Clinic In Kampala Research Articles

Video-based education messaging to enhance optimal uptake of malaria preventive therapy in pregnant women: a mixed methods study involving pregnant women and midwives in Uganda

BackgroundMalaria prevention during pregnancy significantly minimizes maternal–fetal adverse events. However, optimal uptake of malaria preventive therapy in pregnancy (MPTp) remains a major challenge for both women living with HIV and those without. In Uganda, suboptimal uptake of MPTp is primarily due to inadequate knowledge among women. This study aimed to develop and assess the feasibility and acceptability of an educational video to improve knowledge of MPTp among pregnant women living with and without HIV.MethodsThis study describes the second phase of a mixed methods study conducted among pregnant women (living with and without HIV) and midwives from a public antenatal care clinic in Kampala, Uganda. The study was conducted from October 2022 to Jan 2024, and the first phase involved qualitative data collection from pregnant women, health workers, and Ministry of Health officials to develop a video-based intervention to enhance uptake of MPTp. The second phase involved administration of the developed intervention to a group of purposively selected pregnant women living with and without HIV. Questionnaires, focus group discussions, and interviews were used to collect data among women and midwives, and to assess feasibility and acceptability of the intervention. Quantitative data were summarized using descriptive statistics and analysed using different scales of measurement including the modified system usability scale and the Evidence-based Practice and Attitude Scale (EBPAS), which assessed acceptability among pregnant women and midwives, respectively. The qualitative data were coded and analysed using inductive and deductive thematic methods in Atlas ti.8.ResultsA total of 45 women and six midwives were enrolled in the current study phase. The mean age (± standard deviation, SD) of the women was 26 ± 6 years, and the median gestational age (interquartile range, IQR) was 24 (20–32) weeks, and less than half (42%, n = 19) were living with HIV. On the system usability scale, most women (91%, n = 41) rated the intervention as good or excellent, and most (93%, n = 42) were satisfied or very satisfied with the intervention. On the EBPAS, midwives perceived the intervention as reliable with Cronbach’s alpha of 0.74, and all midwives found the intervention appropriate and feasible in their facility. All women comprehended and highly accepted the intervention.ConclusionThe video-based intervention for uptake of MPTp was found acceptable among women and midwives and was feasible and appropriate to a public health facility. Future studies would test the effectiveness of the intervention in improving knowledge and uptake of MPTp.

The diagnostic performance of the Visitect Advanced Disease point-of-care CD4 platform: a pragmatic mixed-methods multisite validation, costing, and qualitative analysis.

The Visitect CD4 Advanced Disease test (AccuBio, Alva, United Kingdom) is a rapid, semi-quantitative assay that estimates CD4 results above or below 200 cells/μL. We evaluated the performance of the Visitect CD4 assay in semi-urban laboratories in Uganda. We performed a pragmatic laboratory validation of the Visitect CD4 platform in four routine HIV clinics in Uganda, nested within a cluster randomized trial evaluating an enhanced package of screening and treatment for persons with advanced HIV disease (NCT05085171). As part of the clinical trial, samples processed on the Visitect CD4 platform were confirmed using another CD4 testing method. We compared the diagnostic performance of the Visitect CD4 platform against the confirmatory method by evaluating the sensitivity, specificity, positive and negative predictive values. Of 1495 venous blood samples that were processed both by the Visitect CD4 test and another confirmatory CD4 platform at clinics in Kampala, Uganda, specificity was 81% (95% CI, 79%-84%) and the positive predictive value was 69% (95% CI, 66%-73%). There were no samples for which the Visitect test was >200 cells/μL and the confirmatory test was ≤200 cells/μL, resulting in a sensitivity of 100%. Among Visitect CD4 tests that were read as <200 cells/μL with confirmatory results >200 cells/μL, the median confirmatory CD4 result was 397 (IQR, 281-590) cells/μL. Specificity varied by clinic ranging from 63% to 99%. Given variable specificity of the Visitect CD4 Advanced Disease platform, successful implementation will require consideration of clinic context and laboratory staffing.

Preferences of people living with HIV for features of tuberculosis preventive treatment regimens in Uganda: a discrete choice experiment.

Tuberculosis (TB) preventive treatment (TPT) is recommended for people living with HIV (PLHIV) in high TB burden settings. While 6 months of daily isoniazid remains widely used, shorter regimens are now available. However, little is known about preferences of PLHIV for key features of TPT regimens. From July to November 2022, we conducted a discrete choice experiment among adult PLHIV engaged in care at an urban HIV clinic in Kampala, Uganda. Participants chose between two hypothetical TPT regimens with five different features (pills per dose, frequency, duration, need for adjusted antiretroviral therapy [ART] dosage and side effects), organized across nine random choice tasks. We analysed preferences using hierarchical Bayesian estimation, latent class analysis and willingness-to-trade simulations. Of 400 PLHIV, 392 (median age 44, 72% female, 91% TPT-experienced) had high-quality choice task responses. Pills per dose was the most important attribute (relative importance 32.4%, 95% confidence interval [CI] 31.6-33.2), followed by frequency (20.5% [95% CI 19.7-21.3]), duration (19.5% [95% CI 18.6-20.5]) and need for ART dosage adjustment (18.2% [95% CI 17.2-19.2]). Latent class analysis identified three preference groups: one prioritized less frequent, weekly dosing (N = 222; 57%); another was averse to ART dosage adjustment (N = 107; 27%); and the last prioritized short regimens with fewer side effects (N = 63; 16%). All groups highly valued fewer pills per dose. Overall, participants were willing to accept a regimen of 2.8 months' additional duration [95% CI: 2.4-3.2] to reduce pills per dose from five to one, 3.6 [95% CI 2.4-4.8] months for weekly rather than daily dosing and 2.2 [95% CI 1.3-3.0] months to avoid ART dosage adjustment. To align with preferences of PLHIV in Uganda, decision-makers should prioritize the development and implementation of TPT regimens with fewer pills, less frequent dosing and no need for ART dosage adjustment, rather than focus primarily on duration of treatment.

