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Abstract Background Health systems have experienced unprecedented stress in recent years, and as yet no consensus has emerged as to how to deal with the multiple burden of disease in the context of HIV and AIDS and other competing health priorities. Priority setting is essential, yet this is a complex, multifaceted process. Drawing on a study conducted in five African countries, this paper explores different stakeholders′ perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and Health and how different stakeholders perceive this. Methods A sub-analysis was conducted of selected data from a wider qualitative study that explored the interactions between health systems and HIV and AIDS responses in five sub-Saharan countries (Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi). Key background documents were analysed and semi-structured interviews (n = 258) and focus group discussions (n = 45) were held with representatives of communities, health personnel, decision makers, civil society representatives and development partners at both national and district level. Results Health priorities were expressed either in terms of specific health problems and diseases or gaps in service delivery requiring a strengthening of the overall health system. In all five countries study respondents (with the exception of community members in Ghana) identified malaria and HIV as the two top health priorities. Community representatives were more likely to report concerns about accessibility of services and quality of care. National level respondents often referred to wider systemic challenges in relation to achieving the Millennium Development Goals (MDGs). Indeed, actual priority setting was heavily influenced by international agendas (e.g. MDGs) and by the ways in which development partners were supporting national strategic planning processes. At the same time, multi-stakeholder processes were increasingly used to identify priorities and inform sector-wide planning, whereby health service statistics were used to rank the burden of disease. However, many respondents remarked that health system challenges are not captured by such statistics. In all countries funding for health was reported to fall short of requirements and a need for further priority setting to match actual resource availability was identified. Pooled health sector funds have been established to some extent, but development partners′ lack of flexibility in the allocation of funds according to country-generated priorities was identified as a major constraint. Conclusions Although we found consensus on health priorities across all levels in the study countries, current funding falls short of addressing these identified areas. The nature of external funding, as well as programme-specific investment, was found to distort priority setting. There are signs that existing interventions have had limited effects beyond meeting the needs of disease-specific programmes. A need for more comprehensive health system strengthening (HSS) was identified, which requires a strong vision as to what the term means, coupled with a clear strategy and commitment from national and international decision makers in order to achieve stated goals. Prospective studies and action research, accompanied by pilot programmes, are recommended as deliberate strategies for HSS.

Background: Cervical Cancer stands as the second leading cause of both incident female cancers and deaths in Burkina Faso. Unfortunately, the prevention, early detection, and care of cervical cancers are suboptimal at individual, institutional, and national levels. In October 2023, we organized a stakeholder's workshop to develop cervical cancer awareness messaging for disease control in the country., Methods: A one-text workshop was organized with stakeholders working toward improving health in general or women's health and well-being. A participatory, learning, and adaptive approach was used to facilitate discussions and activities, ensuring the contribution of all participants. Contextual evidence-based and empirical elements about cervical cancer burden and preventive strategies were presented to the participants by key informants. These served as the foundation for a collaborative formulation of messaging content that aimed at raising awareness about cervical cancer., Results: Sixty-two participants from 28 organizations attended the workshop. They work mainly at local and international non-governmental organizations, civil society organizations, universities, university hospitals, research centers, and the Ministry of Health. During the first and second days of the workshop, the participants explored cervical cancer data, its preventive and treatment options available in Burkina Faso, communication strategies for behavioral change, and determinants of the use of prevention and health promotion services. During the following three days, 3 working groups were formed to define strategies, and key messages adapted to diverse tools and targeted audiences. All information was validated during plenary sessions before the end of the workshop and available to all participants and their organizations for cancer awareness activities., Conclusion: Upon conclusion of the workshop, the participants provided insightful information for the development of cervical awareness messaging in Burkina Faso. They formed the first community of practice to serve as a dynamic platform for implementation, monitoring, evaluation, and continued learning activities., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Ouedraogo, Bamogo, Tiendrebeogo, Kaboré, Turcotte-Tremblay, Maiga, Kagoné, Lompo and Meda.)

