The AIDS Support Organisation Research Articles

Effect of the "universal test and treat" policy on the characteristics of persons registering for HIV care and initiating antiretroviral therapy in Uganda.

We examined the effect of the Universal Test and Treat (UTT) policy on the characteristics of people living with HIV (PLHIV) at enrolment in HIV care and initiation of antiretroviral therapy (ART) in Uganda using data from 11 nationally representative clinics of The AIDS Support Organisation (TASO). We created two retrospective PLHIV cohorts: pre-UTT (2004-2016), where ART initiation was conditional on CD4 cell count and UTT (2017-2022), where ART was initiated regardless of World Health Organisation (WHO) clinical stage or CD4 cell count. We used a two-sample test of proportions and Wilcoxon rank-sum test to compare proportions and medians, respectively, between the cohorts. A total of 244,693 PLHIV were enrolled at the clinics [pre-UTT, 210,251 (85.9%); UTT, 34,442 (14.1%)]. Compared to the pre-UTT cohort, the UTT cohort had higher proportions of PLHIV that were male (p < 0.001), aged 18-29 years (p < 0.001), aged >69 years, never married (p < 0.001), and educated to primary (p < 0.001) and post-primary (p < 0.001) school level at enrolment in HIV care and ART initiation. Overall, 97.9% of UTT PLHIV initiated ART compared to 45.2% under pre-UTT. The median time from enrolment in HIV care to ART initiation decreased from 301 [interquartile range (IQR): 58-878] pre-UTT to 0 (IQR: 0-0) under UTT. The median CD4 count at ART initiation increased from 254 cells/μL pre-UTT to 482 cells/μL under UTT (p < 0.001). Compared to the pre-UTT cohort, the UTT cohort had higher proportions of PLHIV with a CD4 count >500 cells/μL (47.3% vs. 13.2%, p < 0.001) and WHO stage 1 (31.7% vs. 4.5%, p < 0.001) at ART initiation. Adoption of the UTT policy in Uganda was successful in enrolling previously unreached individuals, such as men and younger and older adults, as well as those with less advanced HIV disease. Future research will investigate the effect of UTT on long-term outcomes such as retention in care, HIV viral suppression, morbidity, and mortality.

Effect of universal test and treat on retention and mortality among people living with HIV-infection in Uganda: An interrupted time series analysis.

BackgroundFew studies have analysed the effect of HIV universal test and treat (UTT) on retention and mortality among people living with HIV (PLHIV) in routine care. We examined six-month retention and mortality at 11 health facilities (HFs) run by a large NGO, The AIDS Support Organisation (TASO), before and after UTT.MethodsWe used a quasi-experimental study using patient data extracted from 11 TASO HFs. Two periods, one before UTT (2015–2016) and the other during UTT (2017–2018) were compared. The primary outcome was six-month retention defined as the proportion of PLHIV who were alive and in care at six months from enrolment. The secondary outcome was six-month mortality defined as the proportion of PLHIV who died within six months from enrolment. We performed an interrupted time series analysis using graphical aids to study trends in six-month retention and mortality and a segmented regression to evaluate the effect of UTT. We used a generalized linear mixed model (GLMM) and generalized estimating equations (GEE) to account for facility-level clustering.ResultsOf the 20,171 PLHIV registered between 2015 and 2018 and included in the analysis, 12,757 (63.2%) were enrolled during the UTT period. 5256/7414 (70.9%) of the pre-UTT period compared to 12239/12757 (95.9%) of the UTT were initiated on ART treatment with 6 months from enrolment. The median time from enrolment to initiating ART was 14 (interquartile range (IQR): 0–31) days for the pre-UTT compared to 0 (IQR: 0–0) days for the UTT period. The median age at enrolment was 32.5 years for the pre-UTT and 35.0 years for the UTT period. Overall, the six-month retention just after scale-up of UTT, increased by 9.2 percentage points (p = 0.002) from the baseline value of 82.6% (95% CI: 77.6%-87.5%) but it eventually decreased at a rate 1.0 percentage point (p = 0.014) for cohorts recruited each month after UTT. The baseline six-month mortality was 3.3% (95% CI: 2.4%-4.2%) and this decreased by 1.6 percentage points (p = 0.003) immediately after UTT. The six-month mortality continued decreasing at a rate of 0.1 percentage points (p = 0.002) for cohorts enrolled each month after UTT. Retention differed between some health facilities with Rukungiri HF having the highest and Soroti the lowest retention. Retention was slightly higher among males and younger people. Mortality was highest among people aged 50 years and more. The effect of UTT on retention and mortality was similar across sex and age groups.ConclusionOverall, UTT significantly led to an immediate increase in retention and decrease in mortality among PLHIV enrolled in HIV care from 11 HFs run by TASO in Uganda. However, retention (and mortality) significantly decreased for cohorts enrolled each month after UTT. Retention was highest in Rukungiri and lowest in Soroti HFs and slightly higher in males and younger people. Mortality was highest in older patients and lowest in adolescents. We recommend for innovative interventions to improve the overall retention particularly in facilities reporting low retention in order to achieve the UNAIDS 2030 target of 95-95-95.