Sex Differences in the Prevalence of Geriatric Syndromes Among Older People Living with HIV Attending an Urban Outpatient Clinic in Kampala, Uganda.

Older people living with HIV (PLHIV) are at high risk of developing geriatric syndromes. Data on geriatric syndromes among older PLHIV in sub-Saharan Africa are scarce. We examined sex differences in the prevalence and correlates of geriatric syndromes among PLHIV aged ≥60 years on antiretroviral therapy in Kampala, Uganda. This cross-sectional study analyzed data obtained during the enrollment of older PLHIV into a prospective observational cohort in Kampala. We used the Poisson regression model to explore the association between the number of geriatric syndromes and non-communicable diseases (NCDs), sociodemographic factors, and HIV-related factors. We included 500 participants (48.8% women) with a median age of 64 years (interquartile range, IQR: 62.68). Almost all (94.4%) participants had at least one geriatric syndrome. More women were frail (13.1% vs 5.1%, P-value = 0.01) and had lower physical performance measured using the Short Physical Performance Battery (43.3% vs 26.6%, P-value < 0.01).Similarly, more women had cognitive impairment (83.2% vs 62.9%, P-value < 0.01) and reported falling (48.8% vs 34.0%, P-value < 0.01). Women (adjusted mean ratio, AMR 1.17, 95% CI 1.05-1.30, P-value < 0.01), older age (AMR 1.11, 95% CI 1.07-1.16, P-value < 0.01), no formal education (AMR 1.39, 95% CI 1.06-1.82, P-value = 0.01), underweight (AMR 1.49, 95% CI 1.26-1.76, P-value < 0.01), World Health Organization (WHO) stage 3 or 4 (AMR 1.11, 95% CI 0.01-1.22, P-value = 0.04) and having two or more NCDs (AMR 1.11, 95% CI 1.00-1.23, P-value = 0.04) were associated with a higher number of geriatric syndromes. The prevalence of geriatric syndromes was high among older PLHIV and was more common in women. There is a need to incorporate the screening and management of geriatric syndromes into the care of older PLHIV in sub-Saharan Africa, with a particular focus on women.

Usability of a smartphone-compatible, confocal micro-endoscope for cervical cancer screening in resource-limited settings

BackgroundMore efficient methods to detect and treat precancerous lesions of the cervix at a single visit, such as low-cost confocal microscopy, could improve early diagnosis and hence outcomes. We piloted a prototype smartphone-compatible confocal micro-endoscope (SCME) among women presenting to a public cervical cancer screening clinic in Kampala, Uganda. We describe the piloting of the SCME device at an urban clinic used by lower cadre staff.MethodsWe screened women aged 18 and 60 years, who presented for cervical cancer screening at the Kawempe National Referral Hospital Kampala, and evaluated the experience of their providers (nurses). Nurses received a 2-day training by the study doctors on how to use the SCME, which was added to the standard Visual Inspection with Acetic acid (VIA)-based cervical cancer screening. The SCME was used to take colposcopy images before and after VIA at positions 12 and 6 O’clock if VIA negative, and on precancer-suspicious lesions if VIA positive. We used questionnaires to assess the women’s experiences after screening, and the experience of the nurses who operated the SCME.ResultsBetween November 2021 and July 2022, we screened 291 women with a median age of 36 years and 65.7% were HIV positive. Of the women screened, 146 were eligible for VIA, 123 were screened with the SCME, and we obtained confocal images from 103 women. Of those screened with the SCME, 60% found it comfortable and 81% were willing to screen again with it. Confocal images from 79% of the women showed distinguishable cellular features, while images from the remaining 21% were challenging to analyze. Nurses reported a mean score of 85% regarding the SCME’s usefulness to their work, 71% regarding their satisfaction and willingness to use it again, 63% in terms of ease of use, and 57% concerning the ease of learning how to operate the SCME.ConclusionOur findings demonstrate the feasibility of using the SCME by lower cadre staff in low-resource settings to aid diagnosis of precancerous lesions. However, more work is needed to make it easier for providers to learn how to operate the SCME and capture high-quality confocal images.

Evaluating the implementation of weekly rifapentine-isoniazid (3HP) for tuberculosis prevention among people living with HIV in Uganda: A qualitative evaluation of the 3HP Options Trial.

