**3. Results**

#### *3.1. COVID-19 Cases, Deaths and General Effects on Health Services*

There was a gradual increase in COVID-19 cases and deaths during the 12 months, with 105,648 cases and 1,854 deaths reported to WHO by the end of February 2021 (Figure 1).

**Figure 1.** Cumulative number of COVID-19 cases and deaths in Kenya between March 2020 and February 2021, as reported to the World Health Organization.

In terms of general effects on services, there was a national lockdown between March 2020 and the end of June 2020. The lockdown resulted in enforced travel restrictions, shorter working hours and intermittent closures of health facilities (due to lack of personal protective equipment and sickness of healthcare workers from COVID-19). Many staff, including those working in TB and HIV, were repurposed for COVID-19 work. After the period of lockdown, there was a widespread strike by health workers, many of whom refused to come to work from November 2020 to January 2021. This resulted in some health facilities having to temporarily close down or partially close down again. There had also been previous widespread strike action in the health sector in the pre-COVID-19 period from July to October 2019. Finally, there was widespread fear and stigma about COVID-19 in the community, with people reluctant to visit health facilities due to fear of contracting COVID-19 and being diagnosed with the disease.

#### *3.2. TB Case Finding, Diagnosis and Registration*

There was an overall decrease in the aggregate numbers of persons presenting with presumptive PTB and being diagnosed and registered with TB in the COVID-19 period when compared to the pre-COVID-19 period (Table 1).


**Table 1.** Characteristics of persons with presumptive pulmonary TB and registered TB in 18 health facilities in Nairobi,Kenya, during pre-COVID-19 and COVID-19 periods.

> \* absolute change (increase or decrease); TB = tuberculosis; PTB = pulmonary tuberculosis.

For presumptive PTB, the overall decrease was greater in children (50.2%) than in adults (27.3%) and greater in females (35.2%) than in males (26.0%). The yield of bacteriologically positive PTB in those investigated for presumptive TB increased (0.1%) marginally. For registered TB, the overall decrease was greater in bacteriologically confirmed PTB and was similar for the other two types (clinically diagnosed PTB and EPTB). The percentage of patients who were newly HIV tested out of those eligible for testing slightly decreased (1.7%).

The monthly number of people presenting with presumptive PTB and those registered for TB in the pre-COVID-19 and COVID-19 periods are shown in Figure 2A,B. The footnotes in the figures indicate the interventions put in place from August 2020 onwards to counteract the downward trends. Compared with the pre-COVID-19 period, the decline in presumptive TB in the first six months of the COVID-19 pandemic (March to August 2020) was 53.2%, which was very different to the 5.2% increase observed in the second six

months (September 2020 to February 2021). The decline in registered TB in the first six months of the COVID-19 pandemic was 34.7%, which was greater than the 19.9% decrease observed in the second six months.

Interventions applied from August 2020 onwards to counteract the decline in numbers included: (i) integrated screening and fast-tracking of investigations for TB and COVID-19 in patients presenting with respiratory symptoms; (ii) active TB case finding in hot spots in the city; (iii) enhanced TB case finding that included screening of TB through mobile phones using a dedicated USSD dialing code, asking patients to dial into a toll-free TB screening call center staffed by healthcare workers and use of automated TB screening machines positioned at strategic spots in the community; (iv) active tracing of close contacts of index patients; and (v) improved TB screening among people living with HIV.

**B** 

**Figure 2.** (**A**) Numbers presenting each month with presumptive PTB in 18 health facilities in Nairobi, Kenya, during pre-COVID-19 and COVID-19 periods (**B**) Numbers presenting each month with registered TB in 18 health facilities in Nairobi, Kenya, during pre-COVID-19 and COVID-19 periods.

#### *3.3. TB Treatment Outcomes*

The overall aggregate treatment outcomes between the pre-COVID-19 and COVID-19 periods are shown in Table 2. There was a slight increase in treatment success in the COVID-19 period (2.0%), mainly due to an overall decrease in patients "not evaluated" (2.2%). Other adverse programme outcomes were similar between the two periods.

**Table 2.** Treatment outcomes in TB patients enrolled for treatment in 18 health facilities in Nairobi, Kenya, during pre-COVID-19 and COVID-19 periods.


\* absolute change (increase or decrease); TB = tuberculosis; treatment outcome was considered "treatment success" when the TB patient was either cured or had "treatment completed". The success rate was calculated for the month-wise cohort of TB patients commenced on treatment eight months before the reporting month (considering six months of treatment to be completed and another two months to finalize the recording of outcomes).

> The monthly treatment success rates in the pre-COVID-19 and COVID-19 periods are shown in Figure 3. The footnotes indicate the interventions put in place from August 2020 onwards to counteract the downward trends. Compared with the pre-COVID-19 period, the decline in treatment success in the first six months of COVID-19 was 2.5%, which was very different to the 9.7% increase observed in the second six months.

Enrollment occurred eight months before the month of reporting (to allow for six months treatment and two months to follow-up and record the final outcome); interventions applied from August 2020 onwards to counteract the decline in numbers included: (i) longer appointments for TB drugpick-ups; (ii) phone adherence counselling; (iii) home visits for missed appointments; and (iv) attention made to reducing those "not evaluated" by proactively seeking information from the facilities to which patients were transferred. 

**Figure 3.** Treatment success among those enrolled each month in 18 health facilities in Nairobi, Kenya, during pre-COVID-19 and COVID-19 periods.

#### *3.4. HIV Testing Among Those Visiting the Health Facilities and Referral to ART*

There was an overall aggregate decrease in numbers tested for HIV between the pre-COVID-19 and COVID-19 periods (see Table 3). The overall decrease was greater in adults (50.8%) than in children (43.0%) and almost the same between males (51.2%) and females (50.2%). There was a slight increase in the HIV-positivity rate (1.1%), and the proportion of those HIV-positive referred to ART (1.7%) in the COVID-19 period.

**Table 3.** Characteristics of persons tested for HIV and referred for antiretroviral therapy in 18 health facilities in Nairobi, Kenya, during pre-COVID-19 and COVID-19 periods.


\* absolute change (increase or decrease); ART = antiretroviral therapy.

The monthly numbers tested for HIV in the pre-COVID-19 and COVID-19 periods are shown in Figure 4. Numbers were already declining in the pre-COVID period due to several factors that included: promotion of HIV self-testing, with the referral of only those HIV-positive to the health facilities for confirmation of the result; a large number of people already tested in the capital city through various testing campaigns; and more targeted testing of high-risk groups. The decline in HIV testing stabilized once COVID-19 appeared. The more targeted testing strategies and confirmation of HIV self-testing results might have explained the increase in HIV positivity from March 2020 onwards.

Footnotes: interventions applied from August 2020 onwards to counteract the decline in numbers included: (i) vans used to deliver HIV services to key populations in their homes; (ii) community health volunteers reaching out to people who did not know their HIV status; (iii) HIV testing of partners of infected patients was increased; (iv) longer appointments for ART drug pick-ups; (v) treatment buddies who helped with collecting medicines for children; and vi) community deliveries of ART.

**Figure 4.** Numbers presenting each month for HIV testing in 18 health facilities in Nairobi, Kenya, during pre-COVID-19 and COVID-19 periods.

The HIV/AIDS programme implemented several interventions from August 2020 onwards to counteract the low numbers presenting for HIV testing (see Figure 4, footnotes). Compared with the pre-COVID period, the decline in HIV-testing in the first six months of COVID-19 was 59.6%, which was greater than the 39.8% decline observed in the second six months.
