Measuring the performance of computer vision artificial intelligence to interpret images of HIV self-testing results.

Introduction: HIV self-testing (HIVST) is highly sensitive and specific, addresses known barriers to HIV testing (such as stigma), and is recommended by the World Health Organization as a testing option for the delivery of HIV pre-exposure prophylaxis (PrEP). Nevertheless, HIVST remains underutilized as a diagnostic tool in community-based, differentiated HIV service delivery models, possibly due to concerns about result misinterpretation, which could lead to inadvertent onward transmission of HIV, delays in antiretroviral therapy (ART) initiation, and incorrect initiation on PrEP. Ensuring that HIVST results are accurately interpreted for correct clinical decisions will be critical to maximizing HIVST's potential. Early evidence from a few small pilot studies suggests that artificial intelligence (AI) computer vision and machine learning could potentially assist with this task. As part of a broader study that task-shifted HIV testing to a new setting and cadre of healthcare provider (pharmaceutical technologists at private pharmacies) in Kenya, we sought to understand how well AI technology performed at interpreting HIVST results. Methods: At 20 private pharmacies in Kisumu, Kenya, we offered free blood-based HIVST to clients ≥18 years purchasing products indicative of sexual activity (e.g., condoms). Trained pharmacy providers assisted clients with HIVST (as needed), photographed the completed HIVST, and uploaded the photo to a web-based platform. In real time, each self-test was interpreted independently by the (1) client and (2) pharmacy provider, with the HIVST images subsequently interpreted by (3) an AI algorithm (trained on lab-captured images of HIVST results) and (4) an expert panel of three HIVST readers. Using the expert panel's determination as the ground truth, we calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for HIVST result interpretation for the AI algorithm as well as for pharmacy clients and providers, for comparison. Results: From March to June 2022, we screened 1,691 pharmacy clients and enrolled 1,500 in the study. All clients completed HIVST. Among 854 clients whose HIVST images were of sufficient quality to be interpretable by the AI algorithm, 63% (540/854) were female, median age was 26 years (interquartile range: 22-31), and 39% (335/855) reported casual sexual partners. The expert panel identified 94.9% (808/854) of HIVST images as HIV-negative, 5.1% (44/854) as HIV-positive, and 0.2% (2/854) as indeterminant. The AI algorithm demonstrated perfect sensitivity (100%), perfect NPV (100%), and 98.8% specificity, and 81.5% PPV (81.5%) due to seven false-positive results. By comparison, pharmacy clients and providers demonstrated lower sensitivity (93.2% and 97.7% respectively) and NPV (99.6% and 99.9% respectively) but perfect specificity (100%) and perfect PPV (100%). Conclusions: AI computer vision technology shows promise as a tool for providing additional quality assurance of HIV testing, particularly for catching Type II error (false-negative test interpretations) committed by human end-users. We discuss possible use cases for this technology to support differentiated HIV service delivery and identify areas for future research that is needed to assess the potential impacts-both positive and negative-of deploying this technology in real-world HIV service delivery settings.

Cost-effectiveness of dolutegravir vs. efavirenz-based combined antiretroviral therapies in HIV-infected treatment-naive patients in a Nigerian treatment centre.

Background: Dolutegravir (DTG) based antiretroviral therapy (ART) has largely replaced Efavirenz (EFV) based therapy as the preferred first-line regimen in the treatment of adults with HIV. This study was carried out to evaluate the comparative cost-effectiveness of DTG and EFV-based ART in HIV-infected treatment-naïve patients in a treatment centre in Nigeria. Methods: This was a retrospective case-control study of patients initiated on DTG vs. EFV-based regimens from January 2018 to December 2019 at the APIN/HAVARD clinic of Nigeria's Jos University Teaching Hospital. The current viral load result was used to determine treatment effectiveness using a benchmark of ≤200 copies/mL. Sensitivity analysis was carried out to ensure the robustness of the benchmark. The total cost of treatment was obtained by summing up the relevant cost components. Appropriate descriptive and inferential statistics were employed in data analysis using Statistical Product and Services Solutions (SPSS) V.25. The incremental cost-effectiveness ratio of DTG compared to EFV was presented as cost/effectiveness. Results: Treatment was effective in 42(51.9%) and 58(71.6%) patients initiated on DTG and EFV-based regimen, respectively. The incremental cost-effective ratio (ICER) of patients on DTG compared to those on EFV was $10.5076 per effectiveness, which was less than 1% of the Nigerian 2019 per capita Gross Domestic Product. Sensitivity analysis showed the robustness of the result. Conclusion: Efavirenz based regimen had higher treatment effectiveness than DTG-based regimen in treatment-naive patients after initiating treatment in a short term. Compared to EFV, DTG-based regimen is cost-effective in the management of treatment naïve HIV patients.