Background: Globally, the uptake of tuberculosis-preventive treatment (TPT) among children with household tuberculosis contact remains low, partly due to the necessity of bringing children to health facilities for investigations. This study aimed to evaluate the effect on TPT initiation and completion of community-based approaches to tuberculosis contact investigations in Cameroon and Uganda., Methods: We did a parallel, cluster-randomised, controlled trial across 20 clusters (consisting of 25 district hospitals and primary health centres) in Cameroon and Uganda, which were randomised (1:1) to receive a community-based approach (intervention group) or standard-of-care facility-based approach to contact screening and management (control group). The community-based approach consisted of symptom-based tuberculosis screening of all household contacts by community health workers at the household, with referral of symptomatic contacts to local facilities for investigations. Initiation of TPT (3-month course of rifampicin-isoniazid) was done by a nurse in the household, and home visits for TPT follow-up were done by community health workers. Index patients were people aged 15 years or older with bacteriologically confirmed, drug-susceptible, pulmonary tuberculosis diagnosed less than 1 month before inclusion and who declared at least one child or young adolescent (aged 0-14 years) household contact. The primary endpoint was the proportion of declared child contacts in the TPT target group (those aged <5 years irrespective of HIV status, and children aged 5-14 years living with HIV) who commenced and completed TPT, assessed in the modified intention-to-treat population (excluding enrolled index patients and their contacts who did not fit the eligibility criteria). Descriptive cascade of care assessment and generalised linear mixed modelling were used for comparison. This study is registered with ClinicalTrials.gov (NCT03832023)., Findings: The study included nine clusters in the intervention group (after excluding one cluster that did not enrol any index patients for >2 months) and ten in the control group. Between Oct 14, 2019 and Jan 13, 2022, 2894 child contacts were declared by 899 index patients with bacteriologically confirmed tuberculosis. Among all child contacts declared, 1548 (81·9%) of 1889 in the intervention group and 475 (47·3%) of 1005 in the control group were screened for tuberculosis. 1400 (48·4%) child contacts were considered to be in the TPT target group: 941 (49·8%) of 1889 in the intervention group and 459 (45·7%) of 1005 in the control group. In the TPT target group, TPT was commenced and completed in 752 (79·9%) of 941 child contacts in the intervention group and 283 (61·7%) of 459 in the control group (odds ratio 3·06 [95% CI 1·24-7·53])., Interpretation: A community-based approach using community health workers can significantly increase contact investigation coverage and TPT completion among eligible child contacts in a tuberculosis-endemic setting., Funding: Unitaid., Translation: For the French translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests MB has received grants (paid to her institution) from Unitaid and Expertise France for the TB-Speed project on childhood tuberculosis diagnosis, from ANRS for a COVID-19 prevalence study in children with presumptive tuberculosis, and from EDCTP-2 for two therapeutic trials for the treatment of adults with tuberculosis meningitis (INTENSE-TBM) and adults with advanced HIV-TB co-infection (DATURA). All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: One of the main barriers of the management of household tuberculosis child contacts is the necessity for parents to bring healthy children to the facility. We assessed the feasibility of a community intervention for tuberculosis (TB) household child contact management and the conditions for its evaluation in a cluster randomized controlled trial in Cameroon and Uganda., Methods: We assessed three dimensions of feasibility using a mixed method approach: (1) recruitment capability using retrospective aggregated data from facility registers; (2) acceptability of the intervention using focus group discussions with TB patients and in-depth interviews with healthcare providers and community leaders; and (3) adaptation, integration, and resources of the intervention in existing TB services using a survey and discussions with stakeholders., Results: Reaching the sample size is feasible in all clusters in 15 months with the condition of regrouping 2 facilities in the same cluster in Uganda due to decentralization of TB services. Community health worker (CHW) selection and training and simplified tools for contact screening, tolerability, and adherence of preventive therapy were key elements for the implementation of the community intervention. Healthcare providers and patients found the intervention of child contact investigations and TB preventive treatment management in the household acceptable in both countries due to its benefits (competing priorities, transport cost) as compared to facility-based management. TB stigma was present, but not a barrier for the community intervention. Visit schedule and team conduct were identified as key facilitators for the intervention., Conclusions: This study shows that evaluating a community intervention for TB child contact management in a cluster randomized trial is feasible in Cameroon and Uganda., Trial Registration: Clini calTr ials. gov NCT03832023 . Registered on February 6 th 2019., (© 2022. The Author(s).)

