Estimating prevalence and modelling correlates of HIV test positivity among female sex workers, men who have sex with men, people who inject drugs, transgender people and prison inmates in Sierra Leone, 2021.

Key populations (KPs) are particularly vulnerable to HIV infection and efforts to prevent HIV infections among KPs have been less successful, largely due to existing laws and legislation that classify the groups as illegal. Understanding the HIV infection pathway and the burden of HIV infection among Female Sex Workers (FSWs), Transgender people (TG), Men who have sex with Men (MSM), People who Inject Drugs (PWID), and Prison Inmates (PIs) is critical to combatting the HIV epidemic globally. This study aims to estimate HIV prevalence and model the risk factors of HIV positivity rate among the aforementioned KPs in Sierra Leone. This study used Time Location Sampling, Respondent Driven Sampling (RDS), and Conventional cluster Sampling designs to generate a representative sample of FSWs, MSM, TG, PI, and PWID. HIV prevalence and the corresponding 95% confidence intervals among each KP were estimated by adjusting for sampling weight using the logit-transformed confidence intervals. To determine correlates of HIV test positivity among KPs, a multivariable modified Poisson regression model that adjusts for RDS survey weights was used and sensitivity analysis was conducted using a multivariable logistic regression model with cluster robust standard errors. The prevalence of HIV among FSWs in the six regional headquarter towns was estimated to be 11.8% (95% CI: 7.9-17.1); MSM was 3.4% [95% CI: 1.9-5.8]; TGs was 4.2% (95% CI: 2.9-6.1); PWIDs was 4.2% (95% CI: 2.7-6.4) and PI was 3.7% (95% CI: 1.4-9.6). The correlates of HIV test positivity among KPs and PIs include HIV-related knowledge, marital status, district, income, age and sex of KP, level of education, alcohol intake, injecting drugs, and use of lubricants. HIV prevalence is relatively high among FSWs, MSMs, PWID, and TGs as compared to the previous estimate of the general population. There is a need to scale up and strengthen evidence-based HIV prevention interventions such Pre-Exposure Prophylaxis and needle and syringe exchange programmes targeting KPs, including prison inmates. Government must scale up both non-clinical and clinical routine HIV and STI testing and counseling services at the correctional center and drop-in centers for KPs screening/testing, and ensure that services are responsive to the needs of KP.

Optimising scale and deployment of community health workers in Sierra Leone: a geospatial analysis.

BACKGROUND: Little is known about strategies for optimising the scale and deployment of community health workers (CHWs) to maximise geographic accessibility of primary healthcare services. METHODS: We used data from a national georeferenced census of CHWs and other spatial datasets in Sierra Leone to undertake a geospatial analysis exploring optimisation of the scale and deployment of CHWs, with the aim of informing implementation of current CHW policy and future plans of the Ministry of Health and Sanitation. RESULTS: The per cent of the population within 30 min walking to the nearest CHW with preservice training increased from 16.1% to 80.4% between 2000 and 2015. Contrary to current national policy, most of this increase occurred in areas within 3 km of a health facility where nearly two-thirds (64.5%) of CHWs were deployed. Ministry of Health and Sanitation-defined 'easy-to-reach' and 'hard-to-reach' areas, geographic areas that should be targeted for CHW deployment, were less well covered, with 19.2% and 34.6% of the population in 2015 beyond a 30 min walk to a CHW, respectively. Optimised CHW networks in these areas were more efficiently deployed than existing networks by 22.4%-71.9%, depending on targeting metric. INTERPRETATIONS: Our analysis supports the Ministry of Health and Sanitation plan to rightsize and retarget the CHW workforce. Other countries in sub-Saharan Africa interested in optimising the scale and deployment of their CHW workforce in the context of broader human resources for health and health sector planning may look to Sierra Leone as an exemplar model from which to learn.

Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone.

BACKGROUND: The role of community health workers (CHWs) in the West Africa Ebola outbreak has been highlighted to advocate for increasing numbers of CHWs globally to build resilience, strengthen health systems, and provide emergency response capacity. However, the roles CHWs played, the challenges they faced, and their effectiveness during the outbreak are not well documented. This study assessed the impact of Ebola on community-based maternal, newborn, and child health (MNCH) services, documented the contribution of CHWs and other community-based actors to the Ebola response, and identified lessons learned to strengthen resilience in future emergencies. METHODS: This mixed methods study was conducted in Guinea, Liberia, and Sierra Leone, with data collected in four Ebola-affected districts of each country. Qualitative data were collected through in-depth interviews and focus group discussions with stakeholders at national, district, and community levels. Quantitative program data were used to assess trends in delivery of community-based MNCH services. RESULTS: There was a sharp decline in MNCH service provision due to weak service delivery, confusion over policy, and the overwhelming nature of the outbreak. However, many CHWs remained active in their communities and were willing to continue providing services. When CHWs received clear directives and were supported, service provision rebounded. Although CHWs faced mistrust and hostility from community members because of their linkages to health facilities, the relationship between CHWs and communities proved resilient over time, and CHWs were more effectively able to carry out Ebola-related activities than outsiders. Traditional birth attendants, community health committees, community leaders, and traditional healers also played important roles, despite a lack of formal engagement or support. Service delivery weaknesses, especially related to supply chain and supervision, limited the effectiveness of community health services before, during, and after the outbreak. CONCLUSIONS: CHWs and other community-level actors played important roles during the Ebola outbreak. However, maintenance of primary care services and the Ebola response were hampered because community actors were engaged late in the response and did not receive sufficient support. In the future, communities should be placed at the forefront of emergency preparedness and response plans and they must be adequately supported to strengthen service delivery.

Integrating Vitamin A Supplementation at 6 months into the Expanded Program of Immunization in Sierra Leone.

Since 2004, twice-yearly mass vitamin A supplementation (VAS) has equitably reached over 85% of children 6-59 months old in Sierra Leone. However infants who turn 6 months after the event may wait until they are 11 months old to receive their first dose. The effectiveness of integrating VAS at 6 months into the Expanded Program of Immunization (EPI) in a revised child health card was studied. Health facilities matched according to staff cadre and work load were assigned to provide either a 'mini package' of VAS and infant and young child feeding (IYCF), a 'full package' of VAS, IYCF and family planning (FP), or 'child health card' only. 400 neonates were enrolled into each group, caregivers given the new child health card and followed until they were 12 months old. More infants in the full: 74.5% and mini: 71.7% group received VAS between 6 and 7 months of age compared with the new CH card only group: 60.2% (p = 0.002, p < 0.001 respectively). FP commodities were provided to 44.5% of caregivers in the full compared with <2.5% in the mini and new child health card only groups (p < 0.0001). Integration of VAS within the EPI schedule achieved >60% coverage for infants between 6 and 7 months of age. Provision of FP and/or IYCF further improved coverage. Funding was provided by the Canadian Department of Foreign Affairs, Trade and Development who had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.