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Kirya M, Bwayo D, Otim ME, Mutoo PB, Masaba JPM, Okibure A, Katuramu R. Prevalence of Biomarkers and Associated Factors for Chronic Kidney Disease in Adult Diabetic Out-patients in a Tertiary Hospital in Eastern Uganda - a Cross-sectional Study. Res Sq 2024:rs.3.rs-3992049. [PMID: 38496471 PMCID: PMC10942569 DOI: 10.21203/rs.3.rs-3992049/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Background Chronic kidney disease (CKD) is one of the most common complications of Diabetes Mellitus (DM). DM contributes to about 66% of CKD cases globally. CKiiiD results in increased morbidity and mortality and advanced stages often require renal replacement therapy that is unaffordable for the majority of the patients. Developing countries have scanty data regarding CKD burden in diabetic patients. OBJECTIVES This study aimed at determining the prevalence of biomarkers for CKD and associated factors among diabetic patients attending the adult diabetic clinic of Mbale Regional Referral Hospital (MRRH). Methods A cross-sectional study was conducted at the adult diabetic clinic of Mbale Regional Referral Hospital in Eastern Uganda. 374 adult diabetic patients who consented, were recruited and interviewed. A urine sample for Urine Albumin Creatinine Ratio (UACR) determination and a venous blood sample for measurement of serum creatinine were obtained from each participant. The estimated glomerular filtration rate (eGFR) was determined using the CKD-EPI equation and CKD was staged according to the Kidney Disease Improving Global Outcomes (KDIGO) systems. Results A total of 318 (85%) participants had an eGFR of ≤ 60mls/min/1.72m2, significant proteinuria, or both. 6.1% were aware. Age, Duration of DM, Hypertension, and Dyslipidemia were associated with CKD biomarkers. Conclusion There is a high prevalence of biomarkers for CKD among DM patients, the majority of them being undiagnosed. Over half of the DM patients had an eGFR consistent with advanced CKD. Strengthening routine screening for CKD biomarkers and enhancing the DM clinics with more diagnostic resources is recommended.
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Bayowa JR, Kalyango JN, Baluku JB, Katuramu R, Ssendikwanawa E, Zalwango JF, Akunzirwe R, Nanyonga SM, Amutuhaire JS, Muganga RK, Cherop A. Mortality rate and associated factors among patients co-infected with drug resistant tuberculosis/HIV at Mulago National Referral Hospital, Uganda, a retrospective cohort study. PLOS Glob Public Health 2023; 3:e0001020. [PMID: 37410761 DOI: 10.1371/journal.pgph.0001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
Drug resistant tuberculosis (DR-TB)/HIV co-infection remains a growing threat to public health and threatens global TB and HIV prevention and care programs. HIV is likely to worsen the outcomes of DR-TB and DR-TB is likely to worsen the outcomes of HIV despite the scale up of TB and HIV services and advances in treatment and diagnosis. This study determined the mortality rate and factors associated with mortality among persons on treatment co-infected with drug resistant TB and HIV at Mulago National Referral Hospital. We retrospectively reviewed data of 390 persons on treatment that had a DR-TB/HIV co-infection in Mulago National Referral Hospital from January 2014 to December 2019.Modified poisson regression with robust standard errors was used to determine relationships between the independent variables and the dependent variable (mortality) at bivariate and multivariate analysis. Of the 390 participants enrolled, 201(53.9%) were males with a mean age of 34.6 (±10.6) and 129 (33.2%,95% CI = 28.7-38.1%) died. Antiretroviral therapy(ART) initiation (aIRR 0.74, 95% CI = 0.69-0.79), having a body mass index (BMI)≥18.5Kg/m2 (aIRR 1.01, 95% CI = 1.03-1.17), having a documented client phone contact (aIRR 0.85, 95% CI = 0.76-0.97), having a mid-upper arm circumference,(MUAC) ≥18.5cm (aIRR 0.90, 95% CI = 0.82-0.99), being on first and second line ART regimen (aIRR 0.83, 95% CI = 0.77-0.89),having a known viral load (aIRR 1.09, 95% CI = 1.00-1.21) and having an adverse event during the course of treatment (aIRR 0.88, 95% CI = 0.83-0.93) were protective against mortality. There was a significantly high mortality rate due to DR-TB/HIV co-infection. These results suggest that initiation of all persons living with HIV/AIDS (PLWHA) with DR-TB on ART and frequent monitoring of adverse drug events highly reduces mortality.