Professional views on priorities for cervical cancer policy in Uganda: a qualitative study

BackgroundCervical cancer incidence in Uganda is three-times that of the global average, and is a leading cause of mortality for women. The main cause is human papillomavirus (HPV). Women living with HIV have a greater risk of acquiring HPV and need better cervical cancer care than their HIV-negative counterparts. Although funding and infrastructure exist for HIV control, they are not in place for cervical cancer. We aimed to assess Ugandan health professionals' knowledge of and perspectives regarding cervical cancer among women with HIV to identify perceived barriers and facilitators, and to guide potential interventions to reduce the burden of cervical cancer. MethodsWe used qualitative interviews to obtain primary data from professionals working in the HIV field in Uganda, identified through purposive and snowball sampling, and through consultation with colleagues at The AIDS Support Organisation (TASO) and Makerere University in Kampala. Inclusion criteria required the respondent to be a provider, researcher, community health worker, or other authority on cervical cancer and HPV and to be conversant in English. Exclusion criteria included being younger than 18 years. Written and verbal informed consent were obtained in accordance with the Medical College of Wisconsin and Makerere University human subjects protection protocols. Virtual, 1 h-long interviews were conducted and recorded. Interviews consisted of open-ended questions exploring perspectives on, knowledge about, and practices surrounding HPV and cervical cancer among women with HIV in Uganda. Institutional review board approval was obtained from TASO, the Uganda National Council for Science and Technology, and Medical College of Wisconsin. Transcripts were analysed and coded via MaxQDA software for common themes; emerging codes were generated from meaningful quotes as used in specific interviewee contexts of facilitators and barriers to HPV vaccination, cervical cancer screening, and treatment. FindingsTo date, we have conducted 50 interviews of health professionals with experience across Uganda. Common themes regarding barriers to cervical cancer control include misconceptions about treatment cost and effectiveness, scarce access to and distance to cervical cancer services, transient funding for cervical cancer screening and treatment supplies, and fears of social exclusion and death. Potential solutions offered by participants include decentralising care through integration with existing health programmes, and prioritising education that targets misconceptions surrounding cervical cancer. InterpretationProfessionals indicated numerous misconceptions and fears held by women with HIV and inaccessibility of care due to lack of funding and integration of services. Priorities should include increasing mass media campaigns that target misconceptions, decentralising care through integration with existing health-care infrastructure and HIV screening and treatment programmes, and training more professionals in rural areas. FundingMedical College of Wisconsin Cancer Center and Dr Elaine Kohler Global Health Research.

The Prevalence and Determinants of Anaemia among Clients of the AIDS Support Organisation-Entebbe, Uganda

Anaemia, a common hematological disorder in HIV infection, compromises the quality of life and treatment outcomes. At The AIDS Support Organisation (TASO), Entebbe, the records for the 2016-2018 period show a 10% prevalence of anaemia which is lower than that in literature where it is said to be up to 95%. This study determined the prevalence, type, severity, and determinants of anaemia among people living with HIV and AIDS who receive care from TASO Entebbe in Uganda. A questionnaire was used to collect data from 624 TASO clients. A checklist identified the clients’ Antiretroviral Therapy (ART) combination and viral load. The selected clients’ Body Mass Index (BMI) was calculated to assess their nutritional status. A Fully Automated Humacount 60TS Three-Part Hematology Analyzer was used to measure hemoglobin and to do a full blood count. A blood film from each sample was manually examined for the type of anaemia. Data analysis was done with Stata MP 15. The prevalence of anaemia was 44.4%, and the anaemia was mostly mild (54.15%) to moderate (40.80%). Anaemia of inflammation was the commonest type (&gt;58%). Gender, viral suppression, nutritional status, nutritional education, marital and economic status were significantly associated with the anaemia. Duration on ART had a protective effect, but this was not statistically significant. The prevalence of anaemia (44.4%) among the TASO-Entebbe Uganda clients was high, but the anaemia was mostly mild to moderate (&gt;94%) and of inflammation type (&gt;58%). Management of anaemia in HIV requires intentional screening since it compromises treatment outcomes.

