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Abstract Background Poor medication adherence is a major barrier to HIV control among youth living with HIV (Y-PLWH). The PEERNaija application (app) is an adapted smartphone app grounded in social cognitive and contigency management theories and designed to harness peer-based social incentives and conditional financial incentives to promote medication adherence. The app delivers a multifaceted medication adherence intervention including (1) peer-based social incentives, (2) financial incentives, (3) virtual peer social support, and (4) early clinic-based outreach for non-adherent Y-PLWH. A pilot trial of the app will be conducted in Nigeria, Africa’s most populous country with the 4th largest HIV epidemic, and home to 10% of the world’s four million Y-PLWH. Methods In this randomized controlled trial, we will compare implementation outcomes (feasibility, acceptability, appropriateness measured via validated scales, enrollment and application installation rates, feedback surveys and focus group discussions with participants, and back-end application data), and preliminary efficacy (in improving medication adherence and viral suppression) of the PEERNaija app at 6 months. Participants in Arm 1 (PEERNaija) will receive daily medication reminders, peer-based social incentives, and virtual peer social support. Participants in Arm 2 (PEERNaija +) will additionally receive a conditional financial incentive based on their adherence performance. Eligibility for Y-PLWH includes (1) being aged 14–29 years, (2) being on ART, (3) owning a smartphone, (4) being willing to download an app, and (5) being able to read simple text in English. Discussion This study will serve as the basis for a larger intervention trial evaluating the PEERNaija app (and the integration of mHealth, incentive, and peer-support-based strategies) to improve HIV outcomes in a critically important region of the world for Y-PLWH. Trial registration ClinicalTrials.gov. NCT04930198. First submitted date: May 25, 2021. Study start: August 1, 2021, https://clinicaltrials.gov/ . Protocol version: January 21, 2022.

HIV self-testing (HIVST) holds promise for accessing hard-to-reach populations by overcoming sociocultural and structural barriers to awareness of HIV status. This phenomenological qualitative study explored the experiences and perspectives of married men in Kano, northern Nigeria, regarding HIV testing and counseling (HTC) and HIVST. Twenty married men from diverse socioeconomic backgrounds participated in in-depth interviews conducted in the local language. Thematic analysis was employed to analyze the data, yielding key themes related to prior test experiences, knowledge of self-testing, and perceived ease of use, in addition to motivation for self-testing and concerns about reliability and counseling support. The findings shed light on the impact of facility-based HIV testing experiences on the perspectives of participants. Concerns related to delays, overcrowding, discomfort, fear, and unsupportive attitudes from healthcare providers influenced their perceptions. Among persons with previous self-testing experience, initial uneasiness was overcome with repeated use, highlighting the ease of use associated with HIVST. Motivations for self-testing included privacy, convenience, personal empowerment, improved infection detection, and efficiency. Concerns were raised regarding the reliability of self-testing results compared to hospital-based testing, and the absence of counseling support during self-testing. Our findings underscore the need to address infrastructural limitations, enhance counseling support, and promote awareness and knowledge of HIVST.

Objective: We conducted a systematic review to investigate electroencephalography (EEG) changes during periods of acute respiratory events such as apnoea and the effect of respiratory stimulants on EEG features in infants. Methods: Studies examining respiration and EEG-recorded brain activity in human neonates between 28 and 42 weeks postmenstrual age were included. Two reviewers independently screened all records and included studies were assessed using the Joanna Briggs Institute Critical Appraisal Tool. The protocol was registered in PROSPERO (CRD42022339873). Results: We identified 14 studies with a total of 534 infants. Nine articles assessed EEG changes in relation to apnoea, one assessed hiccups, and four investigated the effect of respiratory stimulants. The relationship between neonatal apnoea and EEG changes was inconsistent; EEG suppression and decreased amplitude and frequency were observed during some, but not all, apnoeas. Respiratory stimulants increased EEG continuity compared with before use. Conclusions: Current studies in this area are constrained by small sample sizes. Diverse exposure definitions and outcome measures impact inference. Significance: This review highlights the need for further work; understanding the relationship between respiration and the developing brain is key to mitigating the long-term effects of apnoea.

Introduction In high-HIV burden settings, such as Nigeria, HIV self-testing and post-exposure prophylaxis (PEP) are often recommended, but not widely practiced. This study aims to identify the predictors of PEP utilization and preferences for HIV self-testing among healthcare workers in Nigeria. Methods A total of 403 healthcare workers from a tertiary hospital in Nigeria completed questionnaires. Adjusted odds ratios were derived from logistic regression models. Results Among the respondents, 141 (35.0%) reported experiencing at least one workplace exposure incident, with 72 (51.1%) of them receiving PEP. The majority of healthcare workers (n = 354, 87.8%) expressed a preference for HIV self-testing over traditional HIV testing and counseling. The occurrence of exposure incidents was predicted by the respondent’s sex (adjusted odds ratio [aOR] = 1.25; 95% confidence interval [CI]: 1.15-3.08, female vs. male), age (aOR = 0. 16; 95% CI: 0.03-0.92, >40 vs.

Abstract Background Microalbuminuria is an independent risk factor for cardiovascular and kidney disease and a predictor of end organ damage, both in the general population and in persons with HIV (PWH). Microalbuminuria is also an important risk factor for mortality in PWH treated with antiretroviral therapy (ART). In the ongoing Renal Risk Reduction (R3) study in Nigeria, we identified a high prevalence of microalbuminuria confirmed by two measurements 4–8 weeks apart in ART-experienced, virologically suppressed PWH. Although Stage 1 or 2 hypertension and exposure to potentially nephrotoxic antiretroviral medications were common in R3 participants, other traditional risk factors for albuminuria and kidney disease, including diabetes, APOL1 high-risk genotype, and smoking were rare. Co-infection with endemic pathogens may also be significant contributors to albuminuria, but co-infections were not evaluated in the R3 study population. Methods In Aim 1, we will cross-sectionally compare the prevalence of albuminuria and established kidney disease risk factors in a cohort of PWH to age- and sex-matched HIV-negative adults presenting for routine care at the Aminu Kano Teaching Hospital in Kano, Nigeria. We will leverage stored specimens from 2500 R3 participants and enroll an additional 500 PLWH recently initiated on ART (≤ 24 months) and 750 age- and sex-matched HIV-negative adults to determine the contribution of HIV, hypertension, and other comorbid medical conditions to prevalent albuminuria. In Aim 2, we will follow a cohort of 1000 HIV-positive, ART-treated and 500 HIV-negative normoalbuminuric adults for 30 months to evaluate the incidence and predictors of albuminuria. Discussion The findings from this study will support the development of interventions to prevent or address microalbuminuria in PWH to reduce kidney and cardiovascular morbidity and mortality. Such interventions might include more intensive monitoring and treatment of traditional risk factors, the provision of renin-angiotensin aldosterone system or sodium-glucose cotransporter-2 inhibitors, consideration of changes in ART regimen, and screening and treatment for relevant co-infections.

