developed to include a greater focus on social accountability.

Nutritional management of cirrhosis patients: A qualitative study exploring perceptions of patients and health workers in Ghana.

BACKGROUND AND AIMS: Malnutrition is common among patients with end stage liver disease including liver cirrhosis and liver cancer. Optimal nutrition is important to reduce morbidity and mortality of these patients. There is limited qualitative data on nutritional status and management of chronic liver disease patients. We aimed to explore the knowledge, opinions and practices of cirrhosis patients and health workers in nutritional management of cirrhosis in Ghana, in order to determine whether there is a need to improve nutritional care for cirrhosis patients. METHODS: We conducted a qualitative study using semi-structured interviews of cirrhotic patients (n = 16) and healthcare providers (n = 27) in three academic centers in Accra, Kumasi and Cape Coast (Ghana). Recruitment was by purposive sampling of patients attending specialist liver disease clinics. The recorded data were analyzed using NVivo 11 software, with generation of codes, themes and subthemes. RESULTS: The major themes that emerged from the data included nutrition as part of care delivery during the hospital visit, nutritional recommendations, dietary changes and long-term practice improvement. The results showed that patients and health workers felt dietary recommendations for patients were frequently addressed, but could be significantly improved. We found that in the opinion of study participants, local guidelines are important and necessary in nutritional management of cirrhosis patients, and that participants felt it was difficult to change dietary habits following cirrhosis diagnosis. CONCLUSIONS: These results suggest that nutritional management of cirrhosis patients in Ghana requires improvement. Strategies to improve this could include a multi-disciplinary approach to nutritional management, development of local guidelines and continued nutritional assessment, monitoring and follow-up.