Three months of isoniazid-rifapentine (3HP) is being scaled up for tuberculosis (TB) preventive treatment (TPT) among people living with HIV (PLHIV) in high-burden settings. More evidence is needed to identify factors influencing successful 3HP delivery. We conducted a qualitative assessment of 3HP delivery nested within the 3HP Options Trial, which compared three optimized strategies for delivering 3HP: facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), and patient choice between facilitated DOT and facilitated SAT at the Mulago HIV/AIDS clinic in Kampala, Uganda. We conducted 72 in-depth interviews among PLHIV purposively selected to investigate factors influencing 3HP acceptance and completion. We conducted ten key informant interviews with healthcare providers (HCPs) involved in 3HP delivery to identify facilitators and barriers at the clinic level. We used post-trial 3HP delivery data to assess sustainability. We conducted an inductive thematic analysis and aligned the emergent themes with the RE-AIM framework dimensions to report implementation outcomes. Understanding the need for TPT, once-weekly dosing, shorter duration, and perceived 3HP safety enhanced acceptance overall. Treatment monitoring by HCPs and reduced risk of HIV status disclosure enabled DOT acceptance. Dosing autonomy enabled SAT acceptance. Switching between DOT and SAT as required enabled acceptance for patient choice. Dosing reminders, reimbursement for clinical visits, and social support enabled 3HP completion; pill burden, side effects, and COVID-19-related treatment restrictions hindered completion. All HCPs were trained and participated in 3HP delivery with high fidelity. Training, care integration, and collaboration among HCPs enabled, whereas initial concerns about 3HP safety among HCPs delayed 3HP adoption and implementation. SAT was maintained post-trial; DOT was discontinued due to inadequate ongoing financial support beyond the study period. Facilitated delivery strategies made 3HP treatment convenient for PLHIV and were feasible and implemented with high fidelity by HCPs. However, the costs of 3HP facilitation may limit wider scale-up.

Diagnostic performance of an albuminuria point-of-care test in screening for chronic kidney disease among young people living with HIV in Uganda: a cross-sectional study

ObjectivesThe main aim was to determine the diagnostic performance of an albuminuria point-of-care test (POC) for diagnosis of chronic kidney disease among young people living with HIV (YPLHIV) in Uganda.DesignWe...

Willingness to Use Long-acting Injectable Pre-exposure Prophylaxis Among Key Populations at a Large Hiv Prevention Clinic in Kampala, Uganda: a Cross-sectional Study.

Long-acting injectable (LAI)-PrEP provides better protection against HIV compared to oral PrEP, which requires taking a daily pill. Our study aimed to assess knowledge about oral and LAI-PrEP and identify factors associated with willingness to use LAI-PrEP among key populations (KP) in Uganda. We conducted a cross-sectional study at the Most at Risk Populations Initiative (MARPI) clinic between November and December 2021. Participants were recruited through convenience sampling and interviewed using a structured questionnaire by trained interviewers. Participants were categorised into three groups based on their oral PrEP use: those who had not yet initiated PrEP, those who had discontinued oral PrEP, and those currently on oral PrEP. Modified Poisson regression analysis was performed to determine factors associated with the participant's willingness to use LAI-PrEP. Data was analysed using STATA 14 software. Of the 234 participants, 135 (56.7%) were female, 82.5% knew about LAI-PrEP, and 67.5% were willing to use it. The mean age was 28.7 years (standard deviation [SD] 5.8). Willingness to use LAI-PrEP was less likely among divorced, widowed, or separated individuals than those in relationships (adjusted prevalence ratio [aPR] 0.65, 95% CI: 0.43-0.98). Relative to current oral PrEP users, willingness to use LAI-PrEP was similar among those who discontinued oral PrEP (aPR 1.39, 95% CI: 0.92-2.11) and those who had not yet initiated PrEP but were at risk for HIV (aPR 1.26, 95% CI: 0.83-1.89). In this cross-sectional analysis of diverse members of key populations in Uganda, previous or non-use of oral PrEP was not associated with willingness to use LAI-PrEP relative to current users. Future studies should investigate effective methods for promoting the uptake of long-acting PrEP formulations among populations at high risk of HIV acquisition.

The association between adherence to antiretroviral therapy and viral suppression under dolutegravir-based regimens: an observational cohort study from Uganda.

Millions of people living with HIV (PLWH) take oral antiretroviral therapy (ART), which requires a lifetime of consistent medication adherence. The relationship between adherence and poor HIV outcomes is well documented. Newer ART regimens that include dolutegravir (DTG) could be more forgiving, but empirical evidence on the relationship between adherence and viral suppression under DTG is only emerging. In this observational cohort study (secondary analysis of data from a randomized trial), we used data from 313 ART clients from a large HIV clinic in Kampala, Uganda. Over the 4-year study period (January 2018-January 2022), 91% switched from non-DTG regimens to DTG regimens. We measured adherence using Medication Event Monitoring Systems-caps and extracted prescription information and viral load measures from electronic health records. We estimated unadjusted linear regressions and adjusted models that included individual and time fixed-effects. Under non-DTG regimens, 96% of participants were virally suppressed (defined as viral load < 200 copies/ml) when adherence was 90% or higher in the 3 months before viral load measurement. Viral suppression was 32 percentage points lower when adherence was between 0% and 49% (95% CI -0.44, -0.20, p < 0.01), 12 percentage points lower when adherence was between 50% and 79% (95% CI -0.23, -0.02, p < 0.01), and not significantly different when adherence was between 80% and 89% (effect of 0.00, 95% CI -0.06, 0.07, p = 0.81). In contrast, for participants taking DTG, there was no statistically significant difference in viral suppression among any of the four adherence levels; more than 95% were virally suppressed at each adherence level. On average, switching to DTG increased viral suppression by 6 percentage points in our adjusted models (95% CI 0.00, 0.13, p = 0.03). There was no significant association between adherence levels and viral suppression among PLWH taking DTG regimens, suggesting a high degree of forgiveness for missed doses. The use of DTG should be prioritized over older regimens, particularly for those with low adherence. NCT03494777.