Interventions to increase mammography screening uptake among women living in low-income and middle-income countries: a systematic review.

OBJECTIVE: To systematically identify interventions that increase the use of mammography screening in women living in low-income and middle-income countries (LMICs). DESIGN: Systematic review. DATA SOURCES: MEDLINE, Embase, Global Health, CINAHL, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials, Google Scholar and African regional databases. ELIGIBILITY CRITERIA: Studies conducted in LMICs, published between 1 January 1990 and 30 June 2021, in the English language. Studies whose population included asymptomatic women eligible for mammography screening. Studies with a reported outcome of using mammography by either self-report or medical records. No restrictions were set on the study design. DATA EXTRACTION AND SYNTHESIS: Screening, data extraction and risk-of-bias assessment were conducted by two independent reviewers. A narrative synthesis of the included studies was conducted. RESULTS: Five studies met the inclusion criteria consisting of two randomised controlled trials, one quasi-experiment and two cross-sectional studies. All included studies employed client-oriented intervention strategies including one-on-one education, group education, mass and small media, reducing client out-of-pocket costs, reducing structural barriers, client reminders and engagement of community health workers (CHWs). Most studies used multicomponent interventions, resulting in increases in the rate of use of mammography than those that employed a single strategy. CONCLUSION: Mass and small media, group education, reduction of economic and structural barriers, client reminders and engagement of CHWs can increase use of mammography among women in LMICs. Promoting the adoption of these interventions should be considered, especially the multicomponent interventions, which were significantly effective relative to a single strategy in increasing use of mammography. PROSPERO REGISTRATION NUMBER: CRD42021269556.

Impact of point-of-care C-reactive protein testing intervention on non-prescription dispensing of antibiotics for respiratory tract infections in private community pharmacies in Nigeria: a cluster randomized controlled trial.

OBJECTIVES: To ascertain if access to C-reactive protein (CRP) test kits-and staff training on how to use them in respiratory tract infection (RTI) management-in private community pharmacies (PCPs) can reduce non-prescription antibiotic dispensing for RTI. METHODS: A parallel cluster randomized controlled trial was conducted in Nigeria. The clusters-which were equally the participating units-were PCPs with blood testing experience. Stratified block randomization was done. PCPs were stratified by the baseline value of the primary outcome. PCPs were not blinded. The intervention PCPs were provided with CRP kits and trained to use them to make decisions regarding non-prescription antibiotic dispensing for RTI. The control PCPs received no intervention. The primary outcome was the non-prescription antibiotic dispensing rate for RTI. Data were collected by blinded simulated clients who visited each PCP 30 times before and after the intervention without prescriptions. Analyses were by intention-to-treat. RESULTS: Twenty PCPs were randomized, 1:1. Ten PCPs were analyzed in each arm. Each PCP contributed 30 data points to the multiple imputation analysis where antibiotic dispensing decreased by 15.66% (209/300 [intervention] vs 256/300 [control]) in the adjusted analysis (odds ratio = 0·279, 95% confidence interval = 0.107-0.726; P-value = 0.0090) and 16% (208/300 [intervention] vs 256/300 [control]) in the crude analysis (odds ratio = 0.299, 95% confidence interval = 0.098-0.911; P-value = 0.034). CONCLUSION: Access to CRP kits-and staff training on how to use them in RTI management-in PCPs reduced non-prescription antibiotic dispensing for RTI.

Dipstick urinalysis profile of an asymptomatic female group in south-east Nigeria.

Objectives: Routine dipstick urinalysis is a useful and inexpensive method for the early detection of asymptomatic diseases. Our study was carried out to detect the prevalence of urinary abnormalities among an apparently asymptomatic healthy female group and emphasize the value of routine dipstick urinalysis. Methods: A cross-sectional study was carried out among second to sixth (final)-year female medical students of Nnamdi Azikiwe University, Nnewi campus between 8 and 30 September 2019. A total of 100 subjects were enrolled. First-morning midstream urine samples were collected and promptly tested with dipstick strips. Subjects with abnormal findings were informed and treated appropriately. Results: In all, 54 (54%) of the subjects had urine abnormalities. Trace proteinuria was the commonest abnormality seen with a prevalence of 33%, followed by abnormal urine appearance (17%), leucocytes (14%), nitrites (8%) and urobilinogen (2%). Urine abnormalities were commoner in students who resided in the school hostel. Abnormal urine appearance was significantly associated with nitrites (0.003) and leucocytes (0.001). Conclusion: Routine dipstick urinalysis should be performed among students and apparently healthy individuals for early detection and diagnosis of renal diseases to facilitate quick interventions and prevent further progression.

