Services In sub-Saharan Africa Research Articles

Quantitative remote sensing of forest ecosystem services in sub-Saharan Africa's urban landscapes: a review.

A dearth of information on urban ecosystem services in the past decades has led to little consolidation of such information for informed planning, decision-making and policy development in sub-Saharan African cities. However, the increasing recognition of the value of urban ecological processes and services as well as their contribution to climate change adaptation and mitigation has recently become an area of great research interest. Specifically, the emerging geospatial analytical approaches like remote sensing have led to an increase in the number of studies that seek to quantify and map urban ecosystem services at varying scales. Hence, this study sought to review the current remote sensing trends, challenges and prospects in quantifying urban ecosystem services in sub-Saharan Africa cities. Literature shows that consistent modelling and understanding of urban ecosystem services using remotely sensed approaches began in the 1990s, with an average of five publications per year after around 2010. This is mainly attributed to the approach's ability to provide fast, accurate and repeated spatial information necessary for optimal and timely quantification and mapping of urban ecosystem services. Although commercially available high spatial resolution sensors (e.g. the Worldview series, Quickbird and RapidEye) with higher spatial and spectral properties have been valuable in providing highly accurate and reliable data for quantification of urban ecosystem services, their adoption has been limited by high image acquisition cost and small spatial coverage that limits regional assessment. Thus, the newly launched sensors that provide freely and readily available data (i.e. Landsat 8 and 9 OLI, Sentinel-2) are increasingly becoming popular. These sensors provide data with improved spatial and spectral properties, hence valuable for past, current and future urban ecosystem service assessment, especially in developing countries. Therefore, the study provides guidance for future studies to continuously assess urban ecosystem services in order to achieve the objectives of Kyoto Protocol and Reducing Emissions from Deforestation and forest Degradation (REDD +) of promoting climate-resilient and sustainable cities, especially in developing world.

Increased Mortality in HIV Infected Individuals with Tuberculosis: A Retrospective Cohort Study, Addis Ababa, Ethiopia.

BackgroundTuberculosis is one of the commonest coinfections and leading causes of death among people living with HIV in resource-limited countries. There is limited evidence on the short- and long-term mortality rate in people receiving antiretroviral therapy and coinfected by tuberculosis in sub-Saharan Africa, where the burden of coinfection is highest.PurposeThis study aimed to compare mortality among HIV positives with and without tuberculosis coinfection receiving antiretroviral therapy in Addis Ababa, Ethiopia.MethodsHIV positives’ medical records were reviewed between 2011 to 2018 and identified 7038 HIV-positive adults enrolled for antiretroviral therapy in Addis Ababa. The outcome of interest for this study was death. A parametric Gompertz regression model was applied to compare mortality between HIV with tuberculosis coinfection versus HIV without tuberculosis.ResultsOverall, 1123 (15.96%, 95% CI: 15.11–16.83%) individuals with HIV had tuberculosis coinfection at antiretroviral therapy enrollment. After adjusting for age, sex, education, marital status, cotrimoxazole therapy, body mass index, baseline CD4 cell count, and year in ART enrollment, HIV positives with tuberculosis coinfection had more than twice a higher overall mortality risk than HIV positives without tuberculosis coinfection (AHR: 2.53; 95% CI 1.63–3.91, p < 0.001).ConclusionThis large retrospective cohort study reveals significantly higher mortality in HIV and tuberculosis coinfected group. This suggests the need for enhanced utility of integrated HIV and tuberculosis health services in sub-Saharan Africa where tuberculosis prevalence is highest.

Mapping evidence of community health workers delivering physical rehabilitation services in sub-Saharan Africa: a scoping review protocol

IntroductionSub-Saharan Africa (SSA) is one of the low-income regions in the world which is affected by the critical shortage of human resources for health amid a high disease burden, including...