Use of dental care services among adolescents living with HIV on antiretroviral treatment in Kampala, Uganda: a cross-sectional study

ObjectiveThe primary purpose of this study was to assess the prevalence and socio-behavioral determinants of ever-use of dental care services among adolescents aged 10–18 years, living with HIV, on Antiretroviral treatment (ART), and attending selected HIV clinics in Kampala, Uganda.MethodsA cross-sectional study was carried out between March and September 2020. The study conveniently recruited 154 adolescents between 10 and 18 years old from 4 specific HIV clinics in Kampala. Andersen’s behavioral model guided the selection of variables, with the ever-use of dental care services as the outcome and predisposing, enabling, need-related factors and personal dental health practices as exposure variables. Data were analyzed using Fischer’s exact test for cross-tabulation and modified Poisson regression for multivariate analysis.ResultsThe prevalence of ever-use of dental care services was 12.3%. The adolescents aged 14–18 had higher odds of using dental care services (Prevalence ratio (PR) of 3.35 than those aged 10–13 years. Fear of the spread of HIV was negatively associated with ever-use of dental care services (PR of 0.06). Participants who were afraid of going to the dentist had higher odds of using dental care services (PR of 2.98) than those not afraid. Failure to receive dental treatment because it was not part of the medical appointment had a positive association with the ever-use of dental care services (PR of 4.50). Those who were satisfied with their dental condition had lower odds of using dental care services. The bad oral odor was positively associated with the ever-use of dental care services (PR of 2.80). The use of soap for toothbrushing was positively associated with the ever-use of dental care services (PR of 2.51).ConclusionThe study found a low frequency of dental care use among HIV-infected adolescents in Kampala, Uganda, with age being a predisposing factor. Enabling factors included fear of HIV spread, medical-dental appointment incoordination, and satisfaction with the dental condition and bad oral odor while under personal dental health practices. The use of soap for toothbrushing was an important association with dental care. Nevertheless, these study results cannot be generalized to the entire HIV adolescent population in Uganda.

Prevalence and Factors Associated with Impaired Maternal-Infant Bonding among Mothers Attending Young Child Clinic in Kampala, Uganda.

Impaired maternal-infant bonding can have a negative impact on the mother-infant relationship, affecting the social, emotional, and cognitive development of a child. In Uganda, there is a paucity of literature on impaired maternal-infant bonding. This quantitative, cross-sectional study aimed to determine the prevalence and factors associated with impaired maternal-infant bonding. Postnatal mothers (n = 422) attending the Young Child Clinic at Kawempe National Referral Hospital participated in the study. Maternal-infant bonding was measured using the Postpartum Bonding Questionnaire (PBQ). Participants with a score ≥ 13 on the PBQ were considered to have impaired maternal-infant bonding. The prevalence of impaired maternal-infant bonding among mothers was 45% (190/422). Logistic regression was used to determine factors associated with impaired maternal-infant bonding. Unmarried mothers (AOR = 2.05, 95% [CI = 1.03-4.09], p = 0.041), unplanned pregnancy (AOR = 5.19, 95% [CI = 3.07-8.82], p < 0.001), first-time mothers (AOR = 2.46, 95% [CI = 1.37-4.43], p = 0.003), female infant (AOR = 1.80, 95% [CI = 1.13-2.86], p = 0.013), mothers with no/low education levels (AOR = 2.29, 95% [CI = 1.05-4.50], p = 0.036), and those who delivered post term (AOR = 2.49, 95% [CI = 1.10-5.67], p = 0.028) were more likely to have impaired maternal-infant bonding. Nurses and midwives in postnatal care should include maternal-infant bonding within their client's assessment and provide supportive mother-centered care. Interventions to improve maternal-infant bonding should be created and implemented in clinical practice.

