Decolonization and antiracism: intersecting pathways to global health equity.

In this paper, as Black scholars, we address ways that interventions designed to promote equity in health can create pathways for coupling decolonization with antiracism by drawing on the intersection of the health of Africans and African Americans. To frame this intersection, we offer the Public Health Critical Race Praxis (PHCRP) and the PEN-3 Cultural Model as antiracism and decolonization tools that can jointly advance research on colonization and racism globally. We argue that racism is a global reality; PHCRP, an antiracism framework, and PEN-3, a decolonizing framework, can guide interventions to promote equity for Africans and African Americans.

Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial).

BACKGROUND: Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients. METHODS: An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients). DISCUSSION: Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers. TRIAL REGISTRATION: Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.

A designathon to co-create HPV screening and vaccination approaches for mothers and daughters in Nigeria: findings from a community-led participatory event.

BACKGROUND: Oncogenic types of human Papillomavirus (HPV) infection cause substantial morbidity and mortality in Nigeria. Nigeria has low cervical cancer screening and vaccination rates, suggesting the need for community engagement to enhance reach and uptake. We organised a designathon to identify community-led, innovative approaches to promote HPV screening and vaccination for women and girls, respectively, in Nigeria. A designathon is a three-phase participatory process informed by design thinking that includes the preparation phase that includes soliciting innovative ideas from end-users, an intensive collaborative event to co-create intervention components, and follow-up activities. METHODS: We organised a three-phase designathon for women (30-65yrs) and girls (11-26yrs) in Nigeria. First, we launched a national crowdsourcing open call for ideas on community-driven strategies to support HPV screening among women and vaccination among girls. The open call was promoted widely on social media and at in-person gatherings. All eligible entries were graded by judges and 16 exceptional teams (with 4-6members each). All six geo-political zones of Nigeria were invited to join an in-person event held over three days in Lagos to refine their ideas and present them to a panel of expert judges. The ideas from teams were reviewed and scored based on relevance, feasibility, innovation, potential impact, and mother-daughter team dynamics. We present quantitative data on people who submitted and themes from the textual submissions. RESULTS: We received a total of 612 submissions to the open call from mother-daughter dyads. Participants submitted ideas via a website designated for the contest (n = 392), in-person (n = 99), email (n = 31), or via an instant messaging application (n = 92). Overall, 470 were eligible for judging after initial screening. The average age of participants for daughters was 19 years and 39 years for mothers. Themes from the top 16 proposals included leveraging local leaders (5/16), faith-based networks (4/16), educational systems (4/16), and other community networks (7/16) to promote awareness of cervical cancer prevention services. After an in-person collaborative event, eight teams were selected to join an innovation training boot camp, for capacity building to implement ideas. CONCLUSIONS: Innovative strategies are needed to promote HPV screening for mothers and vaccination for girls in Nigeria. Our designathon was able to facilitate Nigerian mother-daughter teams to develop cervical cancer prevention strategies. Implementation research is needed to assess the effectiveness of these strategies.

Sustaining sexual health programs: practical considerations and lessons from the President's Emergency Plan for AIDS Relief.

Enhancing the sustainability of sexual health programs is important, but there are few practical tools to facilitate this process. Drawing on a sustainability conceptual framework, this Editorial proposes four ideas to increase the sustainability of sexual health programs - early planning, equitable community engagement, return on investment, and partnerships to address social determinants. Early planning during the design of a sexual health program is important for sustainability because it provides an opportunity for the team to build factors relevant to sustainability into the program itself. Equitable community engagement can expand multi-sectoral partnerships for institutionalisation, identify allies for implementation, and strengthen relationships between beneficiaries and researchers. From a financial perspective, considering the return on investment could increase the likelihood of sustainability. Finally, partnerships to address social determinants can help to identify organisations with a similar vision. Existing sustainability frameworks can be used to measure each of these key elements. Several approaches can be used to enhance the sustainability of sexual health programs. The President's Emergency Plan for AIDS Relief provides potential lessons for increasing the sustainability of sexual health programs in diverse global settings.

Expanding Youth-Friendly HIV Self-Testing Services During the COVID-19 Pandemic: Qualitative Analysis of a Crowdsourcing Open Call in Nigeria.