Background: Endothelial dysfunction constitutes an early pathophysiological event in atherogenesis and cardiovascular disease. This study aimed to assess the prevalence, determinants, and degree of endothelial dysfunction in antiretroviral therapy (ART)–treated people living with HIV (PLWH) in northwestern Nigeria using brachial flow-mediated dilatation (FMD). Methods: This was a comparative, cross-sectional study. A total of 200 ART-treated adults living with HIV with no evidence of kidney disease were compared with 200 HIV-negative participants attending a tertiary hospital in Kano, Nigeria, between September 2020 and May 2021. Endothelial function was evaluated by measuring FMD with a high-resolution vascular ultrasound transducer. FMD was calculated as the ratio of the brachial artery diameter after reactive hyperemia to baseline diameter and expressed as a percentage of change. Blood and urine samples were obtained from participants in both arms. Urine albumin-to-creatinine ratio (uACR) was calculated using the 2021 CKD-EPI estimated glomerular filtration rate (eGFR) creatinine-cystatin C equation without the race variable, and low-density lipoprotein (LDL) cholesterol was measured using enzymatic method. Results: The overall mean age (± standard deviation) of the study participants was 42 ± 11 years. Participants in the comparison arm were younger than PLWH (38 ± 11 versus 46 ± 10 years, respectively). The median (interquartile range) uACR was 41.6 (23.2–162.9) mg/g for the ART-treated PLWH versus 14.5 (7.4–27.0) mg/g for healthy controls. PLWH had a significantly lower mean percent FMD when compared to HIV-negative participants (9.8% ± 5.4 versus 12.1% ± 9.2, respectively). Reduced FMD was independently associated with HIV infection (β = –2.83%, 95% CI, –4.44% to –1.21%, p = 0.001), estimated glomerular filtration rate (β = –0.04%, 95% CI, –0.07% to –0.01%, p = 0.004) and LDL cholesterol (β = –1.12%, 95% CI, –2.13% to –0.11%, p = 0.029). Conclusion: HIV-positive status, lower estimated GFR, and higher LDL cholesterol levels were independently associated with endothelial dysfunction. Future prospective studies with larger cohorts of persons living with HIV (and age- and sex-matched HIV-negative controls) are needed to gain further insight into these important findings. In the interim, aggressive management of modifiable risk factors is warranted.

Abstract Background Ethiopia has a high acute rheumatic fever (ARF) and rheumatic heart disease (RHD) prevalence, and to our knowledge, there are no data on the status of secondary prevention in children with RHD. This study describes the status of secondary RHD prevention. Methods A multicenter, prospective study was performed on children aged 5–17 years with RHD in Ethiopia. Good adherence was defined as at least 80% completion of benzathine penicillin (BPG) or oral Amoxicillin within the previous year. The primary outcome measure was adherence to prophylaxis, expressed as a proportion. Socio-demographics, severity of RHD, and ARF recurrence were evaluated. Results A total of 337 children with a mean age of 12.9 ± 2.6 years were included. The majority (73%) had severe aortic/mitral disease. Participants were on BPG (80%) or Amoxicillin (20%) prophylaxis. Female sex (P = 0.04) use of BPG (0.03) and shorter mean duration of prophylaxis in months (48.5 ± 31.5 vs. 60.7 ± 33, respectively, P

Abstract Background Capacity strengthening initiatives aimed at increasing research knowledge and skills of investigators in low- and middle-income countries (LMICs) have been implemented over the last several decades. With increased capacity, local investigators will have greater leadership in defining research priorities and impact policy change to help improve health outcomes. Evaluations of models of capacity strengthening programs are often limited to short-term impact. Noting the limitations of traditional output-based evaluations, we utilized a broader framework to evaluate the long-term impact of the Vanderbilt Institute in Research Development and Ethics (VIRDE), a decade-old intensive grant development practicum specifically tailored for investigators from LMICs. Methods To assess the impact of VIRDE on the research careers of alumni over the past 10 years, we surveyed alumni on research engagement, grant productivity, career trajectory, and knowledge gained in grant writing. Descriptive statistics, including means and total counts, and paired sample t-tests were used to analyze the data. Results Forty-six of 58 alumni completed the survey. All respondents returned to their home countries and are currently engaged in research. Post-VIRDE grant writing knowledge ratings were significantly greater than pre-VIRDE. The number of respondents submitting grants post-VIRDE was 2.6 times higher than before the program. Eighty-three percent of respondents submitted a total of 147 grants post-VIRDE, of which 45.6% were awarded. Respondents acknowledged VIRDE’s positive impact on career growth and leadership, with 88% advancing in career stage. Conclusions Gains in grant writing knowledge and grant productivity suggest that VIRDE scholars built skills and confidence in grant writing during the program. A substantial proportion of respondents have advanced in their careers and continue to work in academia in their country of origin. Results show a sustained impact on the research careers of VIRDE alumni. The broader framework for research capacity strengthening resulted in an expansive assessment of the VIRDE program and alumni, illuminating successful program elements and implications that can inform similar capacity strengthening programs.

Vaccination is a critical tool in the global response to the COVID-19 pandemic. Yet, COVID-19 vaccine hesitancy has not been well explored in parts of Nigeria. We assessed the predictors of acceptability of the COVID-19 vaccine and identified reasons for vaccine hesitancy among adults in urban Kano, northern Nigeria. Using a mixed-methods design, we administered structured questionnaires to a cross-section of adults (n = 446), complemented with 20 in-depth interviews. Binary logistic regression and the framework approach were used to analyze the data. About one-half (51.1%, n = 228) of the respondents were willing to take the COVID-19 vaccine. Vaccine acceptance was higher among older respondents (≥30 years) (adjusted Odds Ratio (aOR) = 1.76, 95% Confidence Interval (CI): 1.14–2.99 (≥30 vs.

Abstract Background Acute respiratory failure, a major cause of death in COVID-19, is managed with high-flow oxygen therapy via invasive mechanical ventilation. In resource-limited settings like Nigeria, the shortage of ventilators and oxygen supply makes this option challenging. Evidence-based non-invasive alternatives to mechanical ventilation such as the use of continuous positive airway pressure (CPAP) devices exist, but there have been concerns that non-invasive ventilation may expose healthcare workers to infection from aerosolized dispersion of SARS-CoV-2. We propose to evaluate the feasibility, adaptability and acceptability of a CPAP/O2 helmet solution for non-invasive ventilation among patients with COVID-19 and health workers in eight COVID-19 treatment and isolation centers in Nigeria. Methods The study will occur in 4 stages: (1) convene a Steering Committee of key stakeholders and recruit implementation sites; (2) use the integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework to guide a needs assessment of treatment centers’ capacity to use high-flow oxygen therapy to treat COVID-19 patients and utilize the findings to develop an implementation strategy for the use of a CPAP/O2 helmet solution; (3) build infrastructure to support training and data monitoring processes and to develop implementation protocols to evaluate the adaptability of the strategy for the use of the CPAP/O2 helmet; and (4) train health workers, distribute a CPAP/O2 helmet solution for non-invasive ventilation, pilot test the implementation strategy, and assess feasibility of its use and acceptability that includes monitoring altered risk of SARS-CoV-2 infection among healthcare workers. Discussion The CPAP/O2 helmet solution for non-invasive ventilation in Nigeria can serve as a scalable model for resource-poor countries, and beyond the COVID-19 pandemic, has the potential to be deployed for the treatment of pneumonia and other respiratory diseases. Trial registration NCT04929691. Registered June 18, 2021—retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04929691