Impact of conditional economic incentives and motivational interviewing on health outcomes of adolescents living with HIV in Anambra State, Nigeria: A cluster-randomised trial.

Background: Adolescents living with HIV (ALHIV) have had worse outcomes compared to adults. They face enormous difficulty in accessing HIV care services. We hypothesize that conditional economic incentives (CEI) and motivational interviewing could increase retention in care, medication adherence and ultimately viral load suppression. Therefore, we evaluated the one-year impact of conditional economic incentives and motivational interviewing on the health outcomes of ALHIV in Anambra State, Nigeria. Methods: Using a cluster-randomised design, we examined the one-year (from December 1, 2018, to November 30, 2019), individual-level impact of an Incentive Scheme comprising conditional economic incentives and motivational interviewing on achieving undetectable viral load (primary outcome), CD4+ count, adherence to antiretroviral therapy and retention in care (secondary outcomes) by ALHIV in Anambra State, Nigeria. Twelve HIV treatment hospitals were stratified according to the type of clinic (secondary or tertiary) and randomly assigned to the intervention arm or control arm to receive the Incentive Scheme or routine care, respectively. ALHIV aged 10-19 years, initiated into HIV care for a minimum of 6 months, and who adhered poorly to medications (<100% adherence rate) were eligible for the study. Participants in the intervention arm received motivational interviewing at the study baseline and every visit. They also received US$5.6 when HIV viral load (VL) was <20 copies/mL at month 3, US$2.8 if the VL remained suppressed at months 6 and 9, and US$5.6 if the VL remained <20 copies/mL at month 12. Results: Of the 246 trial participants, 119 were in the intervention while 127 were in the control arm. There was no difference in the baseline characteristics of the participants between the intervention and control arm except for the number of participants with undetectable viral load and the number of participants with ≥95% adherence. Although participants in the intervention arm had a 10.1% increase while those in the control arm had a 1.6% decrease in proportion with undetectable viral load (≤20 copies/ml) after 12 months, the change in the primary outcome was not statistically significant. Similarly, the differences in the secondary outcomes were not statistically significant. Conclusion: The Incentive Scheme did not improve the virologic outcome of ALHIV after 12 months. Differences in the secondary outcomes after 12 months were also not significantly different from the baseline. Trial registration: We registered the trial retrospectively with The Pan African Clinical Trials Registry: https://pactr.samrc.ac.za/(PACTR201806003040425) on 2/2/2018.

Description of global innovative methods in developing the WHO Community Engagement Package.

OBJECTIVES: Development of a Community Engagement Package composed of (1) database of community engagement (CE) experiences from different contexts, (2) CE learning package of lessons and tools presented as online modules, and (3) CE workshop package for identifying CE experiences to enrich the CE database and ensure regular update of learning resources. The package aims to guide practitioners to promote local action and enhance skills for CE. SETTING AND PARTICIPANTS: The packages were co-created with diverse teams from WHO, Social Innovation in Health Initiative, UNICEF, community practitioners, and other partners providing synergistic contributions and bridging existing silos. METHODS: The design process of the package was anchored on CE principles. Literature search was performed using standardised search terms through global and regional databases. Interviews with CE practitioners were also conducted. RESULTS: A total of 356 cases were found to fit the inclusion criteria and proceeded to data extraction and thematic analysis. Themes were organised according to rationale, key points and insights, facilitators of CE and barriers to CE. Principles and standards of CE in various contexts served as a foundation for the CE learning package. The package comprises four modules organised by major themes such as mobilising communities, strengthening health systems, CE in health emergencies and CE as a driver for health equity. CONCLUSION: After pilot implementation, tools and resources were made available for training and continuous collection of novel CE lessons and experiences from diverse socio-geographical contexts.

Interventions to increase mammography screening uptake among women living in low-income and middle-income countries: a protocol for a systematic review.