BACKGROUND: HIV self-testing (HIVST) among young people is an effective approach to enhance the uptake of HIV testing recommended by the World Health Organization. However, the COVID-19 pandemic disrupted conventional facility-based HIV testing services, necessitating the exploration of innovative strategies for the effective delivery of HIVST. OBJECTIVE: This study analyzed the outcomes of a digital World AIDS Day crowdsourcing open call, designed to elicit youth responses on innovative approaches to promote HIVST among young people (14-24 years) in Nigeria during COVID-19 restrictions. METHODS: From November 2 to 22, 2020, a World AIDS Day 2020 crowdsourcing open call was held digitally due to COVID-19 restrictions. The crowdsourcing open call followed World Health Organization standardized steps, providing a structured framework for participant engagement. Young people in Nigeria, aged 10-24 years, participated by submitting ideas digitally through Google Forms or email in response to this crowdsourcing open call prompt: "How will you promote HIV self-testing among young people during COVID-19 pandemic?" Data and responses from each submission were analyzed, and proposed ideas were closely examined to identify common themes. Four independent reviewers (AE, SM, AZM, and TG) judged each submission based on the desirability, feasibility, and impact on a 9-point scale (3-9, with 3 being the lowest and 9 being the highest). RESULTS: The crowdsourcing open call received 125 eligible entries, 44 from women and 65 from men. The median age of participants was 20 (IQR 24-20) years, with the majority having completed their highest level of education at the senior secondary school level. The majority of participants lived in the South-West region (n=61) and Lagos state (n=36). Of the 125 eligible entries, the top 20 submissions received an average total score of 7.5 (SD 2.73) or above. The panel of judges ultimately selected 3 finalists to receive a monetary award. Three prominent themes were identified from the 125 crowdsourcing open call submissions as specific ways that HIVST can adapt during the COVID-19 pandemic: (1) digital approaches (such as gamification, photoverification system, and digital media) to generate demand for HIVST and avoid risks associated with attending clinics, (2) awareness and sensitization through existing infrastructures (such as churches, schools, and health facilities), and (3) partnerships with influencers, role models, and leaders (such as religious and youth leaders and social influencers in businesses, churches, organizations, and schools) to build trust in HIVST services. CONCLUSIONS: The crowdsourcing open call effectively engaged a diverse number of young people who proposed a variety of ways to improve the uptake of HIVST during the COVID-19 pandemic. Findings contribute to the need for innovative HIVST strategies that close critical knowledge and practice gaps on ways to reach young people with HIVST during and beyond the pandemic. TRIAL REGISTRATION: ClinicalTrials.gov NCT04710784; https://clinicaltrials.gov/study/NCT04710784.

Designathons in health research: a global systematic review.

INTRODUCTION: A designathon is a three-stage participatory activity informed by design thinking. There is a growing literature on designathons in health. This study synthesised designathons' effectiveness and implementation-related factors to address health challenges. METHODS: We searched Cochrane Library, Embase, PubMed, Scopus and the ClinicalTrials.gov registry for articles containing primary data on designathons for health from their dates of inception to 29 November 2022. We retrieved additional studies from citation searching and a complementary open call. We synthesised data on designathons' effectiveness (ie, engagement, outputs and implementation), required resources and implementation-related factors (ie, resources, facilitators, barriers, strengths and limitations). We assessed the risk of bias using a checklist adapted from Joanna Briggs Institute Critical Appraisal tools. RESULTS: In total, 4973 citations were identified, and 42 studies were included. In total, 26 studies (62%) were from high-income countries. The median number of total participants was 49, divided into a median of 8 teams. The duration of the intensive collaboration phase ranged from 3 hours to 7 days. Common evaluation criteria were feasibility, innovation and impact. Idea and prototype outputs included mobile phone applications, educational programmes and medical devices. Interventions developed from a designathon was estimated to be highly cost-effective. The most common facilitators were interdisciplinary participants and high-quality mentorship. The most common barriers were suboptimal execution of the events, difficulties in balancing interdisciplinary participants across teams and limited support for participants along the process. There were limited data on required resources and further implementation of solutions after designathons. CONCLUSION: Given designathons' adaptability in terms of budget, mode of delivery, type of output and involvement of diverse participants, including end users, designathons can be implemented in a wide range of contexts to address various health issues. PROSPERO REGISTRATION NUMBER: CRD42023389685.

