Discussion
To the best of our knowledge, this is one of the first studies assessing the integration of SARS-CoV-2 Ag-RDT into specific service delivery points such as MNCH, HIV and TB clinics. Our study showed that during the first 6 months of programme implementation, about half of clinic attendees were screened for SARS-CoV-2 signs and symptoms or potential exposure, with significant variation between countries (63% in Cameroon vs 32% in Kenya). Approximately, 1 out of 10 participants screened was eligible for testing, and more than two-thirds of those eligible were finally tested, with substantial differences between countries. Screening proportions were similar across clinics while the proportion eligible and tested was higher in TB clinics compared with HIV and MNCH clinics. Country integration strategy, health facility setting, health facility level and clinic type were independently associated with being screened and with being tested while only country was independently associated with SARS-CoV-2 positivity.
The SARS-CoV-2 testing package of service includes screening, pretest counselling, sample collection, testing, result reading and documentation, providing results and post-test counselling, as well as referral for vaccination or to a clinician for disease staging, appropriate care and treatment provision.23–25 Integrating this important package of services within the service delivery entry points for pregnant women, PLHIV and people diagnosed with TB was important to increase early identification of SARS-CoV-2 in these populations known to be more vulnerable to COVID-19.10 23 26 27 Our results show that integrating this package of services into routine care in MNCH, HIV and TB clinics was achieved in the 50 participating health facilities, with almost half of the clinic attendees screened. Two-thirds of those eligible were tested for SARS-CoV-2 and SARS-CoV-2 positive participants were identified and referred to clinicians for care and treatment. Despite the observed gaps in the number screened and tested, the integration of the SARS-CoV-2 package of care in non-COVID-19-specific clinics and non-infectious disease clinics—during the pandemic and with very quick results—is an encouraging achievement for public health programming and epidemic response. Our results align with the available evidence showing that the integration of other health services into specialty MNCH, HIV and TB clinics is feasible and provides good results from the patient and health system perspectives.28–34
In addition, compared with the time it took to integrate the HIV package of services into non-HIV clinics such as MNCH and TB clinics, the integration of the SARS-CoV-2 package of service was rapidly achieved, reaching half of eligible attendees in a 6-month implementation period. Thus, in an epidemic or pandemic when specific groups are more vulnerable to disease than the general population, early integration of a preventive and curative package of services into specific service delivery entry points could be considered among the national strategies to treat and control infection.
The integration of a new package of healthcare services into clinics usually comes with challenges related to the model of integrating service delivery, which can lead to gaps in the service uptake and patient outcomes.31 33 34 Among the challenges identified to the integration of new services, those of supply chain, human resources, referral systems, patient education, stigma, patient records, and monitoring and evaluation are the most common.29 32 33 In our study, two major challenges were observed in the SARS-CoV-2 service coverage. The first is related to the proportion of attendees screened, which reached only half of the targeted population and ranged between 32.4% in Kenya and 62.6% in Cameroon. The second notable challenge was related to the proportion of those eligible for testing that were actually tested, which was two-thirds overall, ranging from 61.9% in Cameroon and 97.9% in Kenya. Missing half of the population targeted for screening and one-third for testing are important gaps that need to be explored to better understand and address the specific causes. Given the differences we found in country performance, we hypothesise that the integration strategy, especially the approach to human resource needs, may be one of the major causes for the differences between countries. Cameroon chose not to involve new staff in the screening and testing phase while Kenya involved community healthcare workers to support the screening and documentation phase and laboratory staff to support the testing phase. These strategies led to a higher screening proportion in Cameroon but a higher testing proportion in Kenya, as well as a significant association between country implementation strategy, screening and testing, suggesting that it might be preferable to integrate the SARS-CoV-2 screening phase into the routine activity of existing staff and to involve additional lab staff for the testing phase. Moreover, the difference in the absolute number of attendees eligible for testing (higher in Cameroon compared with Kenya), and among them the proportion of those finally tested (higher in Kenya compared with Cameroon), also suggests an effect of workload on the testing, which needs to be considered. These challenges could be addressed by considering the use of SARS-CoV-2 self-test that was shown feasible and acceptable among healthcare workers and general population in high-risk populations, remote locations and also in low-resource settings.35 36 However, the integration of SARS-CoV-2 self-test into routine health services still needs to be evaluated.
Finally, the association between being screened or being tested and facility setting, facility type or service delivery clinic suggests that many additional factors need to be considered when designing the service integration model as noted by others.31 33 37 The facility factors such as rural location and lower level in the health pyramid reflect more the facility volume and emphasise the influence of the workload on the integration strategies and the need for alternative testing method that could increase the number of attendees tested in the clinic.
The relatively low COVID-19 case detection rates observed overall in Cameroon and Kenya in this study align with the epidemic trend of SARS-CoV-2 infection reported in each country at the time of the study but likely also reflects an underestimation of the number of cases in Africa.1 38–40 A higher case detection rate was observed in Cameroon compared with Kenya which could be due to the different epidemic trends in both countries and seasonal variations of local epidemic in each country, in addition to the fat that Camerron tested an absolute number more eligible people than Kenya, increasing the possibility to find positive cases. In addition, the case detection rate among TB clinic attendees was more than 4 cases per 1000 attendees, particularly in Cameroon, with 8 cases per 1000 attendees. This is consistent with previous reports suggesting that SARS-CoV-2 infection’s effects on the respiratory system could activate latent TB infection given that both pathogens share the same infection site and same immune reaction processes, leading to some similarities in the pathogenesis.14 41–44 Moreover, patients diagnosed with TB are more likely to develop severe forms of SARS-CoV-2 and to experience unfavourable outcomes.13 14 18 It is, therefore, critical to consider high-yield service delivery entry points such as TB clinics when planning for the integration of a service delivery model.
Some limitations need to be acknowledged in this study, notably, the fact that we were not able to assess all the challenges for implementing a SARS-CoV-2 package of services in the service delivery entry points. Qualitative studies involving healthcare workers and clinic attendees will be useful to gain a deeper understanding of the facilitators and barriers to the integration of SARS-CoV-2 services into the health system. In addition, even though we selected countries among those with the highest prevalence of SARS-CoV-2 in their respective subregions in Africa, the national prevalences were relatively low at the time of the study. Thus, our results may be interpreted with caution for high prevalence periods. Despite these limitations, our study provides important data for decision-makers and programme implementers, specifically in sub-Saharan Africa, where COVID-19 vaccine coverage remains low and health systems can benefit from evidence-based implementation approaches to address future pandemics.