INTRODUCTION: Breast cancer is the most prevalent cancer and the second leading cause of cancer-related deaths among women in low and middle-income countries (LMICs), including sub-Saharan Africa. Mammography screening is the most effective screening method for the early detection of breast cancers in asymptomatic individuals and the only screening test that decreases the risk of breast cancer mortality. Despite the perceived benefits, it has a low utilisation rate in comparison with breast self-examination and clinical breast examination. Several interventions to increase the uptake of mammography have been assessed as well as systematic reviews on mammography uptake. Nonetheless, none of the published systematic reviews focused on women living in LMICs. The review aims to identify interventions that increase mammography screening uptake among women living in LMICs. METHODS AND ANALYSIS: Relevant electronic databases will be systematically searched from 1 January 1990 to 30 June 2021 for published and grey literature, including citation and reference list tracking, on studies focusing on interventions to increase mammography screening uptake carried out in LMICs and written in the English language. The search will incorporate the key terms: mammography, interventions, low- and middle-income countries and their associated synonyms. Randomised controlled trials, observational studies and qualitative and mixed methods studies of interventions (carried out with and without comparison groups) reporting interventions to increase mammography screening uptake in LMICs will be identified, data extracted and assessed for methodological quality by two independent reviewers with disagreements to be resolved by consensus or by a third author. We will use narrative synthesis and/or meta-analysis depending on the characteristics of the data. ETHICS AND DISSEMINATION: Ethical approval is not required as it is a protocol for a systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021269556.

Interventions to increase the uptake and continuation of pre-exposure prophylaxis (PrEP) by adolescent girls and young women at high risk of HIV in low-income and middle-income countries: a scoping review.

INTRODUCTION: Effective strategies to increase pre-exposure prophylaxis (PrEP) uptake and continuation among adolescent girls and young women (AGYW) who engage in sex work or transactional sex are sparsely reported. We aimed to describe the available evidence on strategies for improving the uptake and continuation of PrEP among AGYW who engage in sex work or transactional sex, or otherwise are at high risk of acquiring HIV, and report their implementation outcomes. METHOD: PubMed, Embase, CINAHL and Global Health were searched for studies describing strategies to increase uptake and continuation of PrEP for HIV prevention among AGYW at high risk of acquiring HIV in low-income and middle-income countries. Two independent reviewers screened citations for inclusion and performed data abstraction. Proctor's framework was used to report the implementation outcomes of the interventions. RESULT: We identified 1046 citations, and reviewed 69 full-text documents, of which we included 11 in the scoping review. A social marketing campaign was used in one study to create demand for PrEP. A decision support tool was used in one study to improve PrEP initiation. SMS reminders (two studies), drug-level feedback (two studies), peer group support (one study) and conditional economic incentives (one study) were used to improve PrEP continuation. Five studies reported adoption outcomes, two of which were high. Four studies reported sustainability outcomes; these were low or moderate. One study found private youth-friendly clinics a better fit for AGYW PrEP delivery compared with public hospitals, and prescription of PrEP by non-study staff in the hospital facility was low. CONCLUSION: Multiple promising interventions have been used to deliver PrEP to AGYW at high risk of acquiring HIV; however, more information is needed to understand how these interventions would likely perform at scale outside of a research context.

Cost-effectiveness and feasibility of conditional economic incentives and motivational interviewing to improve HIV health outcomes of adolescents living with HIV in Anambra State, Nigeria.

BACKGROUND: In sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). This is a result of limited adolescent-centred service delivery interventions. This cost-effectiveness and feasibility study were piggybacked on a cluster-randomized trial that assessed the impact of an adolescent-centred service delivery intervention. The service delivery intervention examined the impact of an incentive scheme consisting of conditional economic incentives and motivational interviewing on the health outcomes of adolescents living with HIV in Nigeria. METHOD: A cost-effectiveness analysis from the healthcare provider's perspective was performed to assess the cost per additional patient achieving undetected viral load through the proposed intervention. The cost-effectiveness of the incentive scheme over routine care was estimated using the incremental cost-effectiveness ratio (ICER), expressed as cost/patient who achieved an undetectable viral load. We performed a univariate sensitivity analysis to examine the effect of key parameters on the ICER. An in-depth interview was conducted on the healthcare personnel in the intervention arm to explore the feasibility of implementing the service delivery intervention in HIV treatment hospitals in Nigeria. RESULT: The ICER of the Incentive Scheme intervention compared to routine care was US$1419 per additional patient with undetectable viral load. Going by the cost-effectiveness threshold of US$1137 per quality-adjusted life-years suggested by Woods et al., 2016, the intervention was not cost-effective. The sensitivity test showed that the intervention will be cost-effective if the frequency of CD4 count and viral load tests are reduced from quarterly to triannually. Healthcare professionals reported that patients' acceptance of the intervention was very high. CONCLUSION: The conditional economic incentives and motivational interviewing was not cost-effective, but can become cost-effective if the frequency of HIV quality of life indicator tests are performed 1-3 times per annum. Patients' acceptance of the intervention was very high. However, healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed. TRIAL REGISTRATION: This trial is registered in the WHO International Clinical Trials Registry through the WHO International Registry Network ( PACTR201806003040425 ).