Pilot project demonstrating the feasibility of HIV antiretroviral therapy waste bottle collection and recycling

Background HIV remains a leading cause of morbidity and mortality in Uganda. At current levels of antiretroviral therapy (ART) coverage, ART waste bottles are becoming a challenge to both patients and the environment in Uganda. Additionally, ART improperly disposed of in the environment can end up in the food chain and lead to antimicrobial resistance. We aimed to pilot a feasibility study of collecting and recycling the used ART pill bottles at a large urban HIV clinic in Kampala, Uganda. Methods Patients were first engaged randomly during their clinic visits and asked how they disposed of the waste medication bottles. Verbal information on proper disposal options of these medication containers was provided to patients. Patients and caretakers were then encouraged to return the waste medication bottles to the clinic at the time of their next appointment. Posters conveying information about bottle returns were displayed and information leaflets were distributed. Finally, recycling partners were engaged to explore options for the bottles. Results From the group oral engagements performed, patients reported that a means to discreetly dispose of pill bottles was welcome due to the stigma associated with these bottles in the community. They reported previously throwing these bottles in pit latrines, informal rubbish pits, nearby bushes and burning them, all methods that endanger the environment. The process of returning bottles was widely adopted. 53kg of returned bottles were recycled to make each bench that are used by patients in the clinic. Conclusions This pilot study showed a high willingness among people living with HIV to return their used pill bottles. Collecting, storing and recycling was feasible and successful at one large urban HIV clinic in Kampala, Uganda. We, therefore, recommend expanding this model to more HIV clinics country-wide to reduce the environmental impact of HIV programmes.

Abstract P148: Prevalence and Correlates of Overweight and Obesity Among Adults in an Urban HIV Clinic in Uganda

Background: Obesity has become a major comorbidity faced by people living with HIV (PLH). This study aimed to estimate the prevalence and correlates of overweight and obesity among PLH in Uganda. Methods: From June 2016 and February 2020, we conducted a cross-sectional analysis among PLH receiving comprehensive HIV care in a large urban clinic in Kampala, Uganda. We collected data on socio-demographic and behavioral anthropometry, and included variables such as age, marital status, occupation (farmer/other), migration history (rural to urban, urban to rural, consistently rural, consistently urban), contraceptive use history (pills, injections, implants), previous pregnancies (categorized as 0-2, 3-5, ≥6), and socioeconomic status (SES) index variable developed for Ugandan settings. Standardized weight and height assessments were performed with BMI categorization into normal, overweight and obese categories. We performed sex-stratified analysis employing multinomial logistic regression (Stata 18.0) to estimate adjusted relative risk ratios (aRRR) and 95% confidence intervals (CIs) for overweight and obesity compared to under or normal weight., focusing on correlates of overweight in males due to the limited number of obese male participants (n=15). Results: Of 1939 participants aged 18-80 years, 60.2% were female and the median age (IQR) was 43 (35-50) years for females and 47.5 (40-54) years for males. Median body mass index (BMI) was 24.27(21.09-27.99) kg/m2 for females and 21.63 (19.69-24.11) kg/m2 for males. 27.1% and 17.2% were overweight and 16.7% and 2% were obese among females and males, respectively. In adjusted analysis among females, factors positively associated with being overweight were older age (36-50 years: aRRR=1.84; 95% CI:1.26-2.68, &gt;50 years: aRRR=2.16; 95% CI:1.34-2.46), being married (aRRR=2.00; 95% CI:1.46-2.73), middle SES (aRRR=1.47; 95% CI:1.01-2.13), upper SES (aRRR=2.05; 95% CI:1.44-2.90), and rural-to-urban migration (aRRR=1.52; 95% CI:1.05-2.22). Being a farmer was negatively associated with overweight (aRRR=0.42; 95% CI:0.22-0.77). Similar associations were observed with obesity, with ever use of contraception and having had &gt;2pregnancies also significantly associated with increased risk of obesity. For males, being older (36-50 years: aRRR=2.09; 95% CI:1.06-4.11, &gt;50 years: aRRR=2.04; 95% CI:1.01-4.08) and having high SES (aRRR=2.38; 95% CI:1.53-3.70) were positively associated with overweight, while being a farmer was inversely associated (aRRR=0.43; 95% CI:0.20-0.93). Conclusions: High prevalence of overweight and obesity were observed among PLH in Uganda, notably among females. Migration, SES, and reproductive factors were strongly associated with higher BMI. Identified sociodemographic risk factors can guide targeted interventions in this region.

Preference for daily (1HP) vs. weekly (3HP) isoniazid-rifapentine among people living with HIV in Uganda.

Both 1 month of daily (1HP) and 3 months of weekly (3HP) isoniazid-rifapentine are recommended as short-course regimens for TB prevention among people living with HIV (PLHIV). We aimed to assess acceptability and preferences for 1HP vs. 3HP among PLHIV. In a cross-sectional survey among PLHIV at an HIV clinic in Kampala, Uganda, participants were randomly assigned to a hypothetical scenario of receiving 1HP or 3HP. Participants rated their level of perceived intention and confidence to complete treatment using a 0-10 Likert scale, and chose between 1HP and 3HP. Among 429 respondents (median age: 43 years, 71% female, median time on ART: 10 years), intention and confidence were rated high for both regimens. Intention to complete treatment was rated at least 7/10 by 92% (189/206 randomized to 1HP) and 93% (207/223 randomized to 3HP). Respectively 86% (178/206) and 93% (208/223) expressed high confidence to complete treatment. Overall, 81% (348/429) preferred 3HP over 1HP. Both 1HP and 3HP were highly acceptable regimens, with 3HP preferred by most PLHIV. Weekly, rather than daily, dosing appears preferable to shorter duration of treatment, which should inform scale-up and further development of short-course regimens for TB prevention.

