All community health workers (CHWs) in rural Kenema District, Sierra Leone. CHW programmes provide basic health services to fill gaps in human health resources. We compared trends in the reporting and management of childhood malaria, diarrhoea and pneumonia by CHWs before, during and after the Ebola outbreak (2014-2016). Retrospective cross-sectional study using programme data. CHW reporting increased from 59% pre-outbreak to 95% during the outbreak ( < 0.001), and was sustained at 98% post-outbreak. CHWs stopped using rapid diagnostic tests for malaria mid-outbreak, and their use had not resumed post-outbreak. The average monthly number of presumptive treatments for malaria increased from 2931 pre-outbreak to 5013 during and 5331 post-outbreak ( < 0.001). The average number of monthly treatments for diarrhoea and pneumonia decreased from respectively 1063 and 511 pre-outbreak to 547 and 352 during the outbreak ( = 0.01 and = 0.04). Post-outbreak pneumonia treatments increased (mean 1126 compared to pre-outbreak, = 0.003), and treatments for diarrhoea returned to pre-outbreak levels ( = 0.2). The CHW programme demonstrated vulnerability, but also resilience, during and in the early period after the Ebola outbreak. Investment in CHWs is required to strengthen the health care system, as they can cover pre-existing gaps in facility-based health care and those created by outbreaks.

No abstract

Where antiretroviral therapy is available, the primary source of mortality among HIV-infected people is the delay in starting treatment. Many of these delays occur in the context of care and are modifiable through changes in the protocols followed by healthcare providers for HIV testing, staging and preparation of patients for antiretroviral therapy. A number of potential evidence-based interventions are discussed in the context of sub-Saharan Africa. Included are decentralizing services, initiating counseling on antiretroviral therapy without delay, tracing patients that miss appointments, protecting patient confidentiality, reducing user fees, and providing point-of-care tests for CD4 cell counts, cryptococcal antigen, and for the diagnosis of TB.