Introducing rotavirus vaccine in eight sub-Saharan African countries: a cost-benefit analysis.

BACKGROUND: Stimulated by the economic challenges faced by many sub-Saharan African countries and the changes in the rotavirus burden across these countries, this study aimed to inform the decision of health policy makers of eight sub-Saharan countries, who are yet to introduce the rotavirus vaccine as of Dec 31, 2020, on the health economic consequences of the introduction of the vaccine in terms of the costs and benefits. METHODS: We did a cost-benefit analysis using a simulation-based decision-analytic model for children aged younger than 1 year, who were followed up to 259 weeks, in the Central African Republic, Chad, Comoros, Equatorial Guinea, Gabon, Guinea, Somalia, and South Sudan. Data were collected and analysed between Jan 13, 2020, and Dec 11, 2020. Cost-effectiveness analysis and budget impact analysis were done as secondary analyses. Four rotavirus vaccinations (Rotarix, Rotateq, Rotavac, and Rotasiil) were compared with no vaccination. The primary outcome was disability-adjusted life-years averted, converted to monetary terms. The secondary outcomes include rotavirus gastroenteritis averted, and rotavirus vaccine-associated intussusception. The primary economic evaluation measure was the benefit-cost ratio (BCR). FINDINGS: For the modelling period, Jan 1, 2021, to Dec 31, 2030, we found that the benefits of introducing the rotavirus vaccine outweighed the costs in all eight countries, with Chad and the Central African Republic having the highest BCR of 19·42 and 11·36, respectively. Guinea had the lowest BCR of 3·26 amongst the Gavi-eligible countries. Equatorial Guinea and Gabon had a narrow BCR of 1·86 and 2·06, respectively. Rotarix was the optimal choice for all the Gavi-eligible countries; Rotasiil and Rotavac were the optimal choices for Equatorial Guinea and Gabon, respectively. INTERPRETATION: Introducing the rotavirus vaccine in all eight countries, but with caution in Equatorial Guinea and Gabon, would be worthwhile. With the narrow BCR for Equatorial Guinea and Gabon, cautious, pragmatic, and stringent measures need to be employed to ensure optimal health benefits and cost minimisation of the vaccine introduction. The final decision to introduce the rotavirus vaccine should be preceded by comparing its BCR to the BCRs of other health-care projects. FUNDING: Copenhagen Consensus Center and the Bill & Melinda Gates Foundation.

A systematic review of qualitative research on barriers and facilitators to exclusive breastfeeding practice in sub-Saharan African countries.

BACKGROUND: Studies reporting factors associated with exclusive breastfeeding are mostly quantitative. No study has performed a systematic qualitative summary to document the recurring constraints and facilitators to exclusive breastfeeding in sub-Saharan African countries from breastfeeding mothers' perspective. This study systematically reviews the literature reporting barriers and facilitators to exclusive breastfeeding from the breastfeeding mothers' perspective in sub-Saharan Africa to develop an educational intervention to optimize exclusive breastfeeding. METHODS: A systematic literature review of qualitative studies such as phenomenological studies, followed by a risk of bias and methodological assessment of the included studies' quality using the Critical Appraisal Skills Programme (CASP) tool was conducted. MEDLINE and Google Scholar were searched from January 1990 to October 2019 to retrieve studies of breastfeeding mothers who had infants aged between 0 and 12 months. Two authors independently carried out the review process and resolved disagreements through consensus. We analyzed the data thematically. RESULTS: After reviewing 92 studies, 20 studies involving 836 participants from 11 countries were eligible. Of the 72 studies excluded, 39 were not conducted in sub-Saharan Africa, and 33 included other participants such as fathers. Three themes emerged as barriers to exclusive breastfeeding (EBF) and five additional themes were identified with facilitators of maternal-infant factors being the most significant in both cases. Maternal employment and knowledge of the benefits of EBF were the most common maternal-infant factors that served as a barrier and a facilitator, respectively. The study's limitations were that the review involved only primary research among breastfeeding mothers living in sub-Saharan Africa and excluded studies not available in the English language. The information synthesized from this review could be used to develop communication strategies employed during individual and group patient education in the hospitals to improve breastfeeding mothers' understanding, acceptance, and practice of exclusive breastfeeding. This review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42020133761. CONCLUSIONS: This review found that maternal-infant factors have the most significant influence over the practice of exclusive breastfeeding. Therefore, interventions targeted towards maternal-infant factors will improve and optimize exclusive breastfeeding significantly and, ultimately, improve maternal-child health outcomes.