Abstract Antiretroviral therapy has turned HIV into a chronic condition, with morbidity from HIV-associated noncommunicable diseases (NCDs) becoming more common as HIV-infected individuals live longer. In Nigeria, the additional challenge of an under-capacitated health system highlights the need for skilled clinical investigators who can generate evidence to tackle the double burden of HIV and NCDs. The Vanderbilt-Nigeria Building Research Capacity in HIV and Non-communicable Diseases (V-BRCH) programme is a training platform to create a cohort of skilled Nigerian investigators with the capacity to lead independent clinical trial research focused on the intersection of HIV and NCDs. V-BRCH will solidify an atmosphere of continuous mentoring and skills acquisition for physician faculty at the Aminu Kano Teaching Hospital via short- and medium-term learning opportunities, paired mentoring arrangements, and mentored research projects. Trainees will attend an annual faculty enrichment programme in Nashville, in addition to on-site workshops in Nigeria on HIV-associated NCD epidemiology, clinical trials methodology, evidence synthesis, qualitative research methods, stakeholder engagement, knowledge translation, and grant writing. Research-oriented junior faculty will undergo focused training in clinical trials administration and regulatory oversight. Scholars will share best practices through mentoring panels, regular ‘Works in Progress’ meetings, and monthly career development seminars. Competitive seed grants will be provided to mentor–mentee teams to promote targeted in-country pilot studies focused on HIV-associated NCDs. For long-term training, physician scientists will be supported to undergo enhanced Master of Public Health (MPH) training at Bayero University in Nigeria and Master of Science in Clinical Investigation (MSCI) training at Vanderbilt. Short-term regional courses, staff development workshops, and MPH curriculum refinement will help to strengthen institutional capacity in HIV-associated NCD clinical trial research. V-BRCH will create a cohort of skilled Nigerian scientists who will be able to compete for independent funding and design and implement high quality research that will generate evidence to inform policy and practice and lead to improved outcomes for Nigerians impacted by HIV-associated NCDs.

Abstract Background In Nigeria, there is an estimated 1.9 million people living with HIV (PLHIV), 53% of whom utilize HIV care and services. With decreasing HIV-related deaths and increasing new infections, HIV with its associated comorbidities continue to be a key public health challenge in Nigeria. Untreated, comorbid mental disorders are a critical but potentially modifiable determinant of optimal HIV treatment outcomes. This study aimed to identify the challenges and opportunities related to integrating mental health care into existing HIV programs in Nigeria. Method Attendees at the Nigeria Implementation Science Alliance (NISA)‘s 2019 conference participated in nominal group technique (NGT) exercise informed by the “Exploration, Preparation, Implementation, and Sustainment (EPIS)” framework. The NGT process was conducted among the nominal groups in two major sessions of 30-min phases followed by a 30-min plenary session. Data analysis proceeded in four steps: transcription, collation, theming and content analysis. Results The two major theoretical themes from the study were – opportunities and challenges of integrating mental health treatment into HIV services. Three sub-themes emerged on opportunities: building on health care facilities for HIV services (screening, counseling, task-sharing monitoring and evaluation frameworks), utilizing existing human resources or workforce in HIV programs (in-service training and including mental health in education curriculum) and the role of social and cultural structures (leveraging existing community, traditional and faith-based infrastructures). Four sub-themes emerged for challenges: double burden of stigma and the problems of early detection (HIV and mental health stigma, lack of awareness), existing policy gaps and structural challenges (fragmented health system), limited human resources for mental health care in Nigeria (knowledge gap and burnout) and dearth of data/evidence for planning and action (research gaps). Conclusions Potential for integrating treatments for mental disorders into HIV programs and services exist in Nigeria. These include opportunities for clinicians’ training and capacity building as well as community partnerships. Multiple barriers and challenges such as stigma, policy and research gaps would need to be addressed to leverage these opportunities. Our findings serve as a useful guide for government agencies, policy makers and research organizations to address co-morbid mental disorders among PLHIV in Nigeria.

Abstract Background Traditional healers are frequently exposed to hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) through the widespread practice of traditional “injections”, in which the healer performs dozens of subcutaneous incisions using a razor blade to rub herbs directly into bloodied tissue. An average healer in Agincourt, a rural northeastern sub-district in Mpumalanga province, South Africa, experiences approximately 1500 occupational blood exposures over the course of their lifetime. Healers in Agincourt have an HIV prevalence of 30% compared to 19% in the general population, and healers who report exposure to patient blood have an adjusted 2.4-fold higher odds of being HIV-positive than those with no exposure. Although research on appropriate PPE use has been well documented for allopathic care providers, little is known about the practices of traditional healers. Methods This qualitative study was conducted with 30 traditional healers who practice in the rural Bushbuckridge sub-district of Mpumalanga province, northeastern South Africa. We elicited traditional healer attitudes towards glove use during traditional treatments – including patient baths, injections, or other treatments that exposed healers to patient blood or open sores. Results While 90% of healers reported using latex gloves during some treatments, the majority do not use them regularly. Most employ a combination of gloves, plastic shopping bags, bread bags, paper, and sticks to prevent blood exposure. Healers reported plastic bags slipping or breaking during procedures, exposing them to patient blood. Only three healers consistently used gloves, regardless of the cost. Conclusions Inadequate PPE use and high HIV prevalence make traditional healers particularly susceptible to contracting HIV in rural South Africa. Despite positive attitudes, consistent glove use remains low due to financial constraints and glove availability. Addressing issues of accessibility and cost of gloves for traditional healers could have a significant impact on the adherence to PPE and, in turn, reduce new HIV infections among this high-risk group.

Abstract Background Congenital hypothyroidism is a common, yet easily treatable cause of poor growth and intellectual disability. Newborn screening programs play an important role in the early detection and treatment of congenital hypothyroidism. However, an estimated 71% of children are born in countries such as Ghana, which does not have a screening program. Iodine deficiency, a common cause of congenital hypothyroidism, is present in the Ghanaian population. Mild to moderate maternal iodine deficiency may negatively impact cognitive function in children. A structured approach to examine the association between maternal iodine levels and infant thyroid function may have important ramifications on our understanding of congenital hypothyroidism in Ghana. We investigated the hypothesis that maternal iodine deficiency impacts infant thyroid function, using Thyroid Stimulating Hormone (TSH) as a marker of thyroid function. We also explored potential opportunities and barriers to newborn screening for congenital hypothyroidism in Ghana. Methods This was a cross-sectional, multicenter pilot study of 250 women and their neonates recruited from post-natal clinics in Accra and Tamale, Ghana. We compared maternal urine iodine concentration and infant TSH, as well as maternal sociodemographic and nutrition information. Regression models were used to model the relationship between variables. Results Median infant TSH was 4.7 μIU/ml (95% CI: 3.9–5.5) in Accra. In Tamale, the median infant TSH was 3.5 μIU/ml (95%CI: 3.3 to 3.6) (Δ: 1.3 μIU/ml, 95% CI: 0.5–2.1, p = 0.002). Median maternal urine iodine concentrations were 141.0 μg/L (95% CI: 115.7 to 166.3) and 142.5 μg/L (95% CI: 125.1 to 160.0) in Accra and Tamale, respectively (Δ: − 1.5 μIU/ml, 95% CI: − 32.2 – 29.2, p = 0.925). There was a weakly positive correlation between maternal urine iodine and infant TSH (rho 0.1, p = 0.02). Almost one-third (30%) of women in both locations had biochemical evidence of iodine deficiency. Mothers with any formal education were more likely to have higher iodine levels than their counterparts who had no formal education (coefficient 0.31, p = 0.006). Conclusions Maternal iodine deficiency is prevalent in Ghana and is correlated to infant thyroid function. We recommend studies with larger sample sizes to assess the true scope of this relationship.

