Discontinuation of HIV oral pre-exposure prophylaxis: findings from programmatic surveillance within two general population HIV programs in Nigeria.

BACKGROUND: As oral PrEP scales up in Nigeria, information about uptake, use pattern and client preference in a real-world, implementation setting is invaluable to guide refining service provision and incorporation of oral PrEP and other prevention measures into routine health services. To add to this body of knowledge, our study examines factors associated with discontinuation of PrEP among HIV negative individuals across two large scale programs in Nigeria. METHODS: Using program implementation data from two large-scale HIV projects in Akwa Ibom and Cross River states in Nigeria between January 2020 and July 2021, we used logistic regression to explore factors associated with early discontinuation (i.e., stopping PrEP within one month of starting) among HIV-negative individuals who initiated PrEP in the programs. RESULTS: Of a total of 26,325 clients; 22,034 (84%) discontinued PrEP within the first month. The odds of PrEP discontinuation were higher among clients who enrolled in community-based distribution sites (aOR 2.72; 95% C.I: 2.50-2.96) compared to those who enrolled in program-supported facilities and never married (aOR 1.76; 95% C.I: 1.61-1.92) compared to married clients. Clients who initiated PrEP because of high-risk sexual behaviour (aOR 1.15, 95% C.I 1.03-1.30) or inconsistent use or non-use of condoms (aOR 1.96, 95% C.I 1.60-2.41) had greater odds of discontinuing PrEPthan those who initiated PrEP because they were in a serodifferent relationship. CONCLUSION: The behavioural and demographic factors associated with early discontinuation of PrEP suggest that risk stratification of pre-initiation and follow up counselling may be helpful in raising continuation rates. On the service delivery side, strategies to strengthen follow-up services provided by community-based distribution sites need to be introduced. Overall, the low continuation rate calls for a review of programmatic approaches in provision of PrEP services in Nigeria.

Service Delivery Considerations for Introducing New Injectable Contraceptives Lasting 4 and 6 Months in Nigeria and Uganda: A Qualitative Study.

BACKGROUND: New family planning (FP) product introduction requires understanding the target market and support from stakeholders from across the health sector. We aimed to understand the perspectives of FP providers and other stakeholders on the potential introduction of new subcutaneous (SC) depot medroxyprogesterone acetate (DMPA) injectable contraceptives lasting 4 and 6 months in Nigeria and Uganda. METHODS: Between July 2021 and February 2022, we conducted 48 in-depth interviews (IDIs) and 11 focus group discussions (FGDs) with FP providers and other stakeholders involved with service delivery, program management, and policymaking in Lagos and Abuja in Nigeria and Kampala and Luwero in Uganda. IDIs and FGDs explored respondents' reactions to and preferences for the new injectables lasting 4 and 6 months. RESULTS: Most respondents liked the idea of longer-acting DMPA-SC products, noting the potential for reduced facility visits for clients and workloads for providers, cost savings for users and the health system, and potential for improved commodity logistics. Some nonproviders raised concerns about confusion among providers and clients with the availability of multiple injectable products; however, providers did not share this concern. The greatest interest among all groups was for the 6-month injectable, even without the option for self-injection. Several respondents reported that self-injection is not widespread in either context, and some noted that contact with a provider would be important for products with longer durations. Respondents' acceptability of the new injectables assumed that side effects would be no worse than the existing 3-month product. CONCLUSIONS: Family planning stakeholders in Nigeria and Uganda are supportive of expanding the method mix with new injectables, which they see as having the potential to meet the needs of more users. Concerted engagement of health providers, policymakers, and the community will be necessary for successful introduction once these new contraceptive products are available.

Use of Objective Structured Clinical Examination (OSCE) in a hybrid digital / in-person training for hormonal IUD in Nigeria: findings and applications of the approach.

Background: The hormonal intrauterine device, a long-acting reversible contraceptive method, is being introduced to pilot sites in the private and public sector in Nigeria by the Nigerian Federal Ministry of Health since 2019. To inform training of health care providers, a study was conducted on a hybrid digital and in-person training which utilized Objective Structured Clinical Examination (OSCE) to assess competency of provider trainees. This study represents one of few documented experiences using OSCE to assess the effectiveness of a digital training. Methods: From September - October 2021, in Enugu, Kano and Oyo states of Nigeria, 62 health care providers from public and private sector health facilities were trained in hormonal IUD service provision using a hybrid digital / in-person training approach. Providers, who were skilled in provision of copper IUD, underwent a didactic component using digital modules, followed by an in-person practicum, and finally supervised service provision in the provider trainee's workplace. Skills were assessed using OSCE during the one-day practicum. Results: Use of the OSCE to assess skills provided valuable information to study team. The performance of provider trainees was high (average 94% correct completion of steps in the OSCE). Conclusions: OSCE was used as a research methodology as part of this pilot study; to date, OSCE has not been integrated into the training approach to be scaled up by FMOH. Uniformly high performance of provider trainees was seen on the OSCE, unsurprising since provider trainees were experienced in providing copper IUD. If and when training is rolled out to providers inexperienced with copper IUD, OSCE may have a more important role to assess skills before service provision. The role of OSCE in design of hybrid digital / in-person training approaches should be further explored in rollout of hormonal IUD and other contraceptive technologies.