The effectiveness and characteristics of mHealth interventions to increase adolescent's use of Sexual and Reproductive Health services in Sub-Saharan Africa: A systematic review.

mHealth innovations have been proposed as an effective solution to improving adolescent access to and use of Sexual and Reproductive Health (SRH) services; particularly in regions with deeply entrenched traditional social norms. However, research demonstrating the effectiveness and theoretical basis of the interventions is lacking. Our aim was to describe mHealth intervention components, assesses their effectiveness, acceptability, and cost in improving adolescent's uptake of SRH services in Sub-Saharan Africa (SSA). This paper is based on a systematic review. Twenty bibliographic databases and repositories including MEDLINE, EMBASE, and CINAHL, were searched using pre-defined search terms. Of the 10, 990 records screened, only 10 studies met the inclusion criteria. The mERA checklist was used to critically assess the transparency and completeness in reporting of mHealth intervention studies. The behaviour change components of mHealth interventions were coded using the taxonomy of Behaviour Change Techniques (BCTs). The protocol was registered in the 'International Prospective Register for Systematic Reviews' (PROSPERO-CRD42020179051). The results showed that mHealth interventions were effective and improved adolescent's uptake of SRH services across a wide range of services. The evidence was strongest for contraceptive use. Interventions with two-way interactive functions and more behaviour change techniques embedded in the interventions improved adolescent uptake of SRH services to greater extent. Findings suggest that mHealth interventions promoting prevention or treatment adherence for HIV for individuals at risk of or living with HIV are acceptable to adolescents, and are feasible to deliver in SSA. Limited data from two studies reported interventions were inexpensive, however, none of the studies evaluated cost-effectiveness. There is a need to develop mHealth interventions tailored for adolescents which are theoretically informed and incorporate effective behaviour change techniques. Such interventions, if low cost, have the potential to be a cost-effective means to improve the sexual and reproductive health outcomes in SSA.

Application of the Water Service Sustainability Index to water services in sub-Saharan Africa: the case studies of eight councils in the Southern region of Cameroon (Central Africa)

Abstract The aim of this article is to assess the sustainability of rural water service in the Mvila Division (Southern region of Cameroon) in order to constructively feed the debate on the most effective ways to improve access to rural water service in sub-Saharan Africa. The methodological approach was based on the application of the Water Service Sustainability Index (WSSI) and was implemented through technical inspection of the rural drinking water supply system (RDWSS), the semi-structured interview, and a survey of 103 service providers. Results show that the sustainability performance of rural water service in the Mvila Division is poor–medium. The highest aggregate value of the WSSI was obtained in the Mvangan council (59.54%) followed by the Ngoulemakong council (47.99%), Biwong Bulu (38.53%), Efoulan (33.99%), Biwong Bane (31.51%), Ebolowa I (28.96%), Ebolowa II (28.19%), and Mengong (26.57%). Results also show that rural water service is influenced by factors such as the low pricing of rural water service, climate risk, the poor structuring of the maintenance chain, and the weak commitment of the municipal authorities. However, this study represents only a current snapshot of rural water service delivery conditions and should be conducted at regular intervals to track changes in overall and local conditions.

ChMedical Care of Infants with Down Syndrome in Sub-Sahara Africa; Challenges and the Way Forwardallenges In Managing Children With Down Syndrome In Sub-Saharan Africa; And The Way Forward

Down syndrome is the most common chromosomal malformation, it affects multiple organs, necessitating a need for medical care for different systems. The care needed by infants with Down syndrome is complex and needs planning and coordination at different levels. Medical services in Sub-Saharan Africa are not robust and face challenges in providing accessible and affordable health care. We will review the situation of the medical care provided to infants with Down Syndrome, looking at diagnosis, counselling, and management within the Sub-Saharan context. Exploring the challenges and suggesting recommendations.

PLACE DE LA GASTRECTOMIE DANS LA PRISE EN CHARGE DES CANCERS DE L’ESTOMAC : A PROPOS DE 68 CAS A BOBO DIOULASSO

Introduction : Gastric cancer is at the forefront of digestive cancers in the surgical service in Sub-Saharan Africa. His management is however faced with the delay in diagnosis. We propose to situate the place of gastrectomy in the treatment of cancers in our context. Patients and Methods : This was a 3.5-year retrospective descriptive study that included all patients with confirmed gastric cancer. The therapeutic and pronogsis aspects were the parameters studied. Survival was appreciated by the Kaplan Meier method. Results : We have identified 68 patients including 44 men and 24 women. The average age was 55.3 ± 14. The operability and resectability rates were 69.1% and 59.6% (28/47). Laparoscopy for suspicion of peritoneal carcinomatosis prevented subsequent laparotomy in 6 cases. 4/5 gastrectomy and D1.5 dissection was performed in 18 cases (38.3%) and total gastrectomy in 2 cases. Morbidity and early mortality were 21% (n = 10) and 8.5% (n = 4) respectively, observed in older adults. The overall survival of operated patients was 35% at 1 year and 22.2% at 2 years. The 1-year survival of curative patients was better (50%) than that of patients who received palliative surgery (20%) (p = 0.04). Conclusion: The resection rate for curative purposes remains the challenge to detect early cases, and the addition of perioperative chemotherapy to improve survival. Keywords: Gastric cancer, Surgery, Survival, Souro Sanou Teaching Hospital

Understanding the landscape of electrophysiology services for children in sub-Saharan Africa.

