<div> <span>Making Hydroxyurea Boring: Converting a Proven Generic into Routine Sickle Cell Care</span> </div>

Background. Hydroxyurea has been shown to reduce painful crises in sickle cell anaemia since a randomised trial was stopped early for benefit three decades ago (Charache et al., 1995), while long-term follow-up associated its use with reduced mortality (Steinberg et al., 2010). Concerns that these findings might not apply in malaria-endemic Africa were tested directly and were not supported: among 606 children across four African countries, treatment was associated with substantial reductions in sickle cell events, transfusion, malaria and death (Tshilolo et al., 2019). Extended follow-up over 4,340 patient-years confirmed these benefits without excess toxicity (Aygun et al., 2024).

The problem. Nigeria has the world's largest sickle cell burden, with approximately 100,700 affected births annually (Nnodu et al., 2021), and manufactures hydroxyurea domestically. Yet a national survey found that only 48.5% of surveyed patients had ever used it. Among prescribers, the leading barrier was perceived side effects (67.1%), rather than cost (Okocha et al., 2022). The gap between evidence and treatment is therefore not primarily one of evidence, price or regulatory status.

Argument. This paper argues that hydroxyurea in Nigeria is administered as though it were a specialist cytotoxic agent when it should be treated as an essential chronic medicine. Four structural barriers are identified: monitoring requirements disproportionate to observed toxicity; inadequate prescriber confidence reinforced by the absence of an authoritative protocol; supply chains without a dedicated budget line; and measurement systems that count prescriptions rather than sustained treatment.

Contribution. The paper proposes a three-tier delivery model that shifts continuation and refills to primary care while reserving complex initiation for specialist centres; two dosing protocols matched to laboratory capacity, including a simplified regimen supported by recent Nigerian operational evidence (Nri-Ezedi et al., 2025); a monitoring schedule calibrated to observed dose-limiting toxicity rather than inherited caution; a financing sequence informed by Ghana's inclusion of hydroxyurea in a national benefit package (Ofori-Acquah et al., 2023; Segbefia et al., 2025); and indicators focused on treatment retention rather than prescriptions written.