Promoting the integrated community case management of pneumonia in children under 5 years in Nigeria through the proprietary and patent medicine vendors: a cost-effectiveness analysis.

BACKGROUND: While evidence-based recommendations for the management pneumonia in under-5-year-olds at the community level with amoxicillin dispersible tablets (DT) were made by the World Health Organisation, initiatives to promote the integrated community case management (iCCM) of pneumonia through the proprietary and patent medicine vendors (PPMVs) have been poorly utilized in Nigeria, possibly due to low financial support and perceived benefit. This study provides costs, benefits and cost-effectiveness estimates and implications of promoting the iCCM through the PPMVs' education and support. The outcome of this study will help inform healthcare decisions in Nigeria. METHODS: This study was a cost-effectiveness analysis using a simulation-based Markov model. Two approaches were compared, the 'no promotion' and the 'promotion' scenarios. The health outcomes include disability-adjusted life years averted and severe pneumonia hospitalisation cost averted. The costs were expressed in 2019 US dollars. RESULTS: The promotion of iCCM through the PPMVs was very cost effective with an incremental cost-effectiveness ratio of US$143.77 (95% CI US$137.42-150.50)/DALY averted. The promotion will prevent 28,359 cases of severe pneumonia hospitalisation with an estimated healthcare cost of US$390,578. It will also avert 900 deaths in a year. CONCLUSION: Promoting the iCCM for the treatment of pneumonia in children under 5 years through education and support of the PPMVs holds promise to harness the benefits of amoxicillin DT and provide a high return on investment. A nationwide promotion exercise should be considered especially in remote areas of the country.

Effects of nutritional supplements on the re-infection rate of soil-transmitted helminths in school-age children: A systematic review and meta-analysis.

BACKGROUND: The effect of nutritional supplements on the re-infection rate of species-specific soil-transmitted helminth infections in school-aged children remains complex and available evidence on the subject matter has not been synthesized. METHODS: The review included randomised controlled trials (RCTs) and cluster RCTs investigating food supplements on school-aged children between the age of 4-17 years. A search for RCTs was conducted on eight databases from inception to 12th June 2019. Cochrane Risk of Bias tool was used to assess the risk of bias in all included studies. Meta-analysis and narrative synthesis were conducted to describe and analyze the results of the review. Outcomes were summarized using the mean difference or standardized mean difference where appropriate. RESULTS: The search produced 1,816 records. Six studies met the inclusion criteria (five individually RCTs and one cluster RCT). Four studies reported data on all three STH species, while one study only reported data on Ascaris lumbricoides infections and the last study reported data on only hookworm infections. Overall, the risk of bias in four individual studies was low across most domains. Nutritional supplementation failed to statistically reduce the re-infection rates of the three STH species. The effect of nutritional supplements on measures of physical wellbeing in school-aged children could not be determined. CONCLUSIONS: The findings from this systematic review suggest that nutritional supplements for treatment of STH in children should not be encouraged unless better evidence emerges. Conclusion of earlier reviews on general populations may not necessarily apply to children since children possibly have a higher re-infection rate.

Satisfaction of Nigerian patients with health services: a protocol for a systematic review.

BACKGROUND: Patient-based assessment of health services is becoming popular in measuring the standard of care. Both quantitative and qualitative methods are available. Patient satisfaction surveys are commonly used to record the experiences of patients in hospitals, whereas qualitative designs (e.g., interviews and focus group discussions) are used less frequently. To date, there has been no systematic review published devoted to patient satisfaction with health services in Nigeria. We aim to (1) systematically analyze relevant quantitative studies to pinpoint excellent procedures in measuring patient satisfaction with health services, (2) to investigate if a reference method (gold standard method) exists, and (3) to identify relevant topics which are recognized by patients as important for the delivery of a high-quality health service in Nigeria. METHODS: Searches of eight electronic journal databases, including MEDLINE, EMBASE, CINAHL, PsycINFO, AJOL, CDSR, DARE, and HTA will be conducted to identify studies assessing patient satisfaction with health services in Nigeria. The searches will be supported by manual searches in reference lists of relevant primary studies and systematic reviews. The review will be limited to studies published since 2007. After a stepwise screening process by two reviewers, data from included studies will be extracted and reviewed. The COSMIN RoB checklist will be used to critically appraise included studies. We will carry out an extensive data synthesis to answer the review questions. DISCUSSION: The intended systematic review will provide information on how the satisfaction of patients with health services has earlier been described and assessed in Nigerian studies. It will establish if a gold standard method exists and synthesize information on topics which might be of special interest to patients. Review findings will enrich the debate on patient-centered care and overall performance of health quality standards in Nigeria. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018108140.