Incidence of epilepsy is greatest in infancy and childhood; this is especially evident in sub-Saharan Africa (SSA). The aim of this study was to understand access to electrophysiology services in SSA including which health practitioner performs and interprets paediatric electroencephalogram (EEG) studies as well as their training in paediatric EEG. A web-based survey was sent to a cohort of health care practitioners who manage children with epilepsy in SSA. The questions addressed whether EEG was available to these health care practitioners, how the practitioners accessed EEG and who assisted interpretation of the study results. The survey was circulated (June-December 2019) to 305 participants from 32 African countries. A total of 73 (16 partial and 57 complete) surveys were returned from 18 countries. The respondents fell into two main categories: those with access to an EEG machine (44/73; 60%) and those without access to an EEG machine (29/73; 40%). For 32% (23/73), there was no dedicated technician and for 34% (25/73) no neurologist. Access to a neurologist resulted in the highest proportion of EEGs performed per annum. Of the respondents, 77% (56/73) agreed that there was a need for a paediatric apprenticeship in EEG skills. Qualitative data to justify need for paediatric EEG training was grouped into three themes: (1) "professional development"; (2) "better care"; and (3) "help paediatric patients and neurologists". There is a lack of paediatric EEG training amongst doctors and technicians working with epilepsy in SSA. Expanding training beyond current capacity in SSA, for technicians and practitioners involved in EEG, is necessary.

Surgical Capacity in Rural Southeast Nigeria: Barriers and New Opportunities.

Background:Remarkable gains have been made in global health with respect to provision of essential and emergency surgical and anesthesia care. At the same time, little has been written about the state of surgical care, or the potential strategies for scale-up of surgical services in sub-Saharan Africa, southeast Nigeria inclusive.Objective:The aim was to document the state of surgical care at district hospitals in southeast Nigeria.Methods:We surveyed 13 district hospitals using the World Health Organization (WHO) tool for situational analysis developed by the “Lancet Commission on Global Surgery” initiative to assess surgical care in rural Southeast Nigeria. A systematic literature review of scientific literatures and policy documents was performed. Extraction was performed for all articles relating to the five National Surgical, Obstetric and Anesthesia Plans (NSOAPs) domains: infrastructure, service delivery, workforce, information management and financing.Findings:Of the 13 facilities investigated, there were six private, four mission and three public hospitals. Though all the facilities were connected to the national power grid, all equally suffered electricity interruption ranging from 10–22 hours daily. Only 15.4% and 38.5% of the 13 hospitals had running water and blood bank services, respectively. Only two general surgeon and two orthopedic surgeons covered all the facilities. Though most of the general surgical procedures were performed in private and mission hospitals, the majority of the public hospitals had limited ability to do the same. Orthopedic procedures were practically non-existent in public hospitals. None of the facilities offered inhalational anesthetic technique. There was no designated record unit in 53.8% of facilities and 69.2% had no trained health record officer.Conclusion:Important deficits were observed in infrastructure, service delivery, workforce and information management. There were indirect indices of gross inadequacies in financing as well.

When distance matters: Mapping HIV health care underserved communities in sub-Saharan Africa.

Despite efforts to increase the proportion of individuals diagnosed with HIV who receive anti-retroviral therapy, 28% of people living with HIV (PLHIV) aged 15 years and older in eastern and southern Africa and 42% in western and central Africa were not receiving anti-retroviral therapy in 2019. Therefore, improving access to health care services is key to reduce HIV incidence and prevalence. The main aim of this study was to generate high-resolution maps of underserved areas where people cannot access the closest health care facilities within appropriate travel time in sub-Saharan Africa (SSA). Main sources of data for this study were the estimated number of PLHIV for adults aged 15-49 years in 47 countries in SSA and the global map of travel time to the nearest health care facility by motorized and non-motorized transportation. These data were used to estimate and map the number of PLHIV in underserved areas at a travel distance of 10, 30, and 60 minutes from the nearest healthcare facility. We identified and mapped more than 7 million PLHIV in the areas with a lack of access to health care within 10-minute travel time and 1.5 million PLHIV in the areas with a lack of access to health care within 60-minute travel time. The identified locations of underserved areas are an indicator of the challenge faced by PLHIV in accessing health services in SSA, a situation that is likely worsened by the COVID-19 pandemic. These findings can contribute to developing cost-effective geospatial policies for interventions aimed at underserved areas at a finer resolution for communities that have usually been identified in aggregated spatial areas. Further development and implementation of tailored intervention and treatment programs, especially in areas identified as underserved for PLHIV, should be explored. Geospatial analyses could complement the decision-making process with stakeholders to enhance healthcare access for PLHIV in SSA.