Mutual fidelity and partner reduction have been identified as key behavioural strategies to prevent HIV transmission in sub-Saharan Africa, particularly following recognition of the role that multiple concurrent sexual partnerships play in driving generalised HIV epidemics. We analysed social representations of fidelity and infidelity in a sample of 1,343 narratives about HIV written by young Africans between 1997 and 2014. The narratives were written at four different time points (1997, 2005, 2008, 2014) by authors aged 10-24 in urban and rural areas of Senegal, Burkina Faso, South-east Nigeria, Kenya and Eswatini. We combined three analytical approaches: descriptive statistics of quantifiable characteristics of the narratives, thematic data analysis and a narrative-based approach. In the sample, fidelity is often promoted as the ideal by narrators, peers and romantic partners, in line with broader discourses around HIV prevention, romantic relationships, familial obligations, and religious and moral imperatives. However, mutual fidelity is rarely modelled in the narratives and representations of combining methods to prevent HIV from entering relationships via infidelity are uncommon. Representations of fidelity reflect loss-framed fear arousal techniques that perpetuate HIV-related stigma. Narrative-based approaches that facilitate skills-building, critical reflection and address stigma can better address fidelity and partner reduction.

Background: There are major gaps in the management of pediatric tuberculosis (TB) contact investigation for rapid identification of active tuberculosis and initiation of preventive therapy. This study aims to evaluate the impact of a community-based intervention as compared to facility-based model for the management of children in contact with bacteriologically confirmed pulmonary TB adults in low-resource high-burden settings., Methods/design: This multicenter parallel open-label cluster randomized controlled trial is composed of three phases: I, baseline phase in which retrospective data are collected, quality of data recording in facility registers is checked, and expected acceptability and feasibility of the intervention is assessed; II, intervention phase with enrolment of index cases and contact cases in either facility- or community-based models; and III, explanatory phase including endpoint data analysis, cost-effectiveness analysis, and post-intervention acceptability assessment by healthcare providers and beneficiaries. The study uses both quantitative and qualitative analysis methods. The community-based intervention includes identification and screening of all household contacts, referral of contacts with TB-suggestive symptoms to the facility for investigation, and household initiation of preventive therapy with follow-up of eligible child contacts by community healthcare workers, i.e., all young (< 5 years) child contacts or older (5-14 years) child contacts living with HIV, and with no evidence of TB disease. Twenty clusters representing TB diagnostic and treatment facilities with their catchment areas are randomized in a 1:1 ratio to either the community-based intervention arm or the facility-based standard of care arm in Cameroon and Uganda. Randomization was stratified by country and constrained on the number of index cases per cluster. The primary endpoint is the proportion of eligible child contacts who initiate and complete the preventive therapy. The sample size is of 1500 child contacts to identify a 10% difference between the arms with the assumption that 60% of children will complete the preventive therapy in the standard of care arm., Discussion: This study will provide evidence of the impact of a community-based intervention on household child contact screening and management of TB preventive therapy in order to improve care and prevention of childhood TB in low-resource high-burden settings., Trial Registration: ClinicalTrials.gov NCT03832023 . Registered on 6 February 2019.

Increasingly parents living with HIV will have to confront the dilemmas of concealing their lifelong treatment or disclosing to their children exposed to their daily treatment practices. However, limited data are available regarding parental HIV disclosure to children in Burkina Faso. Do parents on antiretroviral therapy disclose their HIV status to their children? What drives them? How do they proceed and how do children respond? We conducted in-depth interviews with 63 parents of children aged seven and above where the parents had been in treatment for more than 3 years in two major cities of Burkina Faso. Interviews addressed parental disclosure and the children's role in their parents' treatment. The rate of parental HIV status disclosure is as high as that of non-disclosure. Factors associated with parental disclosure include female sex, parent's older age, parent's marital history and number of children. After adjustment, it appears that the only factor remaining associated with parental disclosure was the female gender of the parent. In most of the cases, children suspected, and among non-disclosers many believed their children already knew without formal disclosure. Age of the children and history of divorce or widowhood were associated with parental disclosure. Most parents believed children do not have the necessary emotional skills to understand or that they cannot keep a secret. However, parents who disclosed to their children did not experience blame nor was their secret revealed. Rather, children became treatment supporters. Challenges to parental HIV disclosure to children are neither essential nor specific since disclosure to adults is already difficult because of perceived risk of public disclosure and subsequent stigma. However, whether aware or not of their parents' HIV-positive status, children contribute positively to the care of parents living with HIV. Perceptions about children's vulnerability and will to protect them against stigma lead parents to delay disclosure and not to overwhelm them with their experience of living with HIV. Finally, without institutional counselling support, disclosure to children remains a challenge for both parents and children, which suggests a need for rethinking of current counselling practices.