Rheumatic heart disease (RHD) is a complication of untreated throat infection by Group A beta-hemolytic streptococcus with a high prevalence among socioeconomically disadvantaged populations. Despite its high incidence and prevalence, RHD prevention is not a priority in major global health discussions. The reasons for the apparent neglect are multifactorial, including underestimated morbidity and mortality burden, underappreciated economic burden, lack of public awareness, and lack of sustainable investment. In this review, we recommend multisectoral collaboration to tackle the burden of RHD by engaging the public, health experts, and policymakers; augmenting funding for clinical care; improving distribution channels for prophylaxis, and increasing research and innovation as critical interventions to save millions of people from preventable morbidity and mortality.

The increasing volume and complexity of research activities in Nigeria necessitates urgent measures to improve research infrastructure in grants administration and management. The **V**anderbilt-Nigeria **R**esearch **A**dministration and **M**anagement Training **P**rogram (V-RAMP) seeks to build infrastructure capacity in research administration and management and research ethics at a major teaching hospital in Nigeria. We will perform a mixed methods needs assessment of the administrative and management environment and develop an action plan to address infrastructure needs, prioritize processes, and guide program implementation. We will capacitate a newly established Office of Research Administration and improve the knowledge and skills of research administrators and grant managers via short term in-person trainings in Nashville, Tennessee and in Kano, Nigeria and through remote learning opportunities. We will enhance local administrative efficiency and performance of research ethics operations through training and mentoring of members and staff of the ethics review committee. Systematic processes to streamline protocols, including a Research Electronic Data Capture (REDCap) protocol tracking database and standard operating procedures in the responsible conduct of research and rigor and reproducibility will also be developed. V-RAMP will enable the creation of a high-quality research administration environment that is knowledgeable, efficient, and compliant regarding the fiscal, management and ethical standards of sponsored research.

Background: Against a background of security challenges, Nigeria conducted recently the largest population-based HIV survey in the world to ascertain the burden of the HIV disease in the country. Objective: We evaluated the main outcomes of the survey and the level of success using participation/response indicators. Methods: The survey was conducted from July–December 2018 by over 6,000 field staff across Nigeria in six consecutive webs, using two-stage cluster sampling. We estimated the prevalence of HIV, hepatitis B and hepatitis C in the entire country and by conflict zone status. Adjusted odds ratios (OR) and 95% confidence intervals (CI) from survey logistic regression models were used to compare the likelihood of test positivity for the three infections between zones. Findings: A total of 186,405 adults were interviewed from 97,250 households in 3,848 census enumeration areas. The overall HIV, hepatitis B and hepatitis C positivity rates were 1.55%, 7.63% and 1.73%, respectively. The prevalence of HIV, hepatitis B and C infection was significantly greater in conflict than non-conflict zones (HIV: 1.75% versus 1.0%; hepatitis B: 9.9% versus 7.3%; and hepatitis C: 3.2% versus 0.3%; p < 0.01 in all cases). Individuals living in conflict zones were about three times as likely to test positive for HIV (OR = 2.80, 95% CI = 2.08, 3.60) and nearly six times as likely to test positive for hepatitis C (OR = 5.90, 95% CI = 2.17, 16.67). Conclusion: Large population-based surveys are feasible, even in armed conflict settings. The burden of HIV, hepatitis B and hepatitis C was significantly higher in areas of conflict in Nigeria, highlighting the need for reinforced public health control measures in these settings in order to attain UNAIDS’ 95-95-95 targets of controlling the HIV epidemic in sub-Saharan Africa by 2030.

Background Persons living with HIV often face discrimination in safe sex and reproductive choices, especially in lowresource settings. This study assessed fertility desires and intentions, risk perception and correlates of ever use of at least one safer conception method among HIV-infected women attending a tertiary health facility in Kano, Nigeria. Methods Structured questionnaires were administered to a cross section of 328 of 427 eligible HIV-infected women. Fertility desires and intentions, risk perception and safer conception practice were analyzed. Logistic regression was employed to assess for predictors. Results Of the 328 respondents, 150 respondents (45.7%) wanted more children. The proportions of respondents aware of their transmission risk during pregnancy, delivery, and breastfeeding were 69.5%, 75.3%, and 78.9%, respectively. Further, 68.9% of respondents were aware of the prospects of bearing HIV-negative children without infecting their partners. About 64.8% of women were aware of at least one safer conception method. Safer conception methods everused by the participants include: antiretroviral therapy (ART) (36.7%), timed unprotected intercourse with (10.9%), and without pre-exposure prophylaxis (PrEP) (17.2%), intravaginal insemination (7.3%) and intrauterine insemination (4.7%). Safer conception practice was predicted by marital status (married versus single, adjusted odds ratio [AOR] = 1.50, 95% CI = 1.10-3.55), parity (2-4 versus 0, AOR = 12.1, 95% CI = 3.7-39.8), occupation (civil servants versus traders, AOR = 0.37, 95% CI = 0.16-0.86), husband’s serostatus (seroconcordant versus serodiscordant) (AOR = 1.51, 95% CI = 1.13-4.64), couple contraceptive use (users versus non-users) (AOR = 1.62, 95% CI = 1.16-5.83) and transmission risk perception (high risk versus low/no risk) (AOR = 2.14, 95% CI = 1.18-3.90). Conclusion We found high levels of fertility desires and intentions and moderate risk perception among a cohort of HIV-infected women in urban Kano, Nigeria. The use of safer conception practices was not common. Our findings underscore the need for healthcare provider capacity building to enhance safer conception counseling and service delivery.

Abstract Background Individuals with two copies of the apolipoprotein-1 (APOL1) gene risk variants are at high risk (HR) for non-diabetic kidney disease. The presence of these risk variants is highest in West Africa, specifically in Nigeria. However, there is limited availability of dialysis and kidney transplantation in Nigeria, and most individuals will die soon after developing end-stage renal disease. Blocking the renin angiotensin aldosterone system with angiotensin-converting enzyme inhibitors (ACEi) is a well-recognized strategy to slow renal disease progression in patients with diabetes mellitus with chronic kidney disease (CKD) and in patients with HIV-associated nephropathy. We propose to determine whether presence of the APOL1 HR genotype alters or predicts responsiveness to conventional therapy to treat or prevent CKD and if addition of an ACEi to standard combination antiretroviral therapy (ART) reduces the risk of kidney complications among non-diabetic Nigerian adults. Methods/design We will screen 2600 HIV-positive adults who have received ART to (1) determine the prevalence of APOL1 risk variants and assess whether APOL1 HR status correlates with prevalent albuminuria, estimated glomerular filtration rate (eGFR), and/or prevalent CKD; (2) assess, via a randomized, placebo-controlled trial (RCT) in a subset of these participants with microalbuminura (n = 280) whether addition of the ACEi, lisinopril, compared to standard of care, significantly reduces the incidence or progression of albuminuria; and (3) determine whether the APOL1 HR genotype is associated with worse kidney outcomes (i.e. eGFR slope or regression of albuminuria) among participants in the RCT. Conclusions This study will examine the increasing prevalence of kidney diseases in HIV-positive adults in a West African population, and the relationship between these diseases and the APOL1 high-risk genotype. By evaluating the addition of an ACEi to the care of individuals with HIV infection who have albuminuria, our trial will provide definitive evidence to guide strategies for management and clinical care in this population, with the goal of reducing HIV-related kidney complications. Trial registration ClinicalTrials.gov, NCT03201939. Registered on 26 August 2016.