Effects of the Coronavirus Disease 2019 Pandemic on Human Immunodeficiency Virus Services: Findings from 11 Sub-Saharan African Countries.

BackgroundDue to concerns about the effects of the coronavirus disease 2019 (COVID-19 pandemic on health services, we examined its effects on human immunodeficiency virus (HIV) services in sub-Saharan Africa.MethodsQuarterly data (Q1, 10/2019–12/2019; Q2, 1/2020–3/2020; Q3, 4/2020–6/2020; Q4, 7/2020–9/2020) from 1059 health facilities in 11 countries were analyzed and categorized by stringency of pandemic measures. We conducted a difference-in-differences assessment of HIV service changes from Q1–Q2 to Q3–Q4 by higher vs lower stringency.ResultsThere was a 3.3% decrease in the number HIV tested from Q2 to Q3 (572 845 to 553 780), with the number testing HIV-positive declining by 4.9% from Q2 to Q3. From Q3 to Q4, the number tested increased by 10.6% (612 646), with an increase of 8.8% (23 457) in the number testing HIV-positive with similar yield (3.8%). New antiretroviral therapy (ART) initiations declined by 9.8% from Q2 to Q3 but increased in Q4 by 9.8%. Across all quarters, the number on ART increased (Q1, 419 028 to Q4, 476 010). The number receiving viral load (VL) testing in the prior 12 months increased (Q1, 255 290 to Q4, 312 869). No decrease was noted in VL suppression (Q1, 87.5% to Q4, 90.1%). HIV testing (P < .0001) and new ART initiations (P = .001) were inversely associated with stringency.ConclusionsAfter initial declines, rebound was brisk, with increases noted in the number HIV tested, newly initiated or currently on ART, VL testing, and VL suppression throughout the period, demonstrating HIV program resilience in the face of the COVID-19 crisis.

Regulating sanitation services in sub-saharan africa: An overview of the regulation of emptying and transport of faecal sludge in 20 cities and its implementation

Onsite sanitation is widely used in Sub-Saharan African (SSA) cities. Safe transportation and emptying of the resulting faecal sludge are essential for healthy cities. Typically provided by an informal and unmonitored private sector, these services are being increasingly regulated. This research provides an overview of the regulatory mechanisms in place in 20 cities across SSA, their implementation and emerging common trends. Findings highlight the diversity of tools, mechanisms, and capabilities. We conclude that incremental and pragmatic change is needed to achieve fully regulated services, with adequate implementation particularly facilitated by support and incentive mechanisms, and participation of all stakeholders.

Stated Preference Research in Reproductive and Maternal Healthcare Services in Sub-Saharan Africa: A Systematic Review

Understanding the preferred choice of healthcare service attributes for women is important, particularly in sub-Saharan Africa where resources are constrained and improving reproductive and maternal healthcare services is of high importance. The aim of this systematic review was to identify attributes of reproductive and maternal healthcare services in sub-Saharan Africa, and summarise the factors shaping women's preference to access these services. PubMed/MEDLINE, EMBASE, PsycINFO and CINAHL were searched from the inception of each database until March 2021 for published studies reporting stated preferences for maternal and reproductive healthcare services in sub-Saharan Africa. Data were extracted using a predefined extraction sheet, and the quality of reporting of included studies was assessed using PREFS and ISPOR (International Society for Pharmacoeconomics and Outcomes Research) checklists. The Donabedian's model for quality of healthcare was used to categorise attributes into "structure", "process" and "outcome". A total of 13 studies (12 discrete choice experiments and one best-worst scaling study) were included. Attributes related to the structure of healthcare services (e.g. availability of technical equipment, medications or diagnostic facilities, having good system conditions) are often included within the studies, and are considered the most important by women. Of the three dimensions of quality of healthcare, the outcome dimension was the least frequently studied across studies. All except one study explored women's preferences and the participants were pregnant women, women aged 18-49 years who had recently given birth and women living with human immunodeficiency virus. The included studies came from five sub-Saharan Africa countries of which Ethiopia and South Africa each contributed three studies. All of the included studies reported on the purpose, findings and significance of the study. However, none of the studies reported on the differences between responders vs non-responders. Nine of the 13 studies employed the ISPOR checklist and reported each item including the research question and the methods for identifying and selecting attributes, and provided the findings in sufficient detail and clarity. Aligning maternal healthcare service provision with women's preferences may foster client-oriented services and thereby improve service uptake and better patient outcomes.