Systematic reviews as a "lens of evidence": Determinants of cost-effectiveness of breast cancer screening.

Systematic reviews with economic components are important decision tools for stakeholders seeking to evaluate technologies, such as breast cancer screening (BCS) programs. This overview of systematic reviews explores the determinants of the cost-effectiveness of BCS and assesses the quality of secondary evidence. The search identified 30 systematic reviews that reported on the determinants of the cost-effectiveness of BCS, including the costs of breast cancer and BCS. While the quality of the reviews varied widely, only four out of 30 papers were considered to be of a high quality. We did not identify publication bias in the original evidence on the cost-effectiveness of mammography screening; however, we highlight a need for improved clarity in both reporting and data verification. The reviews consisted mainly of studies from high-income countries. Breast cancer costs varied widely among the studies. Factors leading to higher costs included: time (diagnosis and last months before death), later stage or metastases, recurrence of the disease, age below 64 years and type of follow-up (more intensive or more specialized). Overall, screening with mammography was considered cost-effective in the age range 50-69 years in Western European and Northern American countries but not for older or younger women. Its cost-effectiveness was questionable for low-income settings and Asia. Mammography screening was more cost-effective with biennial screening compared to annual screening and single reading using computer-aided detection vs double reading. No information on the cost-effectiveness of ultrasonography was found, and there is much uncertainty on the cost-effectiveness of CBE because of methodological limitations.

Conditional economic incentives and motivational interviewing to improve adolescents' retention in HIV care and adherence to antiretroviral therapy in Southeast Nigeria: study protocol for a cluster randomised trial.

BACKGROUND: Adolescent HIV patients face enormous difficulty in accessing HIV care services. Given their vulnerability to risk-taking behaviour, this group also have worse treatment outcomes compared to other age groups. Poor treatment outcomes will impact negatively on HIV/AIDS management and control particularly in sub-Saharan Africa (SSA) as more than eight out of ten of the world's HIV-infected adolescents live in this region of the world. Limited evidence exists on the effectiveness of service delivery interventions to support adolescents' retention on antiretroviral therapy (ART) and adherence to ART. This trial is designed to evaluate the impact of conditional economic incentive and motivational interviewing on adolescents' retention in HIV care and adherence to ART in Anambra State, Southeast Nigeria. METHODS/DESIGN: The study will be a cluster randomised controlled trial that will be conducted in selected HIV treatment hospitals in Anambra State, Nigeria. Based on sample size calculation, 12 HIV treatment hospitals from Anambra will be selected for the study. Six HIV treatment hospitals each will be randomised to either the intervention or the control arm. A structured adherence support scheme termed the 'Incentive Scheme' will be applied to the intervention arm while the control arm will receive routine HIV care (usual care). Additionally, patients in the intervention arm will receive motivational interviewing at baseline and following initiation of antiretroviral therapy (ART), they will receive a gift voucher of US$5.6 when HIV viral load (VL) is < 20 copies/mL at 12 weeks, a gift voucher of US$2.8 if the VL remains suppressed for the next 3 months, and the next 6 months, and finally a gift voucher of US$5.6 if the VL remains < 20 copies/mL at 1 year. All gift vouchers will be conditional not only on VL results but attending the motivational interviews. The primary outcome for the trial will be the difference between groups in the proportion with HIV VL suppression (≤ 20 copies/mL) by 12 months and then 24 months after withdrawal of incentive. DISCUSSION: The findings of this proposed trial will provide evidence on the feasibility of applying conditional economic incentives combined with motivational interviewing to improve retention and adherence to antiretroviral therapy of adolescents living with HIV in Nigeria and possibly in other sub-Saharan African countries. TRIAL REGISTRATION: Registered in the Pan African Clinical Trials Registry, ID: PACTR201806003040425 . Registered on 2 February 2018.

Cost-effectiveness analysis of diarrhoea management approaches in Nigeria: A decision analytical model.