Abstract Background The modulatory effects of psychosocial and biophysical environments on sickle cell disease (SCD) severity during childhood has not been well characterized in high burden settings, such as Nigeria. Objectives We identified socio‐demographic correlates and explored caregivers' perceptions on socio‐behavioral and environmental influences on hospitalization for pain and blood transfusion of children with SCD in Kano, Nigeria. Methods Using mixed methods, structured questionnaires were administered to a clinic‐based sample of caregivers of children with SCD (n = 372), complemented with eight focus group discussions. Binary logistic regression models and the framework approach were used to analyze the data. Results The majority (73.1%, n = 272) of the children had at least one vaso‐occlusive crisis (VOC), and 41.1% (n = 153) required hospitalization in the preceding year. A total of 170 children (45.7%) received blood transfusion. Hospitalization was predicted by the child's age (Adjusted Odds Ratio, AOR = 1.89; 95% Confidence Interval, CI: 1.18‐4.07, ≥10 vs

There are estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 10% (200,000) working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens through the widespread practice of traditional ‘injections’, in which the healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied tissue with their hands. Healers who report exposure to patient blood have a 2.2-fold higher risk of being HIV-positive than those who do not report exposure. We propose a randomized controlled trial (61 healers in the intervention group and 61 healers in the control group) in Mpumalanga Province. Healers will receive personal protective equipment (PPE) education and training, general HIV prevention education, and three educational outreach visits at the healer’s place of practice to provide advice and support for PPE use and disposal. Healers in the control arm will be trained by health care providers, while participants in the intervention arm will receive training and outreach from a team of healers who were early adopters of PPE. We will evaluate intervention implementation using data from surveys, observation, and educational assessments. Implementation outcomes of interest include acceptability and feasibility of PPE use during clinical encounters and fidelity of PPE use during treatments that involve blood exposure. We will test our two intervention strategies to identify an optimal strategy for PPE education in a region with high HIV prevalence.

Background: Human Immunodeficiency Virus (HIV)-exposed and HIV-infected infants are at increased risk of vaccine-preventable diseases. However, little is known about health care workers’ knowledge and immunization counseling practices in this population. We determined the predictors of health care workers’ knowledge of vertical transmission risks, HIV exposed/infected infant immunization, and counseling practices in a tertiary center in Northern Nigeria. Methods: A cross-section of 297 health workers were interviewed using a structured, validated questionnaire. Knowledge and HIV-exposed infant immunization counseling practices were analyzed, and adjusted odds ratios for predictors were derived from logistic regression models. Results: Of the 297 participating health care workers, (32.3%, n=96) had adequate knowledge of HIVexposed/infected infant immunization. Two-thirds (67%, n=199) of the participants appropriately identified the timing of infant diagnosis, while (73%, n=217) and (56.2%, n=167) correctly categorized infants as HIV-exposed and HIV-infected, respectively. Only (19.5%, n=58) participants had ever counselled a HIVpositive mother on infant immunization. Knowledge was predicted by work unit (HIV clinic vs. Obstetrics & Gynecology clinic), (Adjusted Odds Ratio (AOR) =3.78, 95% CI: 1.27-5.54), age (30-39 vs.

The world is currently witnessing a dramatic disruption of everyday life owing to the rapid progression of the coronavirus disease 2019 (COVID-19) pandemic. As the pandemic evolves, there is an urgent need to better understand its epidemiology, characterize its potential impact, and identify mitigatory strategies to avert pandemic-related mortality. There is a need for a tool or algorithm to evaluate the extent to which public health policy and/or economic preparedness measures are effectively averting COVID-19 related mortality. We present a simple and yet practical epidemiological tool, the Pandemic Efficiency Index (PEI), that can be utilized globally to test the relative efficiency of measures put in place to avert death resulting from COVID-19 infection. Using the PEI and current COVID-19-related mortality, we determined that so far Germany demonstrates the highest PEI (5.1) among countries with more than 5,000 recorded cases of the infection, indicating high quality measures instituted by the country to avert death during the pandemic. Italy and France currently have the lowest COVID-19-related PEIs. Epidemics and pandemics come and go, but local, national, and global abilities to determine the efficiency of their efforts in averting deaths is critical. Key words: • COVID-19 • Pandemic Efficiency Index • PEI • Coronavirus • Mortality • Pandemic • Epidemic • Global health Copyright © 2020 Salihu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: Adherence to combination antiretroviral therapy (ART) among pregnant women is essential to attaining the goal of eliminating mother-to-child HIV transmission. The objective of this study was to determine which factors affect adherence to ART among HIV-positive women enrolled in a large prevention of mother-to-child HIV transmission (PMTCT) trial in rural north-central Nigeria. Methods: The parent study included 372 HIV-positive pregnant women enrolled in a cluster-randomized control trial conducted at 12 health facilities in Nigeria between 2013 and 2015. This secondary analysis included HIV-positive women (and their infants) from the original trial with documented adherence data (n=210, 56.5%). The primary outcome was maternal adherence to ART, determined by self-report and based on the visual analogue scale (VAS) of a validated medication adherence tool. Participants with a VAS score of ? 95% were classified as adherent. We employed multivariate logistic regression to evaluate the predictors of maternal ART adherence in the study sample. Results: Approximately 61.0% of study participants (128/210) were adherent to ART. The majority of adherent participants (62.5%, 80/128) were enrolled in the trial intervention arm. The most common cited response for non-adherence was fear of status disclosure. Adherence to ART was associated with study arm (intervention arm vs. control arm, adjusted Odds Ratio (aOR) [95% CI]: 16.95 [5.30-54.23]), maternal ethnicity (Gwari vs. Other, aOR = 0.13 [0.05-0.38]), and partner HIV status (HIV-positive vs. unknown, aOR = 3.14 [1.22-8.07]). Conclusion and Global Health Implications: Adherence to ART among a cohort of pregnant women enrolled in a PMTCT trial in rural North-Central Nigeria was associated with trial arm, maternal self- reported ethnicity, and partner’s HIV status. Increased understanding of the interplay between these factors will enable the development of more targeted and effective interventions. Key words: • HIV/AIDS • PMTCT • Combination antiretroviral therapy • Adherence • PMCTC • Nigeria Copyright © 2020 Calder et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background and Objectives: The identification of risk factors for shorter telomere length, especially during fetal development, would be important towards caffeine consumption recommendations for pregnant women on a global scale. The purpose of this study was to evaluate the association between caffeine intake and fetal telomere length as well as racial/ethnic differences in telomere length regardless of maternal caffeine consumption status. Methods: Caffeine intake was measured using a food frequency questionnaire (FFQ). Three generalized linear models (GLM) were compared based on binary categorical variables of caffeine levels using data mean value of 117.3 mg as cut-off; the World Health Organization (WHO) recommendations of 300 mg; and the American College of Obstetricians and Gynecologists (ACOG) recommendations of 200 mg. The association between caffeine consumption and telomere length (telomere to single-copy [T/S] ratio) was then assessed. Results: Among 57 maternal-fetal dyads, 77.2% reported less than 200 mg of caffeine (ACOG) and 89.5% less than 300 mg (WHO). Both WHO and ACOG models found that caffeine intake was significantly and positively associated with longer telomere length (p