Successes and challenges of speech language therapy service provision in Western Kenya: Three case studies.

BackgroundThe need for communication-related services in sub-Saharan Africa to support individuals experiencing communication disability is a longstanding and well-documented situation. We posit the inequities highlighted by coronavirus disease 2019 (COVID-19) make this a relevant time for speech language therapists and the professional bodies that govern us to broadly consider our roles and practices in education, health and disability in local, national and global contexts.ObjectiveTo illustrate what services developed with local knowledge can look like in Kenya in order to promote dialogue around alternative speech language therapy models, particularly in contexts where there are insufficient services, few trained speech language therapists and limited structures to support the emerging profession.MethodThis article examines three clinical case studies from Western Kenya, using a conceptual framework for responsive global engagement.ResultsService needs in Western Kenya well exceed a direct one-on-one model of care that is common in the minority world. The service delivery models described here emphasise training, skills sharing and engaging the myriad of communication partners available to individuals with communication disabilities.ConclusionWe offer up these case studies of collaborative practice as contextual realities that may be present in any speech language therapy programming in under-resourced communities. We dispel the idea that success in this work has been linear, progressed on planned time frames or come to fruition with targeted goal attainment. The fact that our relationships have endured in these communities since 2007 is our primary success.

The development of a Community Mental Health Education and Detection (CMED) tool in South Africa

BackgroundLow demand for mental health services in sub-Saharan Africa is driven by poor mental health literacy, stigma, and poor service availability. ObjectiveTo develop a Community Mental Health Education and Detection (CMED) Tool for adults for use by community health teams in South Africa aligned with their roles of health promotion, screening and linkage to care. MethodsFormative evaluation methods involving four processes: (1) Ongoing engagement with the KwaZulu-Natal Department of Health (KZN DoH) to ensure co-creation of the CMED tool and alignment with routine community health team activities; (2) Adaptation of the CMED tool from the Community Informant Detection Tool (CIDT), used to promote help-seeking of people with mental health problems in Nepal; (3) Review of the CMED vignettes and illustrations by a panel of local and international mental health care experts to establish accuracy and contextual and cultural relevance; (4) Process mapping and focus group discussions (FGDs) with community health teams in one district to establish cultural and contextual appropriateness as well as coherence and compatibility with existing community-based services. ResultsThe resulting CMED tool consists of five case vignettes and related illustrations to facilitate psychoeducation and the detection of possible depression, anxiety, psychosis, harmful alcohol use, and drug use by community health teams. Based on prototype matching, it includes two structured questions to guide the community health teams in the detection and referral process. The tool was acceptable, culturally and contextually appropriate, and helpful for the services provided by community health teams. Challenges of working in households and the importance of self-care were highlighted as important considerations when developing training content and piloting the tool. ConclusionExtensive consultation with the KZN DoH, community health teams, and the expert mental health panel resulted in developing a tool that was perceived to be culturally sensitive and relevant to the community package of services.

The case for gynaecologist-led point of care ultrasound services in sub-Saharan Africa.

The case for gynaecologist-led point of care ultrasound services in sub-Saharan Africa.

Increased infectious-cause hospitalization among infants who are HIV-exposed uninfected compared with HIV-unexposed.

