Providing TB and HIV outreach services to internally displaced populations in Northeast Nigeria: Results of a controlled intervention study

Autoři: Suraj A. Abdullahi aff001;  Marina Smelyanskaya aff002;  Stephen John aff003;  Haruna I. Adamu aff004;  Emperor Ubochioma aff005;  Ishaya Kennedy aff006;  Fatima A. Abubakar aff007;  Haruna A. Ago aff008;  Robert Stevens aff009;  Jacob Creswell aff002
Působiště autorů: SUFABEL Community Development Initiative, Gombe, Nigeria aff001;  Stop TB Partnership, Geneva, Switzerland aff002;  Janna Health Foundation, Yola, Adamawa State, Nigeria aff003;  World Health Organization, North East Zonal Office, Bauchi, Nigeria aff004;  National TB, Leprosy & Buruli Ulcer Control Programme, Abuja, Nigeria aff005;  Ministry of Health, Gombe, Nigeria aff006;  Ministry of Health, Yola, Adamawa State, Nigeria aff007;  Yobe State TB & Leprosy Control Programme, Damaturu, Nigeria aff008;  Independent Consultant, Manchester, United Kingdom aff009
Vyšlo v časopise: Providing TB and HIV outreach services to internally displaced populations in Northeast Nigeria: Results of a controlled intervention study. PLoS Med 17(9): e32767. doi:10.1371/journal.pmed.1003218
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003218



A decade of Boko Haram insurgency brought conflict, mass displacement, and the destruction of basic infrastructure to Northeast Nigeria. Over 2 million internally displaced persons (IDPs) suffering from lack of basic hygienic conditions, malnutrition, and disease live in camps or are hosted by communities in the region, where the conflict has contributed to a massive destruction of health facilities. Infectious diseases like tuberculosis (TB) and HIV are especially difficult to address under such conditions, and IDPs are vulnerable to both. Although international investment supports some health interventions among IDPs, locally sourced solutions are lacking.

Methods and findings

We evaluated the impact of an active case finding (ACF) intervention for TB and testing for HIV in IDP communities and provided linkages to treatment in 3 states in Northeast Nigeria: Adamawa, Gombe, and Yobe. The ACF was a component of a multistakeholder collaboration between government, civil society, and IDP community partners, which also included mapping of IDP populations and health services, supporting existing health facilities, developing a sample transport network, and organizing community outreach to support ACF. Between July 1, 2017, and June 30, 2018, ACF was conducted in 26 IDP camps and 963 host communities in 12 local government areas (LGAs) with another 12 LGAs serving as a control population. Outreach efforts resulted in 283,556 screening encounters. We screened 13,316 children and 270,239 adults including 150,303 (55.6%) adult women and 119,936 (44.4%) men. We tested 17,134 people for TB and 58,976 for HIV. We detected 1,423 people with TB and 874 people living with HIV. We linked 1,419 people to anti-TB treatment and 874 people with HIV to antiretroviral treatment sites. We evaluated additional TB cases notified and conducted comparative interrupted time series (ITS) analyses to assess the impact of ACF on TB case notifications. Through our efforts, bacteriologically confirmed TB notifications increased by 847 (45.1%) during the intervention period, with IDPs accounting for 46% of these notifications. The ITS analyses detected significant positive postintervention trend differences in TB notification rates between the intervention and control areas in all forms TB (incidence rate ratio [IRR] = 1.136 [1.072, 1.204]; p ≤ 0.001) and bacteriologically positive TB (IRR = 1.141 [1.058, 1.229]; p = 0.001). The TB prevalence (502 cases per 100,000 screening encounters) was 10 times the national notification rates and 2.3 times the estimated national incidence. Rates of HIV infection (1.8%) were higher than HIV prevalence estimates in the 3 states. Our study was limited by the nonrandom selection of LGAs. Furthermore, we did not use sensitive screening tools like chest X-ray and likely missed people with TB.