Annual cost of antiretroviral therapy among three service delivery models in Uganda.

IntroductionIn response to the increasing burden of HIV, the Ugandan government has employed different service delivery models since 2004 that aim to reduce costs and remove barriers to accessing HIV care. These models include community-based approaches to delivering antiretroviral therapy (ART) and delegating tasks to lower-level health workers. This study aimed to provide data on annual ART cost per client among three different service delivery models in Uganda.MethodsCosting data for the entire year 2012 were retrospectively collected as part of a larger task-shifting study conducted in three organizations in Uganda: Kitovu Mobile (KM), the AIDS Support Organisation (TASO) and Uganda Cares (UC). A standard cost data capture tool was developed and used to retrospectively collect cost information regarding antiretroviral (ARV) drugs and non-ARV drugs, ART-related lab tests, personnel and administrative costs. A random sample of four TASO centres (out of 11), four UC clinics (out of 29) and all KM outreach units were selected for the study.ResultsCost varied across sites within each organization as well as across the three organizations. In addition, the number of annual ART visits was more frequent in rural areas and through KM (the community distribution model), which played a major part in the overall annual ART cost. The annual cost per client (in USD) was $404 for KM, $332 for TASO and $257 for UC. These estimates were lower than previous analyses in Uganda or the region compared to data from 2001 to 2009, but comparable with recent estimates using data from 2010 to 2013. ARVs accounted for the majority of the total cost, followed by personnel and operational costs.ConclusionsThe study provides updated data on annual cost per ART visit for three service delivery models in Uganda. These data will be vital for in-country budgetary efforts to ensure that universal access to ART, as called for in the 2015 World Health Organization (WHO) guidelines, is achievable. The lower annual ART cost found in this study indicates that we may be able to treat all people with HIV as laid out in the 2015 WHO guidelines. The variation of costs across sites and the three models indicates the potential for efficiency gains.

Trends in prevalence of diarrhoea, Kaposi's sarcoma, bacterial pneumonia, malaria and geohelminths among HIV positive individuals in Uganda.

BackgroundTrends in prevalence of opportunistic infections (OIs) associated with the human immunodeficiency virus (HIV) in resource poor settings have previously not been well documented. The objective of this study was to describe the trends in prevalence of Diarrhoea, Bacterial pneumonia, Kaposi’s sarcoma, Malaria and Geohelminths among HIV positive individuals over a 12 year period in Uganda.MethodsObservation data for 5972 HIV positive individuals enrolled with the AIDS support organisation (TASO) in Uganda were analysed. Study participants were drawn from three HIV clinics located in different geographical areas of Uganda and followed from January 2002 to December 2013. The prevalence trends for the above OIs were plotted using the Box Jenkins moving average technique. X2-test for trend was used to test for the significance of the trends and Pearson’s correlation coefficient used to test for the strength of linear relationship between OI prevalence and calendar time. Mixed effect linear regression was used to estimate average monthly change in prevalence with monthly variation modelled as a random effect.ResultsA total of 204,871 monthly medical reports were retrieved and analysed. 73 % (4301/5972) were female with a median age of 32 years (inter-quartile range 26–39). Overall, significant decreasing mean annual prevalence trends (p < 0.05, X2trend) were observed for Diarrhoea (<1 month) with Pearson’s correlation coefficient (r = −0.89), Malaria (r = −0.75), Bacterial Pneumonia (r = −0.52), and Geohelminth (r = −0.32). Non-significant increasing mean annual prevalence trend was observed for Kaposis sarcoma (p = 0.20, X2trend; r = +0.26). After adjusting for age, sex and clinic in a mixed effects linear regression model, average monthly prevalence declined significantly at a rate of 0.4 % for Kaposis sarcoma, 0.3 % for Geohelminths, 2 % for Malaria, 1 % for Bacterial Pneumonia and 3 % for Diarrhoea(<1 month). However, the rate of decline per month differed significantly (p < 0.05) by HIV clinic for Diarrhoea (<1 month), and age, sex and clinic for malaria.Conclusions and recommendationsOverall, decreasing trends were observed in the above OIs. However the trends differed significantly by OI, geographical location and demographic characteristics. There is urgent need to integrate interventions targeting malaria and geohelminths in HIV programmes.