Background And Objectives: Studies on male involvement and pregnancy outcomes have often not incorporated the providers’ perspectives, which are potentially critical to understanding program context, evolution, perceived impact, and sustainability. We sought to evaluate the 24/7 Dad® program from the viewpoint of the program providers. Methods: We conducted purposive sampling of 24/7 Dad program facilitators and administrators who were involved in recruitment, training, and follow up of program participants within a federal Healthy Start program (REACHUP) in Tampa, Florida, USA. Using a snowballing approach, we recruited six key informants who had administered the program for at least four years. We elicited and evaluated factors impacting the performance of the father involvement program using content analysis. Results: Under program participation and perceived impact, most providers thought that the program had created a safe space previously unavailable for men in the community. The most useful recruitment strategy was building partnerships with other organizations. The key informants noted an important evolutionary trend in the father involvement program over time as well as the nature of linkages to partner organizations within the area. Threats to program sustainability included the continued reluctance and scepticism to invest funds to address male issues, sub-optimal retention of participants who were living transient lives as well as geographical/transportation barriers. Conclusion and Global Health Implications: The involvement of fathers during pregnancy has significant implications for healthy babies. Our study results provide a clarion call to augment capacity and infuse more resources to improve paternal involvement in order to attain the United Nations Sustainable Goal (2015-2030) of ensuring healthy lives and the promotion of well-being for all at all ages. Key words: • Fatherhood involvement • Fatherhood training • REACHUP • Childhood development • 24/7 Dad program Copyright © 2020 Obure et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Risk perception and recognition of danger signs are important cues for accessing obstetric care. These measures are not well documented in many resource-limited settings, including northern Nigeria, a region with poor maternal health indices. Objective: To assess community level obstetric risk perception, danger sign recognition and their predictors in Kano, northern Nigeria. Method: This is a community-based cross-sectional study. Participants were surveyed using structured, pretested questionnaires. Knowledge of obstetric risk factors and danger sign recognition were analyzed, and their predictors modeled using logistic regression to generate adjusted odds ratios (AORs). Results: The obstetric risk factors identified by the 400 respondents included: maternal age (64.3%), history of abortion (37.0%), postpartum haemorrhage (36.0%), previous operative delivery (31.8%), and high parity (31.3%). The most frequently recognised danger signs during pregnancy were: vaginal bleeding (76.8%), seizures (44.5%), and severe abdominal pain (34.8%). Common intrapartum danger signs recognised included: severe bleeding (77.8%), seizures (55.5%), and loss of consciousness (38.3%). Severe bleeding (80.5%), seizures (42.0%), and high fever (28.5%) were the top three danger signs identified in the postpartum period. At multivariate level, respondent sex (female vs. male) (aOR = 3.10, 95% CI = 1.67–5.74), ethnicity (Yoruba vs. Hausa) (aOR = 7.53, 95% CI = 2.51–22.6), occupation (employed vs. unemployed) (aOR = 4.07, 95% CI = 1.87–8.84) and parity (≥5 versus 0) (aOR = 0.23, 95% CI = 0.06–0.92) predicted good obstetric risk perception. Participants’ ethnicity (Yoruba vs. Hausa) (aOR = 4.40, 95% CI = 1.10–19.2) and obstetric risk perception (good vs. poor) (aOR = 12.0, 95% CI = 6.8–21.2) predicted danger sign recognition. Conclusion: The perception of obstetric risk and recognition of danger signs were influenced by participant sex, parity, employment status, and ethnicity. Targeted communication strategies and community-based education are essential to enhance effective utilisation of emergency obstetric services.

Abstract Background Implementation research (IR) facilitates health systems strengthening and optimal patient outcomes by generating evidence for scale-up of efficacious strategies in context. Thus, difficulties in generating IR evidence, particularly in limited-resource settings with wide disease prevention and treatment gaps, need to be anticipated and addressed. Nigeria is a priority country for the prevention of mother-to-child transmission of HIV (PMTCT). This paper analyses the experiences of four PMTCT IR studies in Nigeria, and proffers solutions to major challenges encountered during implementation. Studies included and findings Multicentre PMTCT IR studies conducted in Nigeria during the Global Plan’s assessment period (2011 to 2015) were included. Four studies were identified, namely The Baby Shower Trial, Optimizing PMTCT, MoMent and Lafiyan Jikin Mata. Major common challenges encountered were categorised as ‘External’ (beyond the control of study teams) and ‘Internal’ (amenable to rectification by study teams). External challenges included healthcare worker strikes and turnover, acts and threats of ethnic and political violence and terrorism, and multiplicity of required local ethical reviews. Internal challenges included limited research capacity among study staff, research staff turnover and travel restrictions hindering study site visits. Deliberate research capacity-building was provided to study staff through multiple opportunities before and during study implementation. Post-study employment opportunities and pathways for further research career-building are suggested as incentives for study staff retention. Engagement of study community-resident personnel minimised research staff turnover in violence-prone areas. Conclusions The IR environment in Nigeria is extremely diverse and challenging, yet, with local experience and anticipatory planning, innovative solutions can be implemented to modulate internal challenges. Issues still remain with healthcare worker strikes and often unpredictable insecurity. There is a dire need for cooperation between institutional review boards across Nigeria in order to minimise the multiplicity of reviews for multicentre studies. External challenges need to be addressed by high-level stakeholders, given Nigeria’s crucial regional and global position in the fight against the HIV epidemic.

Abstract Background Despite being disproportionately burdened by preventable diseases than more advanced countries, low- and middle-income countries (LMICs) continue to trail behind other parts of the world in the number, quality and impact of scholarly activities by their health researchers. Our strategy at the Nigerian Implementation Science Alliance (NISA) is to utilise innovative platforms that catalyse collaboration, enhance communication between different stakeholders, and promote the uptake of evidence-based interventions in improving healthcare delivery. This article reports on findings from a structured group exercise conducted at the 2016 NISA Conference to identify (1) gaps in developing research capacity and (2) potential strategies to address these gaps. Methods A 1-hour structured group exercise was conducted with 15 groups of 2–9 individuals (n = 94) to brainstorm gaps for implementation, strategies to address gaps and to rank their top 3 in each category. Qualitative thematic analysis was used. First, duplicate responses were merged and analyses identified emerging themes. Each of the gaps and strategies identified were categorised as falling into the purview of policy-makers, researchers, implementing partners or multiple groups. Results Participating stakeholders identified 98 gaps and 91 strategies related to increasing research capacity in Nigeria. A total of 45 gaps and an equal number of strategies were ranked; 39 gaps and 43 strategies were then analysed, from which 8 recurring themes emerged for gaps (lack of sufficient funding, poor research focus in education, inadequate mentorship and training, inadequate research infrastructure, lack of collaboration between researchers, research-policy dissonance, lack of motivation for research, lack of leadership buy-in for research) and 7 themes emerged for strategies (increased funding for research, improved research education, improved mentorship and training, improved infrastructure for research, increased collaboration between academic/research institutions, greater engagement between researchers and policy-makers, greater leadership buy-in for research). Conclusions The gaps and strategies identified in this study represent pathways judged to be important in increasing research and implementation science capacity in Nigeria. The inclusion of perspectives and involvement of stakeholders who play different roles in policy, research and implementation activities makes these findings comprehensive, relevant and actionable, not only in Nigeria but in other similar LMICs.