Increased risk of morbidity and hospitalization has been observed in children who are HIV-exposed uninfected (HEU) compared with HIV-unexposed uninfected (HUU). Studies in the era of universal maternal antiretroviral treatment (ART) are limited. Prospective cohort. We investigated hospitalization between 29 days and 12 months of life in a South African cohort of infants born between February 2017 and January 2019 (HEU = 455; HUU = 458). All mothers known with HIV during pregnancy received ART. We reviewed hospital records and classified and graded infectious diagnoses using a standardized tool. We examined factors associated with infectious-cause hospitalization using mixed-effects Poisson regression. Infants HEU vs. HUU had higher all-cause and infectious-cause hospitalization (13 vs. 7%, P = 0.004 and 10 vs. 6%, P = 0.014, respectively). Infectious causes accounted for most hospitalizations (77%). More infants HEU were hospitalized with severe or very severe infections than those HUU (9 vs. 6%; P = 0.031). Mortality (<1%) did not differ between groups. HIV exposure was a significant risk factor for infectious-cause hospitalization [adjusted incidence rate ratios (aIRRs) = 2.8; 95% confidence interval (CI) 1.5-5.4]. Although increased incidence of preterm birth (14 vs. 10%; P < 0.05) and shorter duration of breastfeeding (44 vs. 68% breastfed for ≥3 months, P < 0.001) among infants HEU vs. HUU contributed to increased hospitalization, they did not account for all the increased risk. Infectious-cause hospitalization incidence was higher among infants HEU vs. HUU, likely partly because of higher incidence of preterm birth and lower breastfeeding rates among infants HEU. The increased infectious disease burden in HEU infants has important implications for health services in sub-Saharan Africa.

Private emptiers' perspectives on the regulation of faecal sludge emptying services in Sub-Saharan Africa

AbstractUsing a two-round Delphi study, 15 faecal sludge emptiers from 11 cities in Sub-Saharan Africa have expressed views on the regulation of faecal sludge emptying services. Their responses identify the regulatory mechanisms in place where they operate, their opinions of these mechanisms, and prioritisation of those considered most useful to enable safe emptying services for all urban residents. All respondents (100%) support regulation, with 80% finding the regulation they encounter useful. However, all also state that regulatory mechanisms should extend beyond only rules and sanctions, to incorporate support, incentives and pro-poor mechanisms. This study is the first to provide a first-hand account of Sub-Saharan African private emptiers' willingness to accept clear regulation. In that regard, regulation should be flexible and adapted to the context in order to facilitate fair competition, safe and satisfactory service for customers and workers alike, and to alleviate the public and environmental health risks.

Shaping service delivery through faith-based service inclusion: the case of the Salvation Army in Zambia

Purpose While service inclusion principles raise the awareness of scholars to service that improves holistic well-being, little research explicitly investigates the spiritual dimensions of service inclusion. This study, therefore, aims to explore faith-based service inclusion in sub-Saharan Africa. Design/methodology/approach A qualitative case study of the Salvation Army’s Chikankata Services in Zambia was undertaken. Semi-structured interviews with the organization’s leaders and professionals were analyzed thematically. Findings Service inclusion pillars evince contextualized meaning and priority. In resource-constrained, vulnerable communities, faith-based service inclusion prioritizes two additional pillars – “fostering eudaimonic well-being” and “giving hope,” where existence is precarious, fostering (hedonic) happiness is of low priority. Findings reveal that pillars and processes are mutually reinforcing, harnessed by the individual and collective agency to realize transformative outcomes from service inclusion. Research limitations/implications This paper provides unique insight into faith-based service inclusion but acknowledges limitations and areas warranting further research. Practical implications The study yields important managerial implications. Service providers can use the framework to identify the contextual priority and/or meaning of service inclusion pillars and relevant reciprocal processes. The framework emphasizes the harnessing potential of individual agency and capability development for transformative well-being. Social implications Faith-based service inclusion, predicated on inclusion, human dignity and holistic well-being, has important implications for reducing the burden on scarce resources while building resilience in communities. Originality/value By examining a faith-based service in sub-Saharan Africa, this paper provides a holistic framework conceptualizing pillars, processes, agency and outcomes to extend Fisk et al.’s (2018) service inclusion pillars and to better understand the shaping of service delivery for service inclusion.

HIV services in sub-Saharan Africa: the greatest gap is men

40 years ago the first cases of what would become known as AIDS were reported by the US Centers for Disease Control and Prevention.1 Since then, millions of lives have been lost, but gradually remarkable progress has been made across the HIV continuum of care. By 2019, 81% of people living with HIV (PLHIV) worldwide knew their status, 82% of these were on antiretroviral therapy (ART), and 88% of individuals on ART were virologically suppressed.2 These averages, however, mask substantial variability between and within regions.