Trends in prevalence of selected opportunistic infections associated with HIV/AIDS in Uganda.

BackgroundAfter more than a decade of establishing and expanding access to highly active antiretroviral therapy (HAART), empirical evidence on its impact on trends of opportunistic infections (OIs) associated with the deadly human immunodeficiency virus (HIV) in resource poor settings is scarce. The primary objective of this study was to assess the effect of HAART coverage on trends of five most common OIs in Uganda.MethodsObservational data from January 2002 to December 2013 for 5972 HIV positive individuals attending the AIDS Support Organisation (TASO) HIV/AIDS care programme in Uganda were extracted and analysed. Trends were analysed using autoregressive moving average time series and mixed effects linear regression models adjusting for all available potential confounders.ResultsA total of 204,871 monthly medical reports were retrieved and analysed. Majority of the participants were female (73%) with a median age of 32 years (inter-quartile range 26–39). Overall, significant decreasing mean annual prevalence trends were observed for Mycobacterium tuberculosis, herpes zoster, genital ulcer and oral candidiasis (p < 0.05, X2trend). Non-significant declining mean annual prevalence trend was observed for cryptococcal meningitis (p = 0.181, X2trend). The largest impact of HAART was observed in Oral candidiasis and TB whose average annual prevalence reduced by 61% and 43% respectively following the introduction of HAART. Monthly series for TB, Herpes zoster and genital ulcers differed significantly by age and clinic but only genital ulcer series differed significantly by sex (p < 0.05, kruskal wallis). After controlling for the effects of age, sex and clinic (fixed) and monthly clustering (random effect) in a mixed effects linear regression model, all the five OIs showed a significant monthly change in prevalence (p < 0.001).ConclusionOverall, prevalence of most OIs declined especially after the introduction of HAART. However significant variations exist in the trends of different OIs in different geographical areas in Uganda. It is therefore important that site specific factors are properly identified to enable the development of targeted interventions.

Civil Society Leadership in the Struggle for Aids Treatment in South Africa and Uganda

This thesis is an attempt to theorise and operationalise empirically the notion of ‘civil society leadership’ in Sub-Saharan Africa. ‘AIDS leadership,’ which is associated with the intergovernmental institutions charged with coordinating the global response to HIV/AIDS, is both undertheorised and highly context-specific. In this study I therefore opt for an inclusive framework that draws on a range of approaches, including the literature on ‘leadership’, institutions, social movements and the ‘network’ perspective on civil society mobilisation.This framework is employed in rich and detailed empirical descriptions (‘thick description’) of civil society mobilisation around AIDS, including contentious AIDS activism, in the key case studies of South Africa and Uganda. South Africa and Uganda are widely considered key examples of poor and good leadership (from national political leaders) respectively, while the Treatment Action Cam- paign (TAC) and The AIDS Support Organisation (TASO) are both seen as highly effective civil society movements. These descriptions emphasise ‘transnational net- works of influence’ in which civil society leaders participated (and at times actively constructed) in order to mobilise both symbolic and material resources aimed at exerting influence at the transnational, national and local levels. They endeav- oured to influence both AIDS policy and the course of the epidemic directly. I conclude that these networks played a key role in the effectiveness of both TAC and TASO.These qualitative case studies are complemented by econometric analyses. At the continental level, I attempt to measure the impact of civil society mobilisation on the performance of national governments through a cross-country regression analysis applied to 42 Sub-Saharan African states. This analysis fails to show a strong relationship between the presence of AIDS NGOs and HAART and PMTCT coverage (controlling for a range of factors) — potentially supporting my hypothesis that civil society mobilisation is only effective in certain circumstances. At the local level, a second set of regression models using household survey data investigates whether TAC’s mobilisation in Cape Town impacted appreciably on HIV prevention efforts. They show a significant relationship between contact with TAC and not endorsing false conspiracy beliefs about AIDS as well as condom use, indicating that TAC’s impact is not restricted to the national policy level.

