Recommendations for Enhancing COVID-19 Test and Treat Programs in Four African Countries: Insights and Strategies from a Qualitative Study

Sub-Saharan Africa had a significant burden of infections and deaths from COVID-19. However, throughout the pandemic, the region experienced delays and more limited access to diagnostics and treatment than high-income countries. From late 2022 to 2023, nirmatrelvir/ritonavir was introduced in four sub-Saharan African countries (Ghana, Malawi, Rwanda and Zambia) in a test and treat (T&T) model. This manuscript aims to understand the perspectives of key stakeholders, Ministry of Health, public sector personnel and health care workers on the recommendations for improvement and strengthening of national COVID-19 T&T programs deployed in the four study countries. We conducted in-depth, semi-structured interviews with individuals from two key stakeholder groups: Ministry of Health or public sector personnel involved in developing and/or implementation of COVID-19 T&T policy (purposive sampling) and healthcare workers involved in administering COVID-19 testing and/or treatment at study sites (convenience sampling). Sample size was driven by information power; our target sample size was ten to 12 interviews per stakeholder group per country. We conducted a descriptive qualitative study to explore recommendations for improvement and strengthening of national COVID-19 T&T programs using the Consolidated Framework for Implementation Research to guide qualitative data collection and analysis. Four key themes were identified by key stakeholders as critical to scaling up COVID-19 T&T programs across all study countries: increasing community education, engagement and awareness of COVID-19 and the T&T program; adjusting the T&T program to ensure program integration, decentralization and sustainability; expansion of SARS-COV-2 testing and ensuring availability of testing kits and oral antivirals through reliable national supply chains; and ensuring ongoing training and support for healthcare workers on the COVID-19 T&T program. Our finding, that recommendations were largely common across countries, suggest that a unifying framework for introducing new drugs through T&T programs during future pandemics in Sub-Saharan countries may be possible, particularly when implementation strategies can be customized to fit local contexts.