**1. Introduction**

On 11 March 2020, the World Health Organization (WHO) declared a global pandemic of coronavirus disease 2019 (COVID-19), caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). By the end of 2020, nearly 80 million cases of COVID-19 and 1.8 million deaths had been reported globally to the organization [1]. In the first few months of the global pandemic, the epicenters of the pandemic were China, Europe and the USA, and there was concern that Africa, with its large volume of air traffic connections with these countries, would be the next region hit hard by COVID-19 [2,3].

At the beginning of the COVID-19 pandemic, political attention, healthcare workers, resources and finances were directed to the health sector to enable it to cope with the looming crisis. There was also quarantine, restricted movement and increased time spent indoors by the general population. All of this led to concerns that countries with high burdens of tuberculosis (TB) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) might be unable to provide uninterrupted and quality healthcare services to their patients [4]. It was thought that health-seeking behavior and access to care for affected patients might also be adversely affected [5].

Similarities were drawn with the Ebola virus disease outbreak in Sierra Leone and Liberia in 2014, which took the two West African countries by surprise. Through restrictions in travel, "no-touch" policies and community fear of health facilities, the ability of the national TB programmes in these countries to diagnose TB and continue with HIV testing of TB patients was adversely affected, and, in the case of Liberia, treatment success rates in TB patients declined [6,7]. HIV testing capabilities for the general population decreased in both countries, although access to antiretroviral therapy (ART) was maintained [8,9]. Early on in the COVID-19 pandemic, The Stop TB Partnership and WHO issued guidance about how people with TB could protect themselves and how national TB programmes might adapt to the COVID-19 pandemic and national lockdowns [10,11]. UNAIDS provided similar advice to people living with HIV [12]. This global advice was augmented by urgen<sup>t</sup> calls for practical planning to tackle the looming threat of COVID-19 in Africa [5,13].

We, therefore, set up a pilot project to measure the burden of COVID-19 and assess its impact on TB and HIV services in three Sub-Saharan African countries, Kenya, Malawi and Zimbabwe. This is the report from Kenya.

The first COVID-19 case reported to WHO by Kenya was on the 14 March 2020. By 15 April, Kenya had reported 216 COVID-19 cases (with nine deaths) [14]. How severe the COVID-19 storm would be, how long it would last and what impact it would have on public health services for TB and HIV/AIDS, was unknown. It was felt that being prepared, however, was key to being able to cope. Guinea in West Africa, for example, weathered the Ebola virus disease storm and managed to uphold TB services during this challenging period [15].

Relevant public health authorities in Kenya (including the National Tuberculosis, Leprosy and Lung Disease Programme (NTLD-P), the National AIDS & STI Control Programme (NASCOP) and the Respiratory Society of Kenya), working in close collaboration with the International Union Against Tuberculosis and Lung Disease (The Union), the Special Programme for Research and Training in Tropical Disease at WHO (TDR) and Vital Strategies (RESOLVE) therefore aimed at the early stage of the COVID-19 pandemic to strengthen the routine and real-time monitoring and evaluation system for TB and HIV case detection. The quarterly (every three months) recording and reporting system was strengthened in selected health facilities in the capital city of Nairobi by recording and reporting on TB and HIV parameters every month. We hypothesized that if there were decreases in TB case detection, diagnosis and treatment, and reductions in persons presenting for HIV testing or those diagnosed HIV-positive being referred for ART, then programmes could act more quickly on monthly information than quarterly information to try and reverse these trends.

The overall aim of the study was to determine the impact of the COVID-19 pandemic on TB programme activities and HIV services through strengthened real-time surveillance in 18 selected health facilities in Nairobi, Kenya. The specific objectives were on a monthly basis to: (i) document the increase in nationally reported cases and deaths due to COVID-19 and its effects on general health services; (ii) collect, collate and report on specific TB and HIV-related parameters during the COVID-19 period (March 2020–February 2021), (iii) document the programmatic responses to changes in TB and HIV diagnosis and treatment during the COVID-19 period; and (iv) compare the findings with data collected and collated for the same TB and HIV parameters during the pre-COVID-19 period (March 2019–February 2020).

#### **2. Materials and Methods**

### *2.1. Study Design*

This was a cohort study using programmatically collected aggregate data.