The HI V O pen Call on I nformed C onsent and E thics in Research (VOICE) for Adolescents and Young Adults: A Digital Crowdsourcing Open Call in Low- and Middle-Income Countries.

BACKGROUND: Many adolescents and young adults (AYAs; 10-24 years old) are excluded from HIV research because of social, ethical, and legal challenges with informed consent, resulting in limited AYA-focused data. We use a participatory approach to identify strategies for improving AYA consent processes in HIV research in low- and middle-income countries (LMICs). METHODS: We conducted a digital crowdsourcing open call for ideas to improve AYA consent to HIV research in LMICs. Crowdsourcing involves engaging a group of people in problem-solving, then sharing emergent solutions. Submissions were evaluated by 3 independent judges using predefined criteria, with exceptional strategies receiving prizes. Demographic data were collected, and textual data were qualitatively analyzed for emergent themes in barriers and facilitators for improving AYA consent in HIV research, guided by a socioecological model. RESULTS: We received 110 strategies total; 65 were eligible for evaluation, 25 of which were identified as finalists. Fifty-eight participants from 10 LMICs submitted the 65 eligible submissions, of which 30 (52%) were 18 to 24 years old. Thematic analysis identified 10 barriers to AYA consent, including HIV stigma, limited education, and legal/regulatory barriers. Strategies for improving AYA consent processes revealed 7 potential facilitators: enhancing AYA engagement in research, involving parents/guardians, improving education/awareness, improving institutional practices/policy, making research participation more AYA-friendly, enhancing engagement of other key communities of interest, and empowering AYA. CONCLUSIONS: Diverse communities of interest in LMICs developed compelling strategies to enhance informed consent that may improve AYA inclusion in HIV research. These data will be used to develop practical guidance on improving AYA consent processes.

A designathon to co-create HPV screening and vaccination approaches for mothers and daughters in Nigeria: findings from a community-led participatory event.

Background: Oncogenic types of human Papillomavirus (HPV) infection cause substantial morbidity and mortality in Nigeria. Nigeria has low cervical cancer screening and vaccination rates, suggesting the need for community engagement to enhance reach and uptake. We organised a designathon to identify community-led, innovative approaches to promote HPV screening and vaccination for women and girls, respectively, in Nigeria. A designathon is a three-phase participatory process informed by design thinking that includes the preparation phase that includes soliciting innovative ideas from end-users, an intensive collaborative event to co-create intervention components, and follow-up activities. Methods: We organised a three-phase designathon for women (30-65yrs) and girls (11-26yrs) in Nigeria. First, we launched a national crowdsourcing open call for ideas on community-driven strategies to support HPV screening among women and vaccination among girls. The open call was promoted widely on social media and at in-person gatherings. All eligible entries were graded by judges and 16 exceptional teams (with 4-6members each). All six geo-political zones of Nigeria were invited to join an in-person event held over three days in Lagos to refine their ideas and present them to a panel of expert judges. The ideas from teams were reviewed and scored based on relevance, feasibility, innovation, potential impact, and mother-daughter team dynamics. We present quantitative data on people who submitted and themes from the textual submissions. Results: We received a total of 612 submissions to the open call from mother-daughter dyads. Participants submitted ideas via a website designated for the contest (n=392), in-person (n=99), email (n=31), or via an instant messaging application (n=92). Overall, 470 were eligible for judging after initial screening. The average age of participants for daughters was 19 years and 39 years for mothers. Themes from the top 16 proposals included leveraging local leaders (5/16), faith-based networks (4/16), educational systems (4/16), and other community networks (7/16) to promote awareness of cervical cancer prevention services. After an in-person collaborative event, eight teams were selected to join an innovation training boot camp, for capacity building to implement ideas. Conclusions: Innovative strategies are needed to promote HPV screening for mothers and vaccination for girls in Nigeria. Our designathon was able to facilitate Nigerian mother-daughter teams to develop cervical cancer prevention strategies. Implementation research is needed to assess the effectiveness of these strategies.

Interventions connecting young people living in Africa to healthcare; a systematic review using the RE-AIM framework.