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Affiliation(s)
- Joan Rokani Bayowa
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joan N Kalyango
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Richard Katuramu
- Ministry of Health, Tuberculosis Control Program, Kampala, Uganda
| | - Emmanuel Ssendikwanawa
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jane Frances Zalwango
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rebecca Akunzirwe
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Stella Maris Nanyonga
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Ronald Kivumbi Muganga
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adolphus Cherop
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
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Eric E, Olupot-Olupot P, Bwayo D, Meya D, Katuramu R. Prevalence and Factors Associated With Cryptoccocal Antigenemia Among Patients With Advanced Human Immunodeficiency Virus in Eastern Uganda: A Facility-Based Cross-sectional Study. Open Forum Infect Dis 2023; 10:ofad351. [PMID: 37520409 PMCID: PMC10372861 DOI: 10.1093/ofid/ofad351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/15/2023] [Indexed: 08/01/2023] Open
Abstract
Background Cryptoccocal infection remains an important cause of morbidity and mortality among people with advanced human immunodeficiency virus disease (AHD). In resource-limited settings, there is a paucity of data on cryptoccocal infections. We described the prevalence and factors associated with cryptoccocal antigenemia among people with AHD in Mbale Regional Referral Hospital in Eastern Uganda. Methods In this cross-sectional study, data on sociodemographic, clinical, and laboratory characteristics of adults with AHD were collected, and factors associated with cryptoccocal antigenemia were determined using multivariate logistic regression models. Results We enrolled 228 participants with a median CD4 cell count of 194/µL (interquartile range, 129-370/µL). The prevalence of cryptoccocal antigen was 10 in 228 (4.4% [95% confidence interval, 2.4%-80%]). CD4 cell counts <100/µL (adjusted odds ratio, 3.70) and poultry keeping were risk factors. The main predictors were headaches (adjusted odds ratio, 1), neck pains (8.817), confusion (6.323), and neck stiffness (676.217). No notable significant associations were found in the multivariate analysis. Conclusions The prevalence of cryptoccocal antigen was 4.4%, and antiretroviral therapy was protective.
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Affiliation(s)
- Ebonu Eric
- Correspondence: Ebonu Eric, MBChB, M.Med, Mbale regional referal Hospital, Department of Internal Medicine, Kumi Road, +256 Mbale city, Uganda ()
| | - Peter Olupot-Olupot
- Busitema University Faculty of Health Sciences, Department of internal Medicine, Mbale city, Uganda
- Mbale Clinical Research Institute, Mbale city, Uganda
| | - Denis Bwayo
- Busitema University Faculty of Health Sciences, Department of internal Medicine, Mbale city, Uganda
| | - David Meya
- Makerere University College of Health Sciences, Department of Internal Medicine, Kampala city, Uganda
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Baluku JB, Nakazibwe B, Wasswa A, Naloka J, Ntambi S, Waiswa D, Okwir M, Nabwana M, Bongomin F, Katuramu R, Nuwagira E, Ntabadde K, Katongole P, Senyimba C, Andia-Biraro I. Prevalence of intestinal helminth co-infection in drug resistant tuberculosis in Uganda. Open Forum Infect Dis 2022; 9:ofac541. [PMID: 36324329 PMCID: PMC9620429 DOI: 10.1093/ofid/ofac541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Although a third of people with tuberculosis (TB) are estimated to be coinfected with helminths, the prevalence is largely unknown among people with drug-resistant TB (DR-TB). We determined the prevalence of helminth coinfection among people with DR-TB in Uganda. Methods In a multicenter, cross-sectional study, eligible Ugandan adults with confirmed DR-TB were consecutively enrolled between July to December 2021 at 4 treatment centers. Sociodemographic data were collected using a questionnaire. Participants underwent anthropometric and blood pressure measurements, and blood samples were evaluated for random blood glucose, glycated hemoglobin, nonfasting lipid profile, human immunodeficiency virus (HIV) infection, and a complete blood count. Fresh stool samples were evaluated for adult worms, eggs, and larvae using direct microscopy after Kato-Katz concentration techniques. Results Of 212 participants, 156 (73.6%) were male, 118 (55.7%) had HIV, and 3 (2.8%) had malaria coinfection. The prevalence of intestinal helminth coinfection was 4.7% (10/212) (95% confidence interval, 2.6%–8.6%). The frequency of helminth infections was Ancylostoma duodenale (n = 4), Schistosoma mansoni (n = 2), Enterobius vermicularis (n = 2), Ascaris lumbricoides (n = 1), and Trichuris trichiura (n = 1). Conclusions The prevalence of helminth coinfection was low among people with DR-TB. More studies are needed to determine the clinical relevance of helminth/DR-TB coinfection.