Health-related quality of life and hypertension in people with HIV on long-term antiretroviral therapy in Uganda.

The presence of hypertension could reduce the health-related quality of life (HRQoL) of people with HIV (PWH). Yet, literature describing the HRQoL of PWH who have hypertension in Uganda is scarce making the design of locally adapted interventions cumbersome. In our study, we compared HRQoL scores of people with HIV with and without hypertension on long term antiretroviral therapy (ART) in Uganda. We recruited 149 PWH with hypertension and 159 PWH without hypertension in the long-term ART cohort at an urban clinic in Kampala, Uganda. Data on socio-demographics were collected using an interviewer designed questionnaire while data on the World Health Organisation clinical stage viral load and CD4 count as well as ART duration were extracted from clinic electronic database and a generic EuroQol -5D- 5L (EQ-5D- 5L) and Medical Outcome Study (MOS-HIV) questionnaire used to collect HRQoL data. Data were summarized using descriptive statistics while inferential statistics were used to determine associations between key variables and HRQoL. Mann-Whitney U tests were used to compare HRQoL between groups of interest. One hundred ninety (61.7%) participants were female. PWH who had hypertension were older (Mean ± SD: 53.7 ± 8.3 vs 49.9 ± 8.6, p value <0.001) than those without hypertension. Participants with hypertension had lower overall median health utility scores (0.71 (0.33-0.80) vs 0.80 (0.44-0.80), p value = 0.029) and mean physical health score (48.44 ± 10.17 vs 51.44 ± 9.65, p value < 0.001) as opposed to those without hypertension. Hypertension (p value = 0.023), high income status, >70,000 UGX, (p value = 0.044), disclosure of the HIV status of the participants to their partner (p value = 0.026), and current history of smoking (p value = 0.029) were associated with low HRQoL scores. Among people with HIV, those with hypertension had lower HRQoL compared to those without. This calls for inclusion of quality-of-life assessment in the management of PWH who have been diagnosed with hypertension to identify those at risk and plan early interventions.

Uptake of human papilloma virus vaccination among adolescent girls living with HIV in Uganda: A mixed methods study.

Human Papilloma Virus (HPV) vaccination can prevent more than 90% of cancers caused by HPV. Although this vaccination is recommended and provided at no cost to all adolescent girls aged 9 to19 years in Uganda, its uptake remains low. We sought to determine the uptake of, and factors associated with HPV vaccination among adolescent girls living with HIV in Uganda. We conducted an explanatory sequential mixed methods study, among adolescent girls living with HIV, attending HIV care at the Mulago ISS HIV clinic in Kampala, Uganda. We administered a structured questionnaire to elicit data on HPV vaccination and its covariates to a systematic random sample of 264 adolescent girls with HIV. A participant who had received all the three recommended HPV vaccine doses was classified as fully vaccinated. We then conducted four focus group discussions among adolescent girls living with HIV (n = 32), eight in-depth interviews among their parents and five Key informant interviews among their healthcare providers. We conducted descriptive statistics and logistic regression analyses for the quantitative data before thematic analysis for the qualitative data. Of 264 adolescent girls, 31% (83/264) had at least one HPV vaccine dose; 22% (59/264) two doses, while 8.0% (21/264) were fully vaccinated (received three doses). While most participants received their first and second doses (48% (40/83)) and 57.6% (34/59), respectively) from school, the largest number of participants (47.1% (12/21)) received their third dose at community outreaches. Participants who received counseling from community members were three times more likely to get fully vaccinated compared to those who did not receive counseling (aOR 3.28, Cl:1.07-10.08, P = 0.038). From the qualitative follow-up, three major themes were identified: (1): Limited information about HPV vaccination, which gave room for misconceptions and doubts about the vaccine; (2) Parental influence on adolescent decisions was strong despite parents having limited knowledge about HPV vaccination and (3) Inadequacy of HPV vaccination services at the hospital and in the schools. Full HPV vaccination was low among adolescent girls living with HIV. Counseling of the adolescents by community members, alongside HPV vaccination community outreaches, provided a platform for vaccination. There should be strategies to provide adequate information about HPV vaccine to health workers, parents, and the adolescents. In addition to schools, community-based initiatives, including outreaches and lay-health workers can be utilized to improve HPV vaccine uptake among girls with HIV.

Evaluating the implementation of weekly rifapentine-isoniazid (3HP) for tuberculosis prevention among people living with HIV in Uganda: A qualitative evaluation of the 3HP Options Trial.