Introduction: Africa's young people are among the least focused groups in healthcare linkage. The disproportionally high burden of youth-related health problems is a burden, especially in developing regions like Africa, which have a high population of young people. More information is needed about factors that impact linkages in healthcare and the sustainability of health interventions among young people in Africa. Methods: A systematic literature search was performed from October 2020 to May 2022 in PubMed, CINAHL, Scopus, Global Health, and the Web of Science. Studies included in the review were conducted among young people aged 10-24 living in Africa, written in English, and published between 2011 and 2021. Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data was analyzed using narrative synthesis, synthesizing the details of the RE-AIM reporting component. Interventions were systematically compared using the Cochrane Collaboration risk-of-bias tool to evaluate the rigor of each intervention. Results: A total of 2,383 potentially relevant citations were obtained after an initial database search. Retained in the final group were seventeen articles from electronic data searches; among these articles, 16 interventions were identified. Out of the seventeen studies, nine (53%) were randomized controlled trials, three (18%) were quasi-experimental designs, and five (29%) were observational studies. At the same time, the included interventions were reported on 20 (76.92%) of the 26 components of the RE-AIM dimensions. In eastern Africa, twelve (80%) interventions were conducted, and all the interventions addressed linkage to care for young people in preventing and treating HIV. The least reported RE-AIM dimensions were implementing and maintaining interventions connecting young people to care. Discussion: Timely care remains critical to treating and preventing ailments. This review indicates that interventions created to link young people to care, especially HIV care, can help link them to health care and strengthen the programs. It is also clear that further research with more extended follow-up periods is needed to examine connections to care in all other aspects of health and to bridge the gap between research and practice in the care of young people in Africa. Systematic Review Registration: PROSPERO [CRD42022288227].

Assets for integrating task-sharing strategies for hypertension within HIV clinics: Stakeholder's perspectives using the PEN-3 cultural model.

BACKGROUND: Access to antiretroviral therapy has increased life expectancy and survival among people living with HIV (PLWH) in African countries like Nigeria. Unfortunately, non-communicable diseases such as cardiovascular diseases are on the rise as important drivers of morbidity and mortality rates among this group. The aim of this study was to explore the perspectives of key stakeholders in Nigeria on the integration of evidence-based task-sharing strategies for hypertension care (TASSH) within existing HIV clinics in Nigeria. METHODS: Stakeholders representing PLWH, patient advocates, health care professionals (i.e. community health nurses, physicians and chief medical officers), as well as policymakers, completed in-depth qualitative interviews. Stakeholders were asked to discuss facilitators and barriers likely to influence the integration of TASSH within HIV clinics in Akwa Ibom, Nigeria. The interviews were transcribed, keywords and phrases were coded using the PEN-3 cultural model as a guide. Framework thematic analysis guided by the PEN-3 cultural model was used to identify emergent themes. RESULTS: Twenty-four stakeholders participated in the interviews. Analysis of the transcribed data using the PEN-3 cultural model as a guide yielded three emergent themes as assets for the integration of TASSH in existing HIV clinics. The themes identified are: 1) extending continuity of care among PLWH; 2) empowering health care professionals and 3) enhancing existing workflow, staff motivation, and stakeholder advocacy to strengthen the capacity of HIV clinics to integrate TASSH. CONCLUSION: These findings advance the field by providing key stakeholders with knowledge of assets within HIV clinics that can be harnessed to enhance the integration of TASSH for PLWH in Nigeria. Future studies should evaluate the effect of these assets on the implementation of TASSH within HIV clinics as well as their effect on patient-level outcomes over time.

An Unstructured Supplementary Service Data System to Verify HIV Self-Testing Among Nigerian Youths: Mixed Methods Analysis of Usability and Feasibility.