Use of a hybrid digital training approach for hormonal IUD providers in Nigeria: results from a mixed method study.

BACKGROUND: In Nigeria, in-service trainings for new family planning (FP) methods have typically been conducted using a combination of classroom-based learning, skills labs, and supervised practicums. This mixed-methods study evaluated the feasibility, acceptability, provider competency, and costs associated with a hybrid digital and in-person training model for the hormonal intrauterine device (IUD). METHODS: The study was conducted in Enugu, Kano, and Oyo states, Nigeria, and enrolled FP providers previously trained on non-hormonal IUDs. Participants completed a digital didactic training, an in-person model-based practicum with an Objective Structured Clinical Examination (OSCE), followed by supervised provision of service to clients. Provider knowledge gains and clinical competency were assessed and described descriptively. Data on the feasibility, acceptability, and scalability of the approach were gathered from participating providers, clinical supervisors, and key stakeholders. Training costs were captured using an activity-based approach and used to calculate a cost per provider trained. All analyses were descriptive. RESULTS: Sixty-two providers took the hybrid digital training, of whom 60 (91%) were included in the study (n = 36 from public sector, n = 15 from private sector, and n = 9 both public/private). The average knowledge score increased from 62 to 86% pre- and post-training. Clinical competency was overall very high (mean: 94%), and all providers achieved certification. Providers liked that the digital training could be done at the time/place of their choosing (84%), was self-paced (79%), and reduced risk of COVID-19 exposure (75%). Clinical supervisors and Ministry of Health stakeholders also had positive impressions of the training and its scalability. The hybrid training package cost $316 per provider trained. CONCLUSIONS: We found that a hybrid digital training approach to hormonal IUD service provision in Nigeria was acceptable and feasible. Providers demonstrated increases in knowledge following the training and achieved high levels of clinical competency. Both providers and clinical supervisors felt that the digital training content was of high quality and an acceptable (sometimes preferable) alternative to classroom-based, in-person training. This study provided insights into a hybrid digital training model for a long-acting contraceptive, relevant to scale-up in Nigeria and similar settings.

A comparative analysis of cervical cancer prevention between Nigeria and Nordic countries that have experienced a decline in cervical cancer incidence.

BACKGROUND: A modelling analysis carried out in 2014 suggested that, without cervical cancer screening programmes, the incidence of cervical cancer in Denmark, Finland, Norway and Sweden would have been as high as that in some low- and middle-income countries. We compare programme strategies between Nigeria and these Nordic countries and develop translatable recommendations. METHODS: A literature review using a systematic approach through Medline, Popline, Global Health, CINAHL PLUS, Cochrane Library, EMBASE, Google Scholar, Africa Wide and WHO databases was conducted. RESULTS: Fifteen journal articles and two grey literature reports met our criteria. Six descriptive studies from Nigeria noted that services in Nigeria were mainly provided in urban secondary/tertiary facilities and that uptake was low even where screening was free. Trials in Nigeria and Sweden noted that subsidies and free programmes alone did not improve uptake; a Danish trial demonstrated that reminders and invitations issued by general practitioners improved participation. CONCLUSION: Free screening programmes are important but should also consider incentivisation of treatment when needed and demand creation among health workers. Additionally, effective monitoring and evaluation of programme data are key to improving and maintaining quality. More broadly, we suggest that Nigeria can build success through stakeholder-led implementation of well-defined policies with national consensus to ensure coordination and sustainability.

'When she rises, we all rise': a crowdsourcing challenge to increase women's participation in an infectious diseases research fellowship.

BACKGROUND: Women are under-represented in many mid-career infectious diseases research fellowships, including a TDR fellowship for low- and middle-income country (LMIC) researchers. TDR solicited creative ideas as part of a challenge contest to increase the number of women fellowship applicants. The purpose of this study is to examine themes from submitted ideas and the impact of implementing the top three ideas on the number of women applicants. METHODS: We solicited ideas for modifying the TDR fellowship using a crowdsourcing challenge. Then we used a mixed methods approach to evaluate texts submitted in response to the challenge. The qualitative analysis identified themes from eligible submissions. The quantitative analysis examined the mean score (1-10 scale) assigned to submitted ideas and also the number of eligible women applicants before (2014-7) and after (2018) implementing the top three ideas. RESULTS: We received 311 ideas on improving women's participation in this fellowship from 63 countries. Among all ideas, 282 (91%) were from women and 286 (92%) were from low- and middle-income countries (LMICs). Thirty-three (17%) ideas received an overall mean score of 7.0 or greater. The top three ideas included enhanced social media communication targeting women, improving career mentorship, and creating a nomination system to nudge women applicants. These ideas were implemented as part of the 2018 fellowship application cycle. The number of eligible women applicants increased from 11 in 2016 to 48 in 2018. The number of eligible men applicants increased from 55 in 2016 to 114 in 2018. Women represent 44% (8/18) of the 2018 cohort. CONCLUSION: This suggests that the challenge contest resulted in strong participation from women in LMICs. The three top ideas likely contributed to a greater number of women applicants to this mid-career fellowship. Further ways of enhancing women's participation in global health training are needed.