Abstract Background Successful tuberculosis (TB) treatment is essential to effective TB control. TB-HIV coinfection, social determinants and access to services influenced by rural residence can affect treatment outcome. We examined the separate and joint effects of rural residence and HIV infection on poor treatment outcome among patients enrolled in a large TB treatment centre in Kano, Nigeria. Methods We retrospectively analysed a cohort of patients with TB enrolled in a large urban TB clinic in northern Nigeria, from January 2010 to December 2014. Poor treatment outcome was defined as death, default or treatment failure. We used Poisson regression to model rates and determine the relative risks (and 95% confidence intervals, CI) of poor treatment outcomes. Results Among 1381 patients included in the analysis, 28.4% were rural residents; 39.8% were HIV-positive; and 46.1% had a poor treatment outcome. Approximately 65 and 38% of rural and urban residents, respectively, had a poor treatment outcome. Rural residents had 2.74 times (95% CI: 2.27–3.29) the risk of having a poor treatment outcome compared to urban residents. HIV-positive patients had 1.4 times (95% CI: 1.16–1.69) the risk of poor treatment outcome compared to HIV-negative patients. The proportion of poor treatment outcome attributable to rural residence (population attributable fraction, PAF) was 25.6%. The PAF for HIV infection was 11.9%. The effect of rural residence on poor treatment outcome among HIV-negative patients (aRR:4.07; 95%CI:3.15–5.25) was more than twice that among HIV-positive patients (aRR:1.99; 95%CI:1.49–2.64). Conclusion Rural residents attending a large Nigerian TB clinic are at increased risk of having poor treatment outcomes, and this risk is amplified among those that are HIV-negative. Our findings indicate that rural coverage of HIV services may be better than TB services. These findings highlight the importance of expanding coverage of TB services to ensure prompt diagnosis and commencement of treatment, especially among rural-dwellers in resource-limited settings.

Background: People living with HIV have the right to healthy, satisfying sex lives and to appropriate services to ensure their sexual and reproductive health, including having healthy children. The reproductive rights of people living with HIV/AIDS are, however, often met with skepticism and discrimination, despite recent advances in HIV treatment. Objective: To assess the attitudes of community members in Kano, Nigeria, toward the right of persons living with HIV/AIDS to have healthy sexual relationships and bear children. Methods: A cross-section of 399 adults was interviewed using pretested structured questionnaires. Logistic regression analysis was used to obtain adjusted estimates for predictors of agreement with the rights of persons with HIV/AIDS to bear children. Findings: A substantial proportion of respondents (28.6%) strongly agreed and agreed (10.5%) that persons with HIV/AIDS should not be allowed to marry. More than a fifth of the respondents disagreed (16.0%) and strongly disagreed (8.0%) with the rights of HIV-infected persons to bear children. Agreement with the statement “HIV-infected persons should have biological children” was independently associated with higher educational status (adjusted odds ratio: 2.26, 95% confidence interval: 1.82-6.73) and awareness of prevention of mother-to-child HIV transmission effectiveness (adjusted odds ratio: 2.53, 95% confidence interval: 1.92-5.37). Of those who agreed that HIV-infected persons should have children (n = 253), 17.8% and 26.1% strongly agreed and agreed, respectively, that persons living with HIV/AIDS should be restricted to having fewer children. Further, 11.5% and 4.8% of respondents disagreed and strongly disagreed, respectively, that infertile HIV-infected couples should receive fertility treatment. Conclusions: People living with HIV/AIDS face discriminatory attitudes to their reproductive rights in northern Nigeria. There is a need for effective, culturally appropriate information, education, and communication approaches to improving community perceptions of sexual and reproductive rights of people living with HIV/AIDS.

BackgroundGlobal health research in resource-limited countries has been largely sponsored and led by foreign institutions. Thus, these countries’ training capacity and productivity in global health research is limited. Local participation at all levels of global health knowledge generation promotes equitable access to evidence-based solutions. Additionally, leadership inclusive of competent local professionals promotes best outcomes for local contextualization and implementation of successful global health solutions. Among the sub-Saharan African regions, West Africa in particular lags in research infrastructure, productivity, and impact in global health research.ObjectiveIn this paper, experts discuss strategies for scaling up West Africa’s participation in global health evidence generation using examples from Ghana and Nigeria.MethodsWe conducted an online and professional network search to identify grants awarded for global health research and research education in Ghana and Nigeria. Principal investigators, global health educators, and representatives of funding institutions were invited to add their knowledge and expertise with regard to strengthening research capacity in West Africa.FindingsWhile there has been some progress in obtaining foreign funding, foreign institutions still dominate local research. Local research funding opportunities in the 2 countries were found to be insufficient, disjointed, poorly sustained, and inadequately publicized, indicating weak infrastructure. As a result, research training programs produce graduates who ultimately fail to launch independent investigator careers because of lack of mentoring and poor infrastructural support.ConclusionsResearch funding and training opportunities in Ghana and Nigeria remain inadequate.RecommendationsWe recommend systems-level changes in mentoring, collaboration, and funding to drive the global health research agenda in these countries. Additionally, research training programs should be evaluated not only by numbers of individuals graduated but also by numbers of independent investigators and grants funded. Through equitable collaborations, infrastructure, and mentoring, West Africa can match the rest of Africa in impactful global health research.

Epilepsy is the most common serious childhood neurological disorder. In the low- and middle-income countries (LMICs) of Africa, children with epilepsy suffer increased morbidity and mortality compared to their counterparts in high-income countries, and the majority do not receive treatment - the childhood epilepsy treatment gap. Reports of the childhood epilepsy treatment gap in Africa are likely underestimates; most surveys do not include several common childhood seizure types, including most types of non-convulsive epilepsy. Efforts to scale up childhood epilepsy care services in the LMICs of Africa must contend with a shortage of physicians and diagnostic technology [e.g., electroencephalograms (EEGs)]. One pragmatic solution is to integrate epilepsy care into primary care by task-shifting to community health extension workers. The aims of this project (BRIDGE) are to: 1) train, develop, and pilot task-shifted epilepsy care teams; 2) develop and pilot innovative childhood epilepsy screening and diagnostic paradigms adapted to the local Hausa language/culture in Kano, northern Nigeria; and, 3) quantify and map the childhood epilepsy treatment gap, using geographic information systems (GIS), to target limited resources to areas of greatest need. Task-shifted teams will diagnose and manage childhood epilepsy using an innovative epilepsy screening tools and diagnostic and management paradigms in environments with limited EEG access. If validated and demonstrated efficacious in clinical trials, this project can be taken to scale across broader areas of west Africa's LMICs that share language and culture. BRIDGE has the potential to enhance access to basic childhood epilepsy care and establish the foundation for childhood epilepsy clinical trials in west Africa. Keywords: Childhood epilepsy, Epilepsy treatment gap, Task shifting, Nigeria, Hausa