BACKGROUND: Mobile health (mHealth) interventions among adolescents and young adults (AYAs) are increasingly available in African low- and middle-income countries (LMICs). For example, the unstructured supplementary service data (USSD) could be used to verify HIV self-testing (HIVST) among AYAs with poor bandwidth. OBJECTIVE: The aim of this study is to describe the creation of an USSD platform and determine its feasibility and usability to promote the verification of HIVST results among AYAs in Nigeria. METHODS: We developed and evaluated a USSD platform to verify HIVST results using a user-centered approach. The USSD platform guided AYAs in performing HIVST, interpreting the result, and providing linkage to care after the test. Following the usability assessment, the USSD platform was piloted. We used a mixed methods study to assess the platform's usability through a process of quantitative heuristic assessment, a qualitative think-aloud method, and an exit interview. Descriptive statistics of quantitative data and inductive thematic analysis of qualitative variables were organized. RESULTS: A total of 19 AYAs participated in the usability test, with a median age of 19 (IQR 16-23) years. There were 11 females, 8 males, and 0 nonbinary individuals. All individuals were out-of-school AYAs. Seven of the 10 Nielsen usability heuristics assessed yielded positive results. The participants found the USSD platform easy to use, preferred the simplicity of the system, felt no need for a major improvement in the design of the platform, and were happy the system provided linkage to care following the interpretation of the HIVST results. The pilot field test of the platform enrolled 164 out-of-school AYAs, mostly young girls and women (101, 61.6%). The mean age was 17.5 (SD 3.18) years, and 92.1% (151/164) of the participants reported that they were heterosexual, while 7.9% (13/164) reported that they were gay. All the participants in the pilot study were able to conduct HIVST, interpret their results, and use the linkage to care feature of the USSD platform without any challenge. A total of 7.9% (13/164) of the AYAs had positive HIV results (reactive to the OraQuick kit). CONCLUSIONS: This study demonstrated the usability and feasibility of using a USSD system as an alternative to mobile phone apps to verify HIVST results among Nigerian youth without smartphone access. Therefore, the use of a USSD platform has implications for the verification of HIVST in areas with low internet bandwidth. Further pragmatic trials are needed to scale up this approach.

Crowdsourcing to support training for public health: A scoping review.

Crowdsourcing is an interactive process that has a group of individuals attempt to solve all or part of a problem and then share solutions with the public. Crowdsourcing is increasingly used to enhance training through developing learning materials and promoting mentorship. This scoping review aims to assess the literature on crowdsourcing for training in public health. We searched five medical and public health research databases using terms related to crowdsourcing and training. For this review, the concept of crowdsourcing included open calls, designathons, and other activities. We used a PRISMA checklist for scoping reviews. Each full-text was assessed by two independent reviewers. We identified 4,071 citations, and 74 studies were included in the scoping review. This included one study in a low-income country, 15 studies in middle-income countries, 35 studies in high-income countries, and 11 studies conducted in multiple countries of varying income levels (the country income level for 12 studies could not be ascertained). Nine studies used open calls, 35 used a hackathon, designathon or other "a-thon" event, and 30 used other crowdsourcing methods, such as citizen science programs and online creation platforms. In terms of crowdsourcing purpose, studies used crowdsourcing to educate participants (20 studies), develop learning materials (17 studies), enhance mentorship (13 studies) and identify trainees (9 studies). Fifteen studies used crowdsourcing for more than one training purpose. Thirty-four studies were done in-person, 31 were conducted virtually and nine used both meeting options for their crowdsourcing events. Seventeen studies generated open access materials. Our review found that crowdsourcing has been increasingly used to support public health training. This participatory approach can be a useful tool for training in a variety of settings and populations. Future research should investigate the impact of crowdsourcing on training outcomes.

Using a Designathon to Develop an HIV Self-Testing Intervention to Improve Linkage to Care Among Youths in Nigeria: Qualitative Approach Based on a Participatory Research Action Framework.