In this study, we observed a burden of TB in IDP populations of Northeast Nigeria many times higher than national rates and HIV rates higher than state level estimates. The impact of the intervention showed that ACF can greatly increase TB case notifications. Engaging IDP communities, local governments, and civil society organizations is essential to ensuring the success of interventions targeting TB and HIV, and such approaches can provide sustained solutions to these and other health crises among vulnerable populations.

Klíčová slova:

Antiretroviral therapy – Health care facilities – HIV – HIV epidemiology – Nigeria – Tuberculosis – Tuberculosis diagnosis and management – Virus testing


1. International Organization for Migration (IOM) [Internet]. Displacement Tracking Matrix, International Organization of Migration, Nigeria. [cited 2019 Sep 16]. Available from:

2. Ekezie W, Timmons S, Myles P, Siebert P, Bains M, Pritchard C. An audit of healthcare provision in internally displaced population camps in Nigeria. J Public Health. 2019 Sep 30;41(3):583–592. doi: 10.1093/pubmed/fdy141 30137460

3. Taylor-Robinson SD, Oleribe O. Famine and disease in Nigerian refugee camps for internally displaced peoples: a sad reflection of our times. QJM Int J Med. 2016 Dec;109(12):831–834. doi: 10.1093/qjmed/hcw171 27795293

4. International Organization for Migration (IOM) [Internet]. Nigeria, displacement tracking matrix. Round 18 report. 2017 [cited 2019 Sep 16]. Available from:

5. UN Office for the Coordination of Humanitarian Affairs (UNOCHA). Nigeria: 2019 humanitarian needs overview. 2019 [cited 2019 Sep 16] Available from:

6. Omole O, Welye H, Abimbola S. Boko Haram insurgency: implications for public health. Lancet. 2015;385:941. doi: 10.1016/S0140-6736(15)60207-0

7. Food Security Cluster [Internet]. FICHE report: Cadre Harmonisé for Identification of Risk Areas and Vulnerable Populations in Sixteen (16) States and the Federal Capital Territory (FCT) of Nigeria. 2018 Oct [cited 2019 Sep 20]. Available from:

8. Nigeria Centre for Disease Control [Internet]. Disease situation reports. [cited 2019 Sep 18]. Available from:

9. Borno State launches first Malaria Operational Plan, reawakens fight against malaria [Internet]. In: WHO | Regional Office for Africa. [cited 2019 Sep 18]. Available from:

10. ACAPS [Internet]. Thematic report –24 May 2017, Nigeria, health in the Northeast. 2017 May [2019 Sep 20]. Available from:

11. Nigeria prevalence rate [Internet]. National Agency for the Control of AIDS (NACA) Nigeria. [cited 2019 Oct 2]. Available from:

12. UNAIDS [Internet]. New survey results indicate that Nigeria has an HIV prevalence of 1.4%. [cited 2019 Oct 2]. Available from:

13. UNAIDS [Internet]. Number of people living with HIV. In: AIDSinfo. [cited 5 May 2020]. Available from:

14. World Health Organization [Internet]. Global Tuberculosis report 2018. Geneva, Switzerland: WHO; 2018 [cited 2019 Oct 2]. Available from:

15. Aregbeshola BS, Khan SM. Primary health care in Nigeria: 24 years after Olikoye Ransome-Kuti’s leadership. Front Public Health. 2017;5. doi: 10.3389/fpubh.2017.00048 28349050

16. Kronfol NM, Mansour Z. Tuberculosis and migration: a review. East Mediterr Health J. 2013;19: 739–748. 24975360

17. Dhavan P, Dias HM, Creswell J, Weil D. An overview of tuberculosis and migration. Int J Tuberc Lung Dis. 2017;21: 610–623. doi: 10.5588/ijtld.16.0917 28482955

18. Eboreime E, Obi FA. How Boko Haram is devastating health services in North-East Nigeria. In: The Conversation [Internet]. [cited 2019 Oct 3]. Available from:

19. World Health Organization [Internet]. Implementing the End TB Strategy: the essentials. 2015 [cited 2019 Oct 2]. Available from:

20. Stop TB Partnership [Internet]. Key populations brief: mobile populations. 2016 [cited 2019 Oct 2]. Available from:

21. Marsh M, Purdin S, Navani S. Addressing sexual violence in humanitarian emergencies. Glob Public Health. 2006;1: 133–146. doi: 10.1080/17441690600652787 19153902

22. World Health Organization. Contributing to health system strengthening: Guiding principles for national tuberculosis programmes. 2008 [cited 2019 Oct 2]. Available from:

23. Justman JE, Koblavi-Deme S, Tanuri A, Goldberg A, Gonzalez LF, Gwynn CR. Developing Laboratory Systems and Infrastructure for HIV Scale-Up: A Tool for Health Systems Strengthening in Resource-Limited Settings. JAIDS J Acquir Immune Defic Syndr. 2009;52:S30. doi: 10.1097/QAI.0b013e3181bbc9f5 19858935

24. Blok L, Creswell J, Stevens R, Brouwer M, Ramis O, Weil O, et al. A pragmatic approach to measuring, monitoring and evaluating interventions for improved tuberculosis case detection. Int Health. 2014;6: 181–188. doi: 10.1093/inthealth/ihu055 25100402

25. State population, 2006 [Internet]. Nigeria data portal. [cited 2019 Oct 3]. Available from:

26. Naitonal Population Commission. 2006 Population and Housing Census, Federal Republic of Nigeria [Internet]. 2017 [cited 2019 Oct 3]. Available from:

27. National guidelines for HIV prevention treatment and care–Nigeria [Internet]. National AIDS and STI’s Control Programme. Federal Ministry of Health, Nigeria; 2016 [cited 2019 Oct 3]. Available from:

28. Ködmön C, Zucs P, van der Werf MJ. Migration-related tuberculosis: epidemiology and characteristics of tuberculosis cases originating outside the European Union and European Economic Area, 2007 to 2013. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull. 2016;21(12). doi: 10.2807/1560-7917.ES.2016.21.12.30164 27039665

29. Kimbrough W, Saliba V, Dahab M, Haskew C, Checchi F. The burden of tuberculosis in crisis-affected populations: a systematic review. Lancet Infect Dis. 2012;12:950–965. doi: 10.1016/S1473-3099(12)70225-6 23174381

30. The national strategic plan for tuberculosis control 2015–2020 [Internet]. National Tuberculosis and Leprosy Control Programme, Department of Public Health, Federal Ministry of Health, Nigeria; 2014 [cited 2019 Oct 3]. Available from:

31. Stop TB Partnership [Internet]. TB diagnosis and treatment targets. 2018 [cited 2019 Oct 3]. Available from:

32. Joint initiative “FIND. TREAT. ALL. #ENDTB.” In: WHO. [cited 2019 Oct 4]. Available from:

33. Stop TB and Global Fund deepen cooperation to find missing cases of TB [Internet]. [cited 4 Oct 2019]. Available from:

34. Challenge TB: annual report year 4 [Internet]. United States Agency for International Development (USAID); 2019 [cited 3 Oct 2019]. Available from:

35. Corbett EL, Bandason T, Duong T, Dauya E, Makamure B, Churchyard GJ, et al. Comparison of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a cluster-randomised trial. Lancet. 2010;376: 1244–1253. doi: 10.1016/S0140-6736(10)61425-0 20923715

36. Yassin MA, Datiko DG, Tulloch O, Markos P, Aschalew M, Shargie EB, et al. Innovative community-based approaches doubled tuberculosis case notification and improve treatment outcome in Southern Ethiopia. PLoS ONE. 2013;8: e63174. doi: 10.1371/journal.pone.0063174 23723975

37. van’t Hoog AH, Meme HK, Laserson KF, Agaya JA, Muchiri BG, Githui WA, et al. Screening strategies for tuberculosis prevalence surveys: the value of chest radiography and symptoms. PLoS ONE. 2012;7: e38691. doi: 10.1371/journal.pone.0038691 22792158

38. Kim AA, Malele F, Kaiser R, Mama N, Kinkela T, Mantshumba J-C, et al. HIV infection among internally displaced women and women residing in river populations along the Congo River, Democratic Republic of Congo. AIDS Behav. 2009;13: 914–920. doi: 10.1007/s10461-009-9536-z 19319674

39. Spiegel PB. HIV/AIDS among conflict-affected and displaced populations: dispelling myths and taking action. Disasters. 2004;28: 322–339. doi: 10.1111/j.0361-3666.2004.00261.x 15344944

40. Omba JK. Sexual violence in the Democratic Republic of Congo: impact on public health? Med Trop Rev Corps Sante Colon. 2008;68: 576–578.