Three months of isoniazid-rifapentine (3HP) is being scaled up for tuberculosis (TB) preventive treatment (TPT) among people living with HIV (PLHIV) in high-burden settings. More evidence is needed to identify factors influencing successful 3HP delivery. We conducted a qualitative assessment of 3HP delivery nested within the 3HP Options Trial, which compared three optimized strategies for delivering 3HP: facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), and patient choice between facilitated DOT and facilitated SAT at the Mulago HIV/AIDS clinic in Kampala, Uganda. We conducted 72 in-depth interviews among PLHIV purposively selected to investigate factors influencing 3HP acceptance and completion. We conducted ten key informant interviews with healthcare providers (HCPs) involved in 3HP delivery to identify facilitators and barriers at the clinic level. We used post-trial 3HP delivery data to assess sustainability. We used thematic analysis (inductive and deductive) to align the emergent themes with the RE-AIM framework dimensions to report implementation outcomes. Understanding the need for TPT, once-weekly dosing, shorter duration, and perceived 3HP safety enhanced acceptance overall. Treatment monitoring by HCPs and reduced risk of HIV status disclosure enabled DOT acceptance. Dosing autonomy enabled SAT acceptance. Switching between DOT and SAT as needed enabled acceptance of patient choice. Dosing reminders, reimbursement for clinical visits, and social support enabled 3HP completion; pill burden, side effects, and COVID-19-related treatment restrictions hindered completion. All HCPs were trained and participated in 3HP delivery with high fidelity. Training, care integration, prior TPT experience with daily isoniazid, and few 3HP-related serious adverse events enabled adoption, whereas initial concerns about 3HP safety among HCPs, and COVID-19 treatment disruptions delayed 3HP adoption. Refresher training and collaboration among HCPs enabled implementation whereas limited diagnostic facilities for adverse events at the clinic hindered implementation. SAT was modified post-trial; DOT was discontinued due to inadequate ongoing financial support beyond the study period. Facilitated delivery strategies made 3HP treatment convenient for PLHIV and were feasible and implemented with high fidelity by HCPs. However, the costs of 3HP facilitation may limit wider scale-up. Trial registration: ClinicalTrials.gov (NCT03934931); Registered 2nd May 2019; https://clinicaltrials.gov/study/NCT03934931?id = NCT03934931&rank = 1.

Effect of Hydroxyurea Treatment on Body Composition in Children with Sickle Cell Anemia in Uganda Using Bioelectrical Impedance Analysis (BIA)

Introduction Children with sickle cell anemia (SCA) experience severe illness and risk of malnutrition in sub-Saharan Africa. Treatment with hydroxyurea (HU) decreases SCA complications. In high-income regions, hydroxyurea also improves pediatric growth and overall quality of life. We assessed the effects of hydroxyurea on growth and body composition of children with SCA in Uganda. Methods This study was nested in an open-label, single-arm pediatric clinical trial of hydroxyurea 20-30mg/kg/day for prevention of neurological and cognitive impairment. In all, 267 study participants with SCA, ages 3-9 years, initiated hydroxyurea treatment at the Mulago Hospital SCA Clinic in Kampala, Uganda. Anthropometric measurements (weight, height) were obtained at enrollment and at month 18 of therapy; age- and sex-specific z-scores were assigned, per World Health Organization (WHO) international standards. Non-invasive bioelectric impedance analysis (BIA), was used to estimate total body fat mass (FM) and fat-free mass (FFM) at both timepoints. A control sample of110 siblings/family members without SCA, aged 3-12 years, established local z-scores for BIA assessments. Results Among SCA participants and controls, 50.6% and 57.3% were female, respectively. Mean age was younger foror the SCA sample: 5.1±0.1 and 7.1±0.3 years ( p&amp;lt;.001). At trial month 18, mean hydroxyurea dose 25.4mg/kg, SCA hemoglobin rose from 7.8±1.2 to 8.9±1.5 g/dL( p&amp;lt;.001), remaining lower than mean hemoglobin level of non-SCA controls 12.5±1.1 ( p&amp;lt;.001). Using the World Health Organization definition of “wasting,” SCA participants at enrollment had a higher proportion of low weight-for-height than controls: 9.8% vs 3.8%, p=.009). By body composition, the SCA sample also had lower FFM (-0.67±0.56 vs. 0.00 ±1.00, p &amp;lt; .001) and FM (-0.68±0.60 vs. 0.00 ±1.00, p&amp;lt;.001) than controls. At month 18, for the 254 active SCA participants (95.1%), the proportion with wasting was unchanged. In contrast, z-scores for FFM (-0.65±0.57 to -0.16±0.57, p &amp;lt; .001) and FM (-0.66±0.61 to -0.18±0.61, p&amp;lt;.001) significantly increased (Figure) to near control levels. Conclusion Hydroxyurea therapy in children with SCA increased hemoglobin yet did not reduce the proportion with wasting after 18 months. Nonetheless, treatment led to significantly improved FM and FFM to near normal levels. These results suggest that hydroxyurea therapy may play a crucial role in enhancing body composition of children with SCA in the region. The ongoing hydroxyurea trial will enable assessment of longer-term impact on health-related growth and body composition in children with SCA in Uganda.