BACKGROUND: UNAIDS (Joint United Nations Programme on HIV and AIDS) and the Nigeria National HIV/AIDS Strategic Framework recommend HIV self-testing and youth-friendly services to enhance HIV testing, linkage to health services, and prevention. However, the voices of youths are seldom incorporated into interventions. We examined qualitative data generated from a series of participatory events in partnership with Nigerian youths focused on enhancing linkage to care. OBJECTIVE: The aim of this study was to assess youth-initiated interventions developed during a designathon to improve linkage to care and sexually transmitted infection services. METHODS: This study conducted a designathon informed by crowdsourcing principles and the participatory research action framework. A designathon is a multistage process including an open call, a sprint event, and follow-up activities. The open call solicited Nigerian youths (14-24 years old) to develop intervention strategies for linkage to care and youth-friendly health services. A total of 79 entries were received; from this, a subset of 13 teams responded to the open call and was invited to participate in a sprint event over 72 hours. Narratives from the open-call proposals were analyzed using grounded theory to identify emergent themes focused on youth-proposed interventions for linkage to care and youth-friendly services. RESULTS: A total of 79 entries (through the web=26; offline=53) were submitted. Women or girls submitted 40 of the 79 (51%) submissions. The average age of participants was 17 (SD 2.7) years, and 64 of 79 (81%) participants had secondary education or less. Two main themes highlighted strategies for enhancing youths' HIV linkage to care: digital interventions and collaboration with youth influencers. A total of 76 participants suggested digital interventions that would facilitate anonymous web-based counseling, text prompt referrals, and related services. In addition, 16 participants noted that collaboration with youth influencers would be useful. This could involve working in partnership with celebrities, gatekeepers, or others who have a large youth audience to enhance the promotion of messages on HIV self-testing and linkage. The facilitators of youths' linkage included health facility restructuring, dedicated space for youths, youth-trained staff, youth-friendly amenities, and subsidized fees. Barriers to HIV linkage to care among youths included a lack of privacy at clinics and concerns about the potential for breaching confidentiality. CONCLUSIONS: Our data suggest specific strategies that may be useful for enhancing HIV linkage to care for Nigerian youths, but further research is needed to assess the feasibility and implementation of these strategies. Designathons are an effective way to generate ideas from youths.

Training primary healthcare workers on a task-strengthening strategy for integrating hypertension management into HIV care in Nigeria: implementation strategies, knowledge uptake, and lessons learned.

BACKGROUND: With improved access to anti-retroviral drugs, persons living with HIV/AIDS (PLWHA) are living longer but with attendant increased risks of non-communicable diseases (NCDs). The increasing burden of NCDs, especially hypertension, could reverse gains attributed to HIV care. Nurses and Community Health Officers (CHO) in Nigeria are cardinal in delivering primary health care. A task-strengthening strategy could enable them to manage hypertension in HIV care settings. This study aimed to assess their knowledge and practice of hypertension management among Healthcare workers (HCWs) and to explore the challenges involved in conducting onsite training during pandemics. METHODS: Nurses and CHOs in the employment of the Lagos State Primary Health Care Board (LSPHCB), Lagos State, Nigeria, were recruited. They were trained through hybrid (virtual and onsite) modules before study implementation and a series of refresher trainings. A pre-and post-training test survey was administered, followed by qualitative interviews to assess skills and knowledge uptake, the potential barriers and facilitators of task-sharing in hypertension management in HIV clinics, and the lessons learned. RESULTS: Sixty HCWs participated in the two-day training at baseline. There was a significant improvement in the trainees' knowledge of hypertension management and control. The average score during the pre-test and post-test was 59% and 67.6%, respectively. While about 75% of the participants had a good knowledge of hypertension, its cause, symptoms, and management, 20% had moderate knowledge, and 5% had poor knowledge at baseline. There was also an increase in the mean score between the pre-test and post-test of the refresher training using paired t-tests (P < 0.05). Role-playing and multimedia video use improved the participants' uptake of the training. The primary barrier and facilitator of task sharing strategy in hypertension management reported were poor delineation of duties among HCWs and the existing task shifting at the Primary Healthcare Centres (PHC) level, respectively. CONCLUSIONS: The task strengthening strategy is relevant in managing hypertension in HIV clinics in Nigeria. The capacity development training for the nurses and CHOs involved in the Integration of Hypertension Management into HIV Care in Nigeria: A Task Strengthening Strategy (TASSH-Nigeria) study yielded the requisite improvement in knowledge uptake, which is a reassurance of the delivery of the project outcomes at the PHCs.

Organizational readiness to implement task-strengthening strategy for hypertension management among people living with HIV in Nigeria.