41. Patel S, Schechter MT, Sewankambo NK, Atim S, Kiwanuka N, Spittal PM. Lost in transition: HIV prevalence and correlates of infection among young people living in post-emergency phase transit camps in Gulu District, Northern Uganda. PLoS ONE. 2014;9: e89786–e89786. doi: 10.1371/journal.pone.0089786 24587034

42. Women in displacement camps in Nigeria resort to transactional sex for survival | Africa Renewal [Internet]. [cited 2020 May 5]. Available from:

43. Supervie V, Halima Y, Blower S. Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries. AIDS Lond Engl. 2010;24: 2841–2847. doi: 10.1097/QAD.0b013e32833fed78 20859191

44. Griffiths K, Ford N. Provision of antiretroviral care to displaced populations in humanitarian settings: a systematic review. Med Confl Surviv. 2013;29: 198–215. doi: 10.1080/13623699.2013.813108 24133930

45. The Government of Nigeria. NAIIS preliminary findings, March 2019 [Internet]. 2019 [cited 2020 May 5]. Available from:

46. Nsikan A, Sunkanmi F, Peter D, Joseph J, Emmanuel O, Paul Y, et al. PMTCT Service Uptake among Pregnant Women in 3 Internally Displace Persons Camps in Borno State Northeast Nigeria. J Adv Med Med Res. 2020;32(4):72–77.

47. UNHCR. Nigeria situation 2017 [Internet]. 2017 [cited 2019 Oct 3]. Available from:

48. United Nations Development Programme. National human development report 2018 [Internet]. Achieving human development in North East Nigeria. Nigeria; 2018 [cited 2019 Oct 3]. Available from:

49. Awojobi O. The socio-economic implications of Boko Haram insurgency in the North-East of Nigeria. Int J Innov Sci Res. 2014;11: 144–150.

50. Biquet J-M. Haiti: between emergency and reconstruction. An inadequate response. Int Dev Policy. 2013;4.3:129–135. doi: 10.4000/poldev.1600

51. Pham PN, Gibbons N, Vinck P. The United Nations material assistance to survivors of cholera in Haiti: consulting survivors and rebuilding trust. PLoS Curr. 2017;9. doi: 10.1371/currents.dis.1b01af244fe3d76d6a7013e2f1e3944d 29188126

52. West Africa’s Ebola epidemic is out of control, but never had to happen [Internet]. O’Neill Instititue; 2014 Aug [cited 2019 Oct 3]. Briefing paper no. 9. Available from:

53. The Ebola response in West Africa: exposing the politics and culture of international aid. In: ODI [Internet]. [cited 2019 Oct 3]. Available from:

54. World Health Organization. Ebola virus disease: Democratic Republic of the Congo. External situation report 61 [Internet]. 2019 Oct [cited 2020 May 5]. Available from:

55. Thiam S, Delamou A, Camara S, Carter J, Lama EK, Ndiaye B, et al. Challenges in controlling the Ebola outbreak in two prefectures in Guinea: why did communities continue to resist? Pan Afr Med J. 2015;22. doi: 10.11694/pamj.supp.2015.22.1.6626 26740850

56. Onozaki I, Law I, Sismanidis C, Zignol M, Glaziou P, Floyd K. National tuberculosis prevalence surveys in Asia, 1990–2012: an overview of results and lessons learned. Trop Med Int Health TM IH. 2015;20: 1128–1145. doi: 10.1111/tmi.12534 25943163

Článek vyšel v časopise

PLOS Medicine

2020 Číslo 9

Nejčtenější v tomto čísle
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se