Feasibility and acceptability of mobile phone short message service as a support for patients receiving antiretroviral therapy in rural Uganda: a cross-sectional study.

IntroductionMobile phone technologies have been promoted to improve adherence to antiretroviral therapy (ART). We studied the receptiveness of patients in a rural Ugandan setting to the use of short messaging service (SMS) communication for such purposes.MethodsWe performed a cross-sectional analysis measuring mobile phone ownership and literacy amongst patients of The AIDS Support Organisation (TASO) in Jinja, Uganda. We performed bivariate and multivariate logistic regression analyses to examine associations between explanatory variables and a composite outcome of being literate and having a mobile phone.ResultsFrom June 2012 to August 2013, we enrolled 895 participants, of whom 684 (76%) were female. The median age was 44 years. A total of 576 (63%) were both literate and mobile phone users. Of these, 91% (527/ 576) responded favourably to the potential use of SMS for health communication, while only 38.9% (124/319) of others were favourable to the idea (p<0.001). A lower proportion of literate mobile phone users reported optimal adherence to ART (86.4% vs. 90.6%; p=0.007). Male participants (AOR=2.81; 95% CI 1.83–4.30), sub-optimal adherence (AOR=1.76; 95% CI 1.12–2.77), those with waged or salaried employment (AOR=2.35; 95% CI 1.23–4.49), crafts/trade work (AOR=2.38; 95% CI 1.11–5.12), or involved in petty trade (AOR=1.85; 95% CI 1.09–3.13) (in comparison to those with no income) were more likely to report mobile phone ownership and literacy.ConclusionsIn a rural Ugandan setting, we found that over 60% of patients could potentially benefit from a mobile phone-based ART adherence support. However, support for such an intervention was lower for other patients.

Integrating public health research trials into health systems in Africa: individual or cluster randomisation?

Integrating public health research trials into health systems in Africa: individual or cluster randomisation?

Stigma trajectories among people living with HIV (PLHIV) embarking on a life time journey with antiretroviral drugs in Jinja, Uganda

BackgroundStigma is a barrier to HIV prevention and treatment. There is a limited understanding of the types of stigma facing people living with HIV (PLHIV) on antiretroviral therapy (ART). We describe the stigma trajectories of PLHIV over a 5-year period from the time they started ART.MethodsLongitudinal qualitative in-depth interviews were conducted with 41 members of The AIDS Support Organisation (TASO) from 2005 to 2008 in Jinja, Uganda, who were part of a pragmatic cluster-randomised trial comparing two different modes of ART delivery (facility and home). Participants were stratified by gender, ART delivery arm and HIV stage (early or advanced) and interviewed at enrolment on to ART and then after 3, 6, 18 and 30 months. Interviews focused on stigma and ART experiences. In 2011, follow-up interviews were conducted with 24 of the participants who could be traced. Transcribed texts were translated, coded and analyzed thematically.ResultsStigma was reported to be very high prior to starting ART, explained by visible signs of long-term illnesses and experiences of discrimination and abuse. Early coping strategies included: withdrawal from public life, leaving work due to ill health and moving in with relatives. Starting ART led to a steady decline in stigma and allowed the participants to take control of their illness and manage their social lives. Better health led to resumption of work and having sex but led to reduced disclosure to employers, colleagues and new sexual partners. Some participants mentioned sero-sorting in order to avoid questions around HIV sero-status. A rise in stigma levels during the 18 and 30 month interviews may be correlated with decreased disclosure. By 2011, ART-related stigma was even more pronounced particularly among those who had started new sexual relationships, gained employment and those who had bodily signs from ART side-effects.ConclusionThis study has shown that while ART comes with health benefits which help individuals to get rid of previously stigmatising visible signs, an increase in stigma may be noticed after about five years on ART, leading to reduced disclosure. ART adherence counselling should reflect changing causes and manifestations of stigma over time.

P6.067 Five Year Survival of Adult HIV-Infected Patients Initiated on HAART at the AIDS Support Organisation(TASO), Uganda

BackgroundThe AIDS Support Organization (TASO) Antiretroviral Program was rolled out in November 2004. The study aimed to assess adherence status of adult patients surviving for 60 months after HAART initiation...

