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.

The authors have declared no competing interest.

Clinicaltrials.gov NCT06360783

https://www.medrxiv.org/content/10.1101/2024.10.25.24316111v1

This work was supported by Open Society Foundations, the Conrad N. Hilton Foundation, and Pfizer. The donors have no role in the design or analysis of this implementation research study.

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This study was approved by the Duke University Institutional Review Board (Pro00111388), The study was also approved by local institutional review boards in each country: the Ghana Health Services Ethics Review Committee (017/11/22), the National Health Sciences Research Committee, Malawi (#23/03/4025), the Rwanda National Research Ethics Committee (105/RNEC/2023) and the Institutional Review Board ERES Converge (Zambia) (23-Jan-023).

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