Background: Contextual research evidence is needed to reduce morbidity and mortality due to chronic but preventable diseases in low- and middle-income countries. Nigeria, Africa’s most populous country, is particularly burdened by these diseases despite its academic and research infrastructure. A major impediment to developing robust evidence on sustainable disease prevention and treatment strategies is the lack of skilled research personnel. Objective: This study aimed to identify (1) training barriers for research assistants and coordinators and (2) potential strategies to counter these barriers using a Nominal Group Technique (NGT) exercise conducted at the 2017 conference of the Nigeria Implementation Science Alliance (NISA). Method: A one-hour NGT exercise was conducted with 26 groups of 2–9 persons each (N = 134) drawn from conference attendees. Group members were presented with questions related to the two objectives. Each member was asked to generate, list, discuss and vote on ideas that were eventually ranked by the group. Qualitative Thematic Analysis (QTA) was conducted for the collated responses. Findings: The QTA identified 166 training gaps and 147 potential solutions, out of which 104 were ranked. Themes that emerged for gaps included: 1) inadequate mentorship; 2) inadequate training/ lack of organized curriculum; 3) limited access to opportunities for training and employment; 4) lack of government funding; 5) lack of interest, motivation; and 6) lack of research culture. Themes for potential strategies to address the gaps were: 1) trainings/curriculum development; 2) research modules implemented in secondary and tertiary institutions; 3) creating a sustainable forum for research-related questions and answers; and 4) advocating for and accessing more government funding for research training. Conclusion: This study identified actionable strategies that reflect practical realities in implementation research in Nigeria, which can guide government agencies, policy makers, research organizations, and local foundations as they work together to increase research capacity in Nigeria.

Anthropometric indices are widely used to assess the health and nutritional status of children. We tested the hypothesis that the 2007 World Health Organization (WHO) reference for assessment of malnutrition in children with sickle cell anemia (SCA) overestimates the prevalence of severe malnutrition when compared to a previously constructed SCA-specific reference. We applied the WHO and SCA-specific references to children with SCA aged 5−12 years living in northern Nigeria (Primary Prevention of Stroke in Children with SCA in sub-Saharan Africa (SPRING) trial) to determine the difference in prevalence of severe malnutrition defined as body mass index (BMI) Z-score 200 cm/s). A total of 799 children were included in the final analysis (median age 8.2 years (interquartile range (IQR) 6.4−10.4)). The application of the WHO reference resulted in lower mean BMI than the SCA-specific reference (−2.3 versus −1.2; p < 0.001, respectively). The use of the WHO reference when compared to the SCA-specific reference population also resulted in a higher prevalence of severe malnutrition (28.6% vs. 6.4%; p < 0.001). The WHO reference significantly overestimates the prevalence of severe malnutrition in children with SCA when compared to an SCA-specific reference. Regardless of the reference population, severe malnutrition was not associated with lower mean hemoglobin levels or abnormal transcranial Doppler (TCD) measurements.

Objective: To assess whether conversion from twin to singleton pregnancy following the demise of a co-twin influences survival. Methods: This retrospective study compared the risk for neonatal, post-neonatal and infant death for converted co-twins versus unconverted co-twins using the US matched multiple file dataset for the period 1995–2000. We also examined the same risks for converted versus same-quantile co-twins, hazard ratios (HR) and 95% confidence intervals (CI) were computed using Cox Proportional Hazards models. Results: The risk for neonatal (HR = 0.18, 95% CI: 0.09–0.34 and HR = 0.69, 95% CI: 0.50–0.96) and infant death (HR = 0.22, 95% CI: 0.12–0.42 and HR = 0.57, 95% CI: 0.42–0.77) were significantly lower for converted twins than for unconverted twins and same-quantile twins, respectively. For black compared to white, the risk for post-neonatal death increased by 89% (HR = 1.89, 95% CI = 1.03, 3.48), and 79% (HR = 1.79, 95% CI = 1.53, 2.09) for converted vs. unconverted and converted vs. same-quantile, respectively. For converted black, the risk for neonatal death decreased by 17% (HR = 0.83, 95% CI = 0.73–0.93) as compared to unconverted. Conclusions: Risks for all mortality types were lower among converted co-twins than their unconverted or same-quantile counterparts. The lower neonatal and higher post-neonatal mortality among black require future research.

Prior research indicates that infants with absent fathers are vulnerable to unfavorable fetal birth outcomes. HIV is a recognized risk factor for adverse birth outcomes. However, the influence of paternal involvement on fetal morbidity outcomes in women with HIV remains poorly understood. Using linked hospital discharge data and vital statistics records for the state of Florida (1998-2007), the authors assessed the association between paternal involvement and fetal growth outcomes (i.e., low birth weight [LBW], very low birth weight [VLBW], preterm birth [PTB], very preterm birth [VPTB], and small for gestational age [SGA]) among HIV-positive mothers ( N = 4,719). Propensity score matching was used to match cases (absent fathers) to controls (fathers involved). Conditional logistic regression was employed to generate adjusted odds ratios (OR). Mothers of infants with absent fathers were more likely to be Black, younger (

Objective. To identify factors associated with opioid use during pregnancy and to compare perinatal morbidity, mortality, and healthcare costs between opioid users and nonusers. Methods. We conducted a cross-sectional analysis of pregnancy-related discharges from 1998 to 2009 using the largest publicly available all-payer inpatient database in the United States. We scanned ICD-9-CM codes for opioid use and perinatal outcomes. Costs of care were estimated from hospital charges. Survey logistic regression was used to assess the association between maternal opioid use and each outcome; generalized linear modeling was used to compare hospitalization costs by opioid use status. Results. Women who used opioids during pregnancy experienced higher rates of depression, anxiety, and chronic medical conditions. After adjusting for confounders, opioid use was associated with increased odds of threatened preterm labor, early onset delivery, poor fetal growth, and stillbirth. Users were four times as likely to have a prolonged hospital stay and were almost four times more likely to die before discharge. The mean per-hospitalization cost of a woman who used opioids during pregnancy was $5,616 (95% CI: $5,166–$6,067), compared to $4,084 (95% CI: $4,002–$4,166) for nonusers. Conclusion. Opioid use during pregnancy is associated with adverse perinatal outcomes and increased healthcare costs.

Recent trials demonstrate the effectiveness of male circumcision (MC) in reducing HIV acquisition in men. However, little is known about the prevalence and acceptability of the practice in northern Nigeria. A cross-sectional study design was employed to explore knowledge and attitudes to MC among university students in Kano, Nigeria ( n = 375). Almost all respondents (98.1%) reported being circumcised ( n = 368; 95% confidence interval = 96.2% to 99.2%). There was no variation in circumcision status by age, ethnicity, religion, or marital status. Majority of the respondents were circumcised by a health worker (51.2%). Most circumcisions were performed between the ages of 5 and 10 years (57.9%) and for religious reasons (79.2%). Only 38% of the respondents ( n = 104) were aware of the role of MC in reducing HIV acquisition in heterosexual males. Three quarters of the respondents agreed that circumcised men still need to use condoms. The practice of MC is nearly universal in northern Nigeria, despite low awareness of its protective role in HIV transmission. Public health programs should seize the opportunity offered by high MC acceptance rates to integrate safe medical MC services into existing HIV/AIDS prevention initiatives.