Does social support in addition to ART make a difference? Comparison of households with TASO and MOH PLWHA in Central Uganda

Social support in addition to antiretroviral therapy (ART) has been indicated to be beneficial to person living with HIV/AIDS (PLWHA) and their families, but very few ART service providers go beyond ART. This study investigates whether receipt of social support in addition to ART for PLWHA makes the households that they reside in better off than households that have PLWHA but are without social support. The analysis uses data comprising of 450 households, which is a sub-sample from the 2010/2011 Centre for Health Economics Ugandan HIV Survey, a cross-sectional survey of 596 households that was undertaken in Uganda. Data were collected from households of clients that obtained ART from two major ART service providers in Central Uganda; The AIDS Support Organisation (TASO) and Ministry of Health (MOH), Uganda. Probit models and ordinary least squares regressions are employed to compare outcomes for individuals from households with a TASO or MOH client. Outcomes for individuals in households with a TASO PLWHA are hypothesised to be superior to those from households with an MOH PLWHA given that the benefits from social support accrue not only to the PLWHA but also to the household and communities they belong to. The results confirm that individuals from a household with a TASO PLWHA are better off in terms of physical health outcomes including better productivity as non-wage labour hours and having more cash in hand and having savings. The findings highlight the importance of additional support to HIV/AIDS clients and have implications for supplementation of ART service provision with other services to maximise the benefits from ART in resource constrained countries like Uganda.

The irresistible rise of the Cohort Profile

In recognition that cohort studies are the backbone of epidemiology, the International Journal of Epidemiology’s (IJE’s) Cohort Profile series was launched in December 2004. Then, as now, the purpose of the series was to describe a particular cohort in sufficient detail to enable readers to form collaborations, learn from each other and, where appropriate, maximize the use of existing resources through data sharing. The first cohort profiled was the British Regional Heart Study and in the Editor’s Choice heralding its appearance Shah Ebrahim wrote ‘We plan to profile a cohort study in each issue, . . . ’. Clearly, we underestimated the response. Had we stuck to that original plan, a profile accepted today would have made it into print by 2030. By the end of last year, with an inclusion rate of three profiles per issue, 4100 profiles were already in print. However, with another 50 published online or in the final stages of the submission process, it was obvious a new approach for reducing the time from acceptance to print was overdue. We decided to do two things: revise our instructions to authors and limit the number of full profiles appearing in print. The current instructions can be found at http://mc. manuscriptcentral.com/ije. Slightly more prescriptive than before, they additionally require each profile to include a Summary and a Key Messages box. Whereas the Summary should describe the rationale, methods, data and data access, the Key Messages should highlight the main scientific findings to date. Together, they should provide a succinct overview of the cohort, at the same time as enticing those interested to read the full profile. The Summary and Key Messages of every profile accepted for publication will appear in the print version of the journal. However, as for cohort profile updates, the full version of some profiles will only be published online. The Summary and Key Messages for the first of these, the QSkin Sun and Health Study, appears in this issue. Queensland in Australia has the highest rate of melanoma and skin cancer in the world, and QSkin was set up prospectively to examine the role of environment and host/genetic characteristics in their aetiology. Recruitment to QSkin closed at the end of 2011, with 23 874 women and 19 920 men aged 40–69 years enrolled from the general population of Queensland. On recruitment, 23% of these participants reported a family history of melanoma, 39% the surgical removal of one or more skin cancers and 19%410 skin cancers/ solar keratoses burnt or frozen. In addition to QSkin, this issue of IJE presents full profiles for five cohorts that cover the lifecourse from the pre-natal period, through childhood and adolescence into adulthood. The highly productive Infancia y Medio Ambiente (INMA or Environment and Childhood) Project is of particular personal interest— one of the projects I worked on in my days as a lab technician was the mother to child transfer of pesticides in breast milk. INMA is a network of birth cohorts in Spain that aims to describe exposure to environmental pollutants during pregnancy, at birth and during childhood, and to evaluate their impact and the interaction between pollutants, nutrients and genetic variants on growth, health and development. Focusing on the period from birth to adolescence, the 1987 Finnish Birth Cohort has linked data for all births in Finland in 1987 (460 000) to health registers and registers that provide information on induced abortions, criminality and state benefits. Also founded in 1987, the Ugandan–Canadian TASO-CAN Collaboration follows a nationally representative cohort of 424 000 HIV-infected patients, who initiated combination anti-retroviral therapy with the AIDS support organisation (TASO), the oldest and largest community-based provider in Africa. Findings have been reported on treatment adherence and outcomes across the lifecourse from infancy to old age and have influenced international policies on provision of therapy, for example, in conflict settings. The remaining two cohorts focus on disease risk factors in adulthood. In Australia, the PATH through life project has used data from three cohorts of people born in 1937–41, 1956–60 and 1975– 79 to identify risk factors for the common mental disorders. It has also examined cognitive development, the transition to cognitive impairment and gene–environment interactions in relation to mental health outcomes, and undertaken brain imaging in participants aged460 years. Finally, the Tromso study in Northern Norway, set up to examine risk factors for cardiovascular disease, includes data from440 000 participants in six surveys between 1974 and 2008. The cohort has produced a wealth of innovative findings, an example of Published by Oxford University Press on behalf of the International Epidemiological Association