Sickle Cell Disease and Hydroxyurea Knowledge, Views and Perceptions Among 400 Sickle Cell Patients and Caregivers at Mulago Hospital Sickle Cell Clinic: A Global Health Study in Kampala, Uganda

Background: In 2017, hydroxyurea was approved for the treatment of all sickle cell patients with genotype HbSS in Uganda following overwhelming support from the NOHARM trial conducted in a malaria endemic region at Mulago National Referral Hospital's Sickle Cell Clinic. Between January 2019 and June 2022, immediately following nationwide approval and distribution of hydroxyurea, hydroxyurea was prescribed a total of 4017 (51.2%) times out of the 7851 HbSS patient visits to the clinic according to data available from the clinic. Aims:The purpose of this study is to investigate the knowledge, perceptions, and beliefs of patients with sickle cell disease and their caregivers attending this clinic in Kampala regarding their disease, complications, genetic impact, general anticipated course of treatment or natural history of disease, and hydroxyurea. Methods: A total of 400 (56%) out of 713 patients were surveyed over a 3-week period using standardized, pretested questionnaires administered orally by trained research personnel in both English (253, 63%) and Luganda (147, 36.8%), which are the most common local languages and dialects spoken by patients in Kampala. Three-hundred and twenty-one (80.3%) participants were caregivers and 79 (19.8%) were children with sickle cell disease between 12- and 17-years-old. Results: Most participants reported receiving counseling about sickle cell disease (333; 83.3%) largely by hematologists (286; 85.9%), however, several knowledge gaps were identified. Two-hundred and ninety-seven (74.3%) participants reported not knowing the type of sickle cell or genotype of the patient. Moreover, presentation of various options did not significantly improve recognition of the correct genotype, with only 121 (30.3%) participants correctly identifying HbSS. Three-hundred and twenty-eight (82%) participants correctly identified the heritable transmission of the disease from both parents; however, caregivers exhibited limited understanding of genetic risk with only 31 (9.7%) correctly identifying the one in four chances of having a subsequent child with sickle cell disease when both parents are carriers. Hydroxyurea counseling was reported by 326 (81.5%) of participants, and 307 (76.7%) participants reported that the patient received hydroxyurea, with most patients taking the medication for at least 1 year. Of the 93 (23.5%) participants who identified the patient had never received hydroxyurea, 32 (34.4%) were uncertain if the patient would be eligible and 56 (57%) believed the patient was eligible to take the medication. Participants identified hydroxyurea benefits as decreases in pain (332; 83%), hospitalization (162; 40.8%), need for blood transfusion (148; 37%), need for pain medication (87; 21.8%), infections (42; 61%), weight loss (22; 31.9%), length of hospital stay (18; 4.5%), and incidence of stroke (10; 2.5%). Slightly more than half of patients had no concerns about hydroxyurea (218; 54.5%). Most patients with concerns (182; 45.5%) identified hydroxyurea's high cost as their main concern (141; 77.5%). Other rumors and fears about hydroxyurea included: negative affects on internal organs such as the liver or kidneys (54; 29.7%), other negative side effects (27; 14.8%), inaccessibility in pharmacies and remote areas (18; 10%), harm due to stopping or missing doses (16; 8.8%), ineffectiveness (16; 8.8%), additional indications as a cancer medication (9; 4.9%), and younger children's difficulty swallowing pills (6; 3.3%). Conclusion:Given the significantly improved morbidity and mortality of sickle cell patients who are adherent to hydroxyurea, it is necessary to address the rumors, misconceptions, and gaps in understanding of the genetic impact of the disease as well as the risks and benefits of hydroxyurea therapy. At the population level, learning is impacted by education levels, literacy rates, health literacy rates, and other cultural and societal factors, thus teaching should be culturally competent and inclusive with verbal and visual methods. The high cost of the medication and lack of consistent supply seem to be the most prohibitive factors in patient acceptance and adherence to take hydroxyurea. With only 1% of Uganda's population covered by health insurance, it is imperative for system-wide changes to address the affordability and accessibility of hydroxyurea and/or to extend the coverage of health insurance to those in need.

Perspectives of people living with HIV on barriers to timely ART initiation following referral for antiretroviral therapy: A qualitative study at an urban HIV clinic in Kampala, Uganda.

Early initiation of antiretroviral therapy (ART) after HIV diagnosis prevents HIV transmission, progression of HIV to AIDS and improves quality of life. However, little is known about the barriers to timely ART initiation among patients who test HIV positive in settings different from where they will receive HIV treatment, hence are referred in the routine setting. Therefore, we explored the perspectives of people living with HIV on barriers faced to initiate ART following HIV testing and referral for treatment. In this qualitative study, we purposively sampled and enrolled 17 patients attending the Mulago ISS clinic. We selected patients (≥18 years) who previously were received as referrals for HIV treatment and had delayed ART initiation, as ascertained from their records. We conducted in-depth interviews, which were audio recorded, transcribed and translated. We used Atlas.ti version 9 software for data management. Data analysis followed thematic and framework analysis techniques and we adopted the socio-ecological model to categorize final themes. Key themes were found at organizational level including; negative experiences at the place of HIV diagnosis attributed to inadequate counselling and support, unclear communication of HIV-positive results and ambiguous referral procedures; and, long waiting time when patients reached the HIV clinic. At individual level, the themes identified were; immediate denial with late acceptance of HIV-positive results attributed to severe emotional and psychological distress at receiving results, fear of perceived side effects and long duration on ART. At interpersonal level, we found that anticipated and enacted stigma after HIV diagnosis resulted in non-disclosure, discrimination and lack of social support. We found that challenges at entry (during HIV test) and navigation of the HIV care system in addition to individual and interpersonal factors contributed to delayed ART initiation. Interventions during HIV testing would facilitate early ART initiation among patients referred for HIV care.