BACKGROUND: Hypertension (HTN) is highly prevalent among people living with HIV (PLHIV), but there is limited access to standardized HTN management strategies in public primary healthcare facilities in Nigeria. The shortage of trained healthcare providers in Nigeria is an important contributor to the increased unmet need for HTN management among PLHIV. Evidence-based TAsk-Strengthening Strategies for HTN control (TASSH) have shown promise to address this gap in other resource-constrained settings. However, little is known regarding primary health care facilities' capacity to implement this strategy. The objective of this study was to determine primary healthcare facilities' readiness to implement TASSH among PLHIV in Nigeria. METHODS: This study was conducted with purposively selected healthcare providers at fifty-nine primary healthcare facilities in Akwa-Ibom State, Nigeria. Healthcare facility readiness data were measured using the Organizational Readiness to Change Assessment (ORCA) tool. ORCA is based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework that identifies evidence, context, and facilitation as the key factors for effective knowledge translation. Quantitative data were analyzed using descriptive statistics (including mean ORCA subscales). We focused on the ORCA context domain, and responses were scored on a 5-point Likert scale, with 1 corresponding to disagree strongly. FINDINGS: Fifty-nine healthcare providers (mean age 45; standard deviation [SD]: 7.4, 88% female, 68% with technical training, 56% nurses, 56% with 1-5 years providing HIV care) participated in the study. Most healthcare providers provide care to 11-30 patients living with HIV per month in their health facility, with about 42% of providers reporting that they see between 1 and 10 patients with HTN each month. Overall, staff culture (mean 4.9 [0.4]), leadership support (mean 4.9 [0.4]), and measurement/evidence-assessment (mean 4.6 [0.5]) were the topped-scored ORCA subscales, while scores on facility resources (mean 3.6 [0.8]) were the lowest. CONCLUSION: Findings show organizational support for innovation and the health providers at the participating health facilities. However, a concerted effort is needed to promote training capabilities and resources to deliver services within these primary healthcare facilities. These results are invaluable in developing future strategies to improve the integration, adoption, and sustainability of TASSH in primary healthcare facilities in Nigeria. TRIAL REGISTRATION: NCT05031819.

Tracking adaptation strategies of an HIV prevention intervention among youth in Nigeria: a theoretically informed case study analysis of the 4 Youth by Youth Project.

BACKGROUND: Although many behavioral interventions are adapted, little is known about the reasons for adaptations and the process and outcomes influencing adaptations. To address this gap, we explored the adaptations made to promote HIV prevention services, including HIV self-testing (HIVST), among Nigerian youth. METHODS: The main objective of this qualitative case study design was to document the adaptations made over time using the Framework for Reporting Adaptations and Modifications - Expanded (FRAME). Between 2018 and 2020, we organized four participatory activities as part of the 4 Youth by Youth project to increase the uptake of HIVST services in Nigeria-an open call, a designathon, a capacity-building bootcamp and a pilot feasibility trial. We also began the process of implementing a final intervention using a pragmatic randomized control trial (RCT). The open call solicited creative strategies to promote HIVST among Nigerian youth and then had experts evaluate them. The designathon brought together youth teams to further develop their HIVST service strategies into implementation protocols. Teams determined to be exceptional were invited to a four-week capacity-building bootcamp. The five teams that emerged from the bootcamp were supported to pilot their HIVST service strategies over a 6-month period. The adapted intervention is currently being evaluated in a pragmatic RCT. We transcribed meeting reports and conducted document reviews of study protocols and training manuals. RESULTS: Sixteen adaptations were identified and categorized into three domains: (1) modifications to the content of the intervention (i.e. photo verification system and/or Unstructured Supplementary Service Data (USSD) system to verify HIVST); (2) modifications to the delivery the intervention (i.e. implement participatory learning community sessions to provide supportive supervision and technical support); (3) modifications to the evaluation processes (i.e. economic evaluation to estimate the cost of implementing intervention on a larger scale). Frequent reasons for adaptation included increasing intervention reach, modifying interventions to enhance their appropriateness and fit with the recipient, and increasing the intervention's feasibility and acceptability. Most adaptations were planned and reactive, and the need for modifications was determined by the youths, 4YBY program staff, and advisory group. CONCLUSIONS: Findings suggest that the nature of adaptations made throughout the implementation process reflects the necessity of evaluating services in context while adjusting to specific challenges as they are identified. Further research is needed to understand the effect of these adaptations on the overall intervention effect as well as the quality of youth engagement.

Sustaining HIV Research in Resource-Limited Settings Using PLAN (People, Learning, Adapting, Nurturing): Evidence from the 4 Youth by Youth Project in Nigeria.