The impact of first year adherence to antiretroviral therapy on long-term clinical and immunological outcomes in the DART trial in Uganda and Zimbabwe

To describe associations between different summaries of adherence in the first year on antiretroviral therapy (ART) and the subsequent risk of mortality, to identify patients at high risk because of early adherence behaviour. We previously described an approach where adherence behaviour at successive clinic visits during the first year on ART was seen as a Markov chain (MC), and the individually estimated transition probabilities between 'good', 'poor' and 'non-response' adherence states were used to classify HIV-infected adults in the DART trial into subgroups with similar behaviour. The impact of this classification and classifications based on traditional 'averaged' measures [mean drug possession ratio (DPR) and self-reported adherence] were compared in terms of their impact on longer-term mortality over the 2-5 years on ART using Cox proportional hazards models. Of 2960 participants in follow-up after 1 year on ART, 29% had never missed pills in the last month and 11% had 100% DPR throughout the first year. The poorest adherers by self-reported measures were more likely to have only none/primary education (P < 0.01). Being in the poorest adherence subgroup by MC and DPR was independently associated with increased mortality [HR = 1.57 (95% CI 1.02, 2.42); 1.82 (1.32, 2.51) respectively]. Classification based on dynamic adherence behaviour is associated with mortality independently of DPR. The classifications could be useful in understanding adherence, targeting focused interventions and improving longer-term adherence to therapy.

Listening to health workers: lessons from Eastern Uganda for strengthening the programme for the prevention of mother-to-child transmission of HIV

BackgroundThe implementation and utilization of programmes for the prevention of mother-to-child transmission (PMTCT) of HIV in most low income countries has been described as sub-optimal. As planners and service providers, the views of health workers are important in generating priorities to improve the effectiveness of the PMTCT programme in Uganda. We explored the lessons learnt by health workers involved in the provision of PMTCT services in eastern Uganda to better understand what more needs to be done to strengthen the PMTCT programme.MethodsA qualitative study was conducted at Mbale Regional Referral Hospital, The AIDS Support Organisation (TASO) Mbale and at eight neighbouring health centres in eastern Uganda, between January and May 2010. Data were collected through 24 individual interviews with the health workers involved in the PMTCT programme and four key informants (2 district officials and 2 officials from TASO). Data were analyzed using the content thematic approach. Study themes and sub-themes were identified following multiple reading of interview transcripts. Relevant quotations have been used in the presentation of study findings.ResultsThe key lessons for programme improvement were: ensuring constant availability of critical PMTCT supplies, such as HIV testing kits, antiretroviral drugs (ARVs) for mothers and their babies, regular in-service training of health workers to keep them abreast with the rapidly changing knowledge and guidelines for PMTCT, ensuring that lower level health centres provide maternity services and ARVs for women in the PMTCT programme and provision of adequate facilities for effective follow-up and support for mothers.ConclusionsThe voices of health workers in this study revealed that it is imperative for government, civil society organizations and donors that the PMTCT programme addresses the challenges of shortage of critical PMTCT supplies, continuous health worker training and follow-up and support for mothers as urgent needs to strengthen the PMTCT programme.

Changes in sexual desires and behaviours of people living with HIV after initiation of ART: implications for HIV prevention and health promotion.