BACKGROUND: Diarrhoea is a leading cause of death in Nigerian children under 5 years. Implementing the most cost-effective approach to diarrhoea management in Nigeria will help optimize health care resources allocation. This study evaluated the cost-effectiveness of various approaches to diarrhoea management namely: the 'no treatment' approach (NT); the preventive approach with rotavirus vaccine; the integrated management of childhood illness for diarrhoea approach (IMCI); and rotavirus vaccine plus integrated management of childhood illness for diarrhoea approach (rotavirus vaccine + IMCI). METHODS: Markov cohort model conducted from the payer's perspective was used to calculate the cost-effectiveness of the four interventions. The markov model simulated a life cycle of 260 weeks for 33 million children under five years at risk of having diarrhoea (well state). Disability adjusted life years (DALYs) averted was used to quantify clinical outcome. Incremental cost-effectiveness ratio (ICER) served as measure of cost-effectiveness. RESULTS: Based on cost-effectiveness threshold of $2,177.99 (i.e. representing Nigerian GDP/capita), all the approaches were very cost-effective but rotavirus vaccine approach was dominated. While IMCI has the lowest ICER of $4.6/DALY averted, the addition of rotavirus vaccine was cost-effective with an ICER of $80.1/DALY averted. Rotavirus vaccine alone was less efficient in optimizing health care resource allocation. CONCLUSION: Rotavirus vaccine + IMCI approach was the most cost-effective approach to childhood diarrhoea management. Its awareness and practice should be promoted in Nigeria. Addition of rotavirus vaccine should be considered for inclusion in the national programme of immunization. Although our findings suggest that addition of rotavirus vaccine to IMCI for diarrhoea is cost-effective, there may be need for further vaccine demonstration studies or real life studies to establish the cost-effectiveness of the vaccine in Nigeria.

Cost-effectiveness of Human Papilloma Virus (HPV) vaccination in Nigeria: a decision analysis using pragmatic parameter estimates for cost and programme coverage.

BACKGROUND: World Health Organisation recommends routine Human Papilloma Virus (HPV) vaccination for girls when its cost-effectiveness in the country or region has been duly considered. We therefore aimed to evaluate cost-effectiveness of HPV vaccination in Nigeria using pragmatic parameter estimates for cost and programme coverage, i.e. realistically achievable in the studied context. METHODS: A microsimulation frame-work was used. The natural history for cervical cancer disease was remodelled from a previous Nigerian model-based study. Costing was based on health providers' perspective. Disability adjusted life years attributable to cervical cancer mortality served as benefit estimate. Suitable policy option was obtained by calculating the incremental costs-effectiveness ratio. Probabilistic sensitivity analysis was used to assess parameter uncertainty. One-way sensitivity analysis was used to explore the robustness of the policy recommendation to key parameters alteration. Expected value of perfect information (EVPI) was calculated to determine the expected opportunity cost associated with choosing the optimal scenario or strategy at the maximum cost-effectiveness threshold. RESULTS: Combination of the current scenario of opportunistic screening and national HPV vaccination programme (CS + NV) was the only cost-effective and robust policy option. However, CS + NV scenario was only cost-effective so far the unit cost of HPV vaccine did not exceed $5. EVPI analysis showed that it may be worthwhile to conduct additional research to inform the decision to adopt CS + NV. CONCLUSIONS: National HPV vaccination combined with opportunist cervical cancer screening is cost-effective in Nigeria. However, adoption of this strategy should depend on its relative efficiency when compared to other competing new vaccines and health interventions.

Cost benefit of investment on quality in pharmaceutical manufacturing: WHO GMP pre- and post-certification of a Nigerian pharmaceutical manufacturer.

BACKGROUND: Pharmaceutical companies in Africa need to invest in both facilities and quality management systems to achieve good manufacturing practice (GMP) compliance. Compliance to international GMP standards is important to the attainment of World Health Organization (WHO) prequalification. However, most of the local pharmaceutical manufacturing companies may be deterred from investing in quality because of many reasons, ranging from financial constraints to technical capacity. This paper primarily evaluates benefits against the cost of investing in GMP, using a Nigerian pharmaceutical company, Chi Pharmaceuticals Limited, as a case study. This paper also discusses how to drive more local manufacturers to invest in quality to attain GMP compliance; and proffers practical recommendations for local manufacturers who would want to invest in quality to meet ethical and regulatory obligations. METHOD: The cost benefit of improving the quality of Chi Pharmaceuticals Limited's facilities and system to attain WHO GMP certification for the production of zinc sulfate 20-mg dispersible tablets was calculated by dividing the annual benefits derived from quality improvement interventions by the annual costs of implementing quality improvement interventions, referred to as a benefit-cost ratio (BCR). RESULT: Cost benefit of obtaining WHO GMP certification for the production of zinc sulfate 20-mg dispersible tablets was 5.3 (95% confidence interval of 5.0-5.5). CONCLUSION: Investment in quality improvement intervention is cost-beneficial for local manufacturing companies. Governments and regulators in African countries should support pharmaceutical companies striving to invest in quality. Collaboration of local manufacturing companies with global companies will further improve quality. Local pharmaceutical companies should be encouraged to key into development opportunities available for pharmaceutical companies in Africa.