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Affiliation(s)
- Joseph Baruch Baluku
- Mildmay Uganda , Kampala , Uganda
- Kiruddu National Referral Hospital , Kampala , Uganda
- Makerere University Lung Institute , Kampala , Uganda
| | | | - Amir Wasswa
- Mulago National Referral Hospital , Kampala , Uganda
| | - Joshua Naloka
- Mulago National Referral Hospital , Kampala , Uganda
| | - Samuel Ntambi
- Mulago National Referral Hospital , Kampala , Uganda
| | | | - Mark Okwir
- Faculty of Medicine, Lira University , Lira , Uganda
| | - Martin Nabwana
- Makerere University - Johns Hopkins University Research Collaboration , Kampala , Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine , Gulu , Uganda
| | | | - Edwin Nuwagira
- Mbarara University of Science and Technology , Mbarara , Uganda
| | | | - Paul Katongole
- School of Medicine, Makerere University College of Health Sciences , Kampala , Uganda
| | | | - Irene Andia-Biraro
- School of Medicine, Makerere University College of Health Sciences , Kampala , Uganda
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Baluku JB, Katuramu R, Naloka J, Kizito E, Nabwana M, Bongomin F. Multidisciplinary management of difficult-to-treat drug resistant tuberculosis: a review of cases presented to the national consilium in Uganda. BMC Pulm Med 2021; 21:220. [PMID: 34246234 PMCID: PMC8272325 DOI: 10.1186/s12890-021-01597-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/03/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Patients with drug resistant tuberculosis (DR-TB) with comorbidities and drug toxicities are difficult to treat. Guidelines recommend such patients to be managed in consultation with a multidisciplinary team of experts (the "TB consilium") to optimise treatment regimens. We describe characteristics and treatment outcomes of DR-TB cases presented to the national DR-TB consilium in Uganda between 2013 and 2019. METHODS We performed a secondary analysis of data from a nation-wide retrospective cohort of DR-TB patients with poor prognostic indicators in Uganda. Patients had a treatment outcome documented between 2013 and 2019. Characteristics and treatment outcomes were compared between cases reviewed by the consilium with those that were not reviewed. RESULTS Of 1,122 DR-TB cases, 189 (16.8%) cases from 16 treatment sites were reviewed by the consilium, of whom 86 (45.5%) were reviewed more than once. The most frequent inquiries (N = 308) from DR-TB treatment sites were construction of a treatment regimen (38.6%) and management of side effects (24.0%) while the most frequent consilium recommendations (N = 408) were a DR-TB regimen (21.7%) and "observation while on current regimen" (16.6%). Among the cases reviewed, 152 (80.4%) were from facilities other than the national referral hospital, 113 (61.1%) were aged ≥ 35 years, 72 (40.9%) were unemployed, and 26 (31.0%) had defaulted antiretroviral therapy. Additionally, 141 (90.4%) had hepatic injury, 55 (91.7%) had bilateral hearing loss, 20 (4.8%) had psychiatric symptoms and 14 (17.7%) had abnormal baseline systolic blood pressure. Resistance to second-line drugs (SLDs) was observed among 9 (4.8%) cases while 13 (6.9%) cases had previous exposure to SLDs. Bedaquiline (13.2%, n = 25), clofazimine (28.6%, n = 54), high-dose isoniazid (22.8%, n = 43) and linezolid (6.7%, n = 13) were more frequently prescribed among cases reviewed by the consilium than those not reviewed. Treatment success was observed among 126 (66.7%) cases reviewed. CONCLUSION Cases reviewed by the consilium had several comorbidities, drug toxicities and a low treatment success rate. Consilia are important "gatekeepers" for new and repurposed drugs. There is need to build capacity of lower health facilities to construct DR-TB regimens and manage adverse effects.
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Affiliation(s)
- Joseph Baruch Baluku
- Division of Pulmonology, Kiruddu National Referral Hospital, Kampala, Uganda.
- Makerere University Lung Institute, Kampala, Uganda.
| | | | | | - Enock Kizito
- USAID/Defeat TB, University Research Co LLC, Kampala, Uganda
| | - Martin Nabwana
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
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Baluku JB, Nakazibwe B, Naloka J, Nabwana M, Mwanja S, Mulwana R, Sempiira M, Nassozi S, Babirye F, Namugenyi C, Ntambi S, Namiiro S, Bongomin F, Katuramu R, Andia-Biraro I, Worodria W. Treatment outcomes of drug resistant tuberculosis patients with multiple poor prognostic indicators in Uganda: A countrywide 5-year retrospective study. J Clin Tuberc Other Mycobact Dis 2021; 23:100221. [PMID: 33553682 PMCID: PMC7856462 DOI: 10.1016/j.jctube.2021.100221] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Comorbid conditions and adverse drug events are associated with poor treatment outcomes among patients with drug resistant tuberculosis (DR - TB). This study aimed at determining the treatment outcomes of DR - TB patients with poor prognostic indicators in Uganda. METHODS We reviewed treatment records of DR - TB patients from 16 treatment sites in Uganda. Eligible patients had confirmed DR - TB, a treatment outcome in 2014-2019 and at least one of 15 pre-defined poor prognostic indicators at treatment initiation or during therapy. