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The Ebola Outbreak: Effects on HIV Reporting, Testing and Care in Bonthe District, Rural Sierra Leone A

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The Ebola Outbreak: Effects on HIV Reporting, Testing and Care in Bonthe District, Rural Sierra Leone A International Union Against Tuberculosis and Lung Disease Public Health Action Health solutions for the poor VOL 7 SUPPLEMENT 1 PUBLISHED 21 JUNE 2017 SORT IT SUPPLEMENT: POST-EBOLA RECOVERY IN WEST AFRICA The Ebola outbreak: effects on HIV reporting, testing and care in Bonthe district, rural Sierra Leone A. H. Gamanga,1 P. Owiti,2,3 P. Bhat,4 A. D. Harries,3,5 I. Kargbo-Labour,6 M. Koroma6 http://dx.doi.org/10.5588/pha.16.0087 over in November 2015, although occasional sporadic AFFILIATIONS Setting: All public health facilities in Bonthe District, ru- 1 Bonthe Government cases occurred thereafter. Prior to the Ebola outbreak, Hospital, Ministry of ral Sierra Leone. the country was struggling to recover from civil war Health and Sanitation Objective: To compare, in the periods before and during (MoHS), Bonthe Sherbro and already had serious deficiencies in its health system Island, Bonthe District, the Ebola virus disease outbreak, 1) the submission and and considerable health worker shortages.2,7 The Ebola Sierra Leone completeness of monthly human immunodeficiency virus outbreak adversely affected the quality of health service 2 Academic Model Providing (HIV) reports, and 2) the uptake of HIV testing and care Access to Health Care delivery, and had a major impact on health-seeking be- (AMPATH), Eldoret, Kenya for pregnant women and the general population. haviour and access to care in the community.8,9 3 International Union Design: A cross-sectional study using routine pro- Against Tuberculosis and In all three countries in the region, including Sierra Lung Disease, Paris, France gramme data. Leone, the outbreak led to disruption of the tuberculo- 4 Ministry of Health, Results: Of the 627 HIV reports expected in each period, Government of Karnataka, sis (TB), human immunodeficiency virus/acquired im- Mangalore, India 406 (65%) were submitted in the pre-Ebola period and mune-deficiency syndrome (HIV/AIDS) and malaria 5 London School of Hygiene & Tropical Medicine, 376 (60%) during the Ebola outbreak (P = 0.08), of 10 programmes. In Sierra Leone, a large proportion of London, UK which respectively 318 (78%) and 335 (89%) had com- clinics offering services for pregnant women with HIV 6 MoHS, Mattru Jong, plete information (P < 0.001). In the pre-Ebola period, Bonthe District, Sierra were reported to have closed, as had a large propor- Leone 5012 pregnant women underwent testing for HIV, of tion of clinics providing HIV testing and antiretroviral whom 25 were HIV-positive, compared to 4254 during CORRESPONDENCE therapy (ART), resulting in reported decreases Abdul Hameed Gamanga the Ebola period, of whom 21 were HIV-positive (P < throughout the country in the number of people with Bonthe Government Hospital Ministry of Health and 0.001). Of those who were HIV-positive, respectively 14 10 HIV being started and retained on therapy. Similar Sanitation (56%) and 21 (100%) received antiretroviral prophylaxis problems were reported in neighbouring Guinea.11 Madina Street or antiretroviral therapy (ART) (P < 0.001). In the general Bonthe Sherbro Island The extent and details of the disruption to HIV di- Sierra Leone population, 5770 persons underwent HIV testing pre-Eb- agnostic and treatment services requires further assess- e-mail: hameedgamanga@ ola vs. 3095 in the Ebola period (P < 0.001); of those ment to prevent this from happening again should gmail.com who tested positive for HIV, respectively 62% (33/53) another Ebola outbreak threaten the health-care sys- KEY WORDS and 81% (33/41) were started on ART (P = 0.06). tem and services. A rapid method of assessment is to antiretroviral therapy; Conclusion: There was suboptimal reporting on HIV/ac- PMTCT; pregnant women; observe whether HIV diagnostic and treatment ser- SORT IT; operational research quired immune-deficiency disease syndrome activities be- vices differed at the district level before and during the fore and during the Ebola virus disease outbreak. HIV Ebola epidemic. testing decreased during the Ebola outbreak, while the Bonthe District, one of 14 medical districts in Sierra uptake of prevention of mother-to-child transmission and Leone, is situated in a remote area in the south of the ART increased. Pre-emptive actions are needed to main- country. This was the district least affected by the Eb- tain the levels of HIV testing in any future outbreak. ola outbreak, with only five recorded cases (the first on 18 May 2015 and the last on 20 December 2015). The measures put in place, i.e., quarantining, re- bola virus disease is a zoonotic, filovirus infection stricted travel, a ‘no touch’ policy and repurposing of Ethat is part of a group of diseases known as viral health-care workers, were nevertheless imposed in all haemorrhagic fevers.1 Transmission occurs through districts of the country, and we were interested to close contact with the body fluids of infected patients; know whether this resulted in disruption of pro- the disease can therefore spread rapidly, especially grammes in a remote district that was not directly or where health systems are fragile and under-resourced.2,3 severely affected by the outbreak. The 2014 Ebola outbreak in West Africa started in The aim of this study was therefore to determine Guinea in December 2013 and spread rapidly to Liberia whether the diagnosis and treatment of people living and Sierra Leone.4 By 3 January 2016, 28 637 cases had with HIV, including pregnant women, differed before been reported in the region, of whom 11 315 were Ebola and during the Ebola outbreak period in the known to have died.5 The extent of the outbreak com- Bonthe District of Sierra Leone. Specific objectives pelled the World Health Organization (WHO) to de- during the two periods were to document the submis- clare an international public health emergency in sion and completeness of monthly reporting for HIV Received 30 September 2016 Accepted 20 February 2017 2014.6 Sierra Leone was the most heavily burdened data, the uptake of HIV testing and care for pregnant country, with almost half of all cases.5 The outbreak women attending antenatal clinics and HIV testing PHA 2017; 7(S1): S10–S15 started in Sierra Leone in May 2014 and was declared and treatment in the general population. © 2017 The Union Public Health Action SORT IT: Liberia and Sierra Leone S11 TABLE The national response to HIV/AIDS in Sierra Leone ACKNOWLEDGEMENTS This research was conducted National response through the Structured Operational Research and The National AIDS Commission and the National AIDS Secretariat provide the leadership and coordination of the HIV/AIDS Training Initiative (SORT IT), a global partnership led by the response. The National AIDS Control Programme, within the MoHS, is responsible for implementation of the national Special Programme for response, which before and during the Ebola epidemic was guided by the multi-sectoral National Strategic Plan of 2011– Research and Training in 201514 Tropical Diseases at the World Health Organization (WHO/ On 1 December 2015, the MoHS launched the 2016 strategy of reducing new HIV infections to zero, in line with the UNAIDS TDR, Geneva, Switzerland). 15 90–90–90 strategy The training model is based Guidelines for HIV testing, PMTCT and ART were developed when HIV/AIDS became a problem in the country, and these are on a course developed jointly regularly updated in line with WHO guidance. The country currently uses ‘Option B’ for PMTCT, and both before and during by the International Union Against Tuberculosis and the Ebola epidemic the 2010 WHO guidelines were followed for ART initiation based on CD4 cell count < 350 cells/μl and Lung Disease (The Union, 16,17 WHO clinical staging Paris, France) and Médecins Progress in terms of the country’s HIV status (HIV prevalence, new HIV infections and AIDS deaths) and national response (HIV Sans Frontières (MSF, Geneva, Switzerland). The specific testing, PMTCT and ART uptake) are provided by annual national AIDS response progress reports; the latest, published in SORT IT programme that 14 2015, reported data for the previous 2 years resulted in this publication was jointly developed and HIV = human immunodeficiency virus; AIDS = acquired immune-deficiency syndrome; MoHS = Ministry of Health and Sanitation; UNAIDS = Joint implemented by the WHO/ United Nations Programme on HIV/AIDS; PMTCT = Prevention of Mother-to-Child Transmission; ART = antiretroviral treatment; WHO = World TDR, the Sierra Leone Health Organization. Ministry of Health and Sanitation (Freetown), the WHO Country Office for Sierra Leone (Freetown) and METHODS living with HIV/AIDS (PLHIV), of whom 4700 were the Centre for Operational children.14 New HIV infections and AIDS-related Research, The Union. Study design Mentorship and the deaths were estimated at 2700 for the year. ART cover- This was a comparative cross-sectional study assessing coordination/facilitation of age in 2014 was 38%, i.e., 10 289/26 495 PLHIV receiv- the SORT IT workshops were monthly reporting and HIV diagnosis and treatment at provided through the Centre ing ART. Prevention of mother-to-child transmission the district level by the use of routine record systems. for Operational Research, The (PMTCT) coverage with antiretroviral (ARV) prophy- Union; The Union South-East Asia Office (New Delhi, Setting laxis, with either single-dose nevirapine at labour or India); the Ministry of Health, General setting: country and district with zidovudine during pregnancy, was much better, Government of Karnataka (Bangalore, India); the Sierra Leone, a small
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