BackgroundAs immune compromised HIV sero-positive people regain health after initiating antiretroviral treatment (ART), they may seek a return to an active 'normal' life, including sexual activity. The aim of the paper is to explore the changing sexual desires and behaviour of people on ART in Uganda over a 30 month period.MethodsThis study employed longitudinal qualitative interviews with forty people starting ART. The participants received their ART, adherence education and counselling support from The AIDS Support Organisation (TASO). The participants were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic or home-based) and HIV progression stage (early or advanced) and interviewed at enrolment, 3, 6, 18 and 30 months of their ART use.ResultsSexual desire changed over time with many reporting diminished desire at 3 and 6 months on ART compared to 18 and 30 months of use. The reasons for remaining abstinent included fear of superinfection or infecting others, fear that engaging in sex would awaken the virus and weaken them and a desire to adhere to the counsellors' health advice to remain abstinent. The motivations for resumption of sexual activity were: for companionship, to obtain material support, social norms around marriage, desire to bear children as well as to satisfy sexual desires. The challenges for most of the participants were using condoms consistently and finding a suitable sexual partner (preferably someone with a similar HIV serostatus) who could agree to have a sexual relationship with them and provide for their material needs.ConclusionsThese findings point to the importance of tailoring counselling messages to the changing realities of the ART users' cultural expectations around child bearing, marriage and sexual desire. People taking ART require support so they feel comfortable to disclose their HIV status to sexual partners.

HIV and identity: the experience of AIDS support group members who unexpectedly tested HIV negative in Uganda

Living with HIV, for many of those infected, has meant adjusting to life with a stigmatised condition and, until recently, the threat of looming death. We explore the adjustment of a group of long-term former clients of The AIDS Support Organisation (TASO) in Uganda who, when tested for HIV during the rollout of antiretroviral therapy in 2004, were found to be HIV negative. In-depth semi-structured interviews with 34 former TASO clients were conducted between 2005 and 2007. Their narratives reveal a great deal about the biographical disruption they have faced, and the biographical work that they have undertaken in both the personal and the social dimensions of their lives in order to manage their new-found HIV-uninfected status. After the negative test result, as they were no longer HIV-infected, they had to leave TASO and that support was sorely missed, as was the friendship of TASO members to whom they often felt reluctant to disclose their new status. The identity 'reversal' or change was often handled privately. Compared with their transition to an HIV-positive identity, they now lacked a social dimension to their identity transformation as they managed their new identity in the face of self- and public doubt.

ABC for people with HIV: responses to sexual behaviour recommendations among people receiving antiretroviral therapy in Jinja, Uganda

People living with HIV who are taking antiretroviral therapy (ART) are increasingly involved in ‘positive prevention’ initiatives. These are generally oriented to promoting abstinence, ‘being faithful’ (partner reduction) and condom use (ABC). We conducted a longitudinal qualitative study with people living with HIV using ART, who were provided with adherence education and counselling support by a Ugandan non-governmental organisation, The AIDS Support Organisation (TASO). Forty people were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic- or home-based) and HIV progression stage (early or advanced) and interviewed at enrolment and at 3, 6, 18 and 30 months. At initiation of ART, participants agreed to follow TASO's positive-living recommendations. Initially poor health prevented sexual activity. As health improved, participants prioritised resuming economic production and support for their children. With further improvements, sexual desire resurfaced and people in relationships cemented these via sex. The findings highlight the limitations of HIV prevention based on medical care/personal counselling. As ART leads to health improvements, social norms, economic needs and sexual desires increasingly influence sexual behaviour. Positive prevention interventions need to seek to modify normative and economic influences on sexual behaviour, as well as to provide alternatives to condoms.

Confidentiality in Architectural Space: A Study of HIV Healthcare Facilities in Uganda

This article analyses and discusses spatial conditions contributing to confidentiality in HIV healthcare facilities carried out by two non-governmental organisations in Uganda, the AIDS Information Centre (AIC) and The AIDS Support Organisation (TASO). The provision of confidential space was found to be the most important architectural quality promoting client wellbeing, where Voluntary Counselling and Testing (VCT) as well as ongoing services to people living with HIV are provided. The study shows that confidential space is a requirement in a number of situations: when the client approaches the health centre; during the visit; and in the meeting between client, counsellor and medical staff. An unobtrusive location of the centre and separate, private counselling rooms are thus the most favourable spatial conditions. This article is based on a qualitative, explorative case study carried out in Jinja, Uganda during four months in 2004. Direct observation, interviews, primarily with clients and staff, spatial analyses and a qualitative content analysis were carried out.