PURPOSE OF REVIEW: Sustaining evidence-based interventions in resource-limited settings is a perennial challenge. Despite growing research on the significance of sustainability, few frameworks describe why and how to plan for sustainability in settings limited with resources. Drawing on a synthesis of the literature on sustainability, including the Dynamic Sustainability Framework, we review lessons learned from research to date, to point out a path forward for sustaining evidence-based interventions in resource-limited settings. RECENT FINDINGS: We describe PLAN or why people learning, adapting, and nurturing the core values of an intervention can enhance its sustainability over time. PLAN is a dynamic framework that simplifies the process of planning for sustainability of evidence-based interventions throughout the lifecyle of an intervention, taking into consideration the people that matter as well as the learning, adaptation, and nurturing involved with understanding and studying the interactions between interventions/innovations, practice settings, intervention fit, and the broader ecological contexts in which implementation occurs. We use case-study data from our ongoing pragmatic HIV implementation trial, the 4 Youth by Youth project, to detail the value and implications of why people learning, adapting, and nurturing HIV interventions implemented in resource-limited settings matter. PLAN is designed to further the dialogue on ways research and practice teams can critically work to ensure the sustainability of their evidence-based interventions from the onset, particularly in settings and with populations limited with resources. It also illustrates how attention to sustainability from the beginning may foster actions necessary for sustained program → sustained benefits → sustained capacity → sustained value, but in the absence of early and active planning, none of this will occur. Ultimately, we hope to accelerate the sustainability of evidence-based HIV interventions, and making a PLAN at the bare minimum may ensure that the goals of continuing and maintaining desirable features of any evidence-based interventions can be realized.

Assessing Engagement of Adolescents and Young Adults (AYA) in HIV Research: A Multi-method Analysis of a Crowdsourcing Open Call and Typology of AYA Engagement in Sub-Saharan Africa.

Engagement of adolescents and young adults (AYA) in HIV research is increasing in many settings. We organized a crowdsourcing open call to solicit examples of how AYA have been engaged in HIV research in Africa and to develop an engagement typology. We formed a steering committee, promoted the open call, organized judging and recognized finalists. We used a multi-methods approach to identify emerging themes and measure engagement. We received 95 entries from individuals in 15 countries; 74 met the eligibility criteria. More than three-quarters of entries were from AYA (55/74, 74%). Four themes characterized AYA engagement: (1) AYA were co-creators in the HIV research process. (2) AYA were involved in community-level capacity building. (3) AYA were co-leaders in minor risk research. (4) AYA used digital methods to enhance engagement. Our open call identified diverse methods of AYA engagement, which can enhance strategies used to reach AYA in African HIV studies.

Understanding factors that promote uptake of HIV self-testing among young people in Nigeria: Framing youth narratives using the PEN-3 cultural model.

It is important to understand how to frame the formats for promoting HIV self-testing to increase uptake among young people. In this study, we used a culture-centered model to understand the narratives of HIV self-testing preferences among young people in Nigeria. We conducted a crowdsourcing contest to solicit ideas surrounding HIV self-testing promotion among young people (10-24 years) in Nigeria from October to November 2018 as part of the 2018 World AIDS Day event. We received 903 submissions and employed thematic content analysis to evaluate 769 eligible youth narratives. Thematic content analysis of the statements from the youth narratives was guided by the PEN-3 cultural model to examine the positive, existential, and negative perceptions (beliefs and values), enablers (resources), and nurturers (roles of friends and family) of HIV self-testing promotion among young people in Nigeria. Several themes emerged as factors that influence the uptake of HIV self-testing among young people in Nigeria. Specifically, seven themes emerged as perceptions: HIV testing accessibility, stigma reduction, and autonomy (positive); HIV self-testing kit packaging and advertisements (existential); lack of knowledge and increased stigma (negative). Seven themes emerged as enablers: social media, school, and government promotion (positive); gamification and animation (existential); high cost and access to linkage to care services (negative); And seven themes emerged as nurturers: peer, families, and faith-based communities (positive); parents and family-centered approach (existential); and partners and family (negative). Our data suggests that increased awareness around HIV self-testing on current youth-friendly platforms, de-stigmatization of HIV and HIV self-testing, decreased prices for HIV self-testing kits, reliability of testing kits, increased linkage to care services, and promotion of self-testing among family members and the community will be beneficial for HIV self-testing scale-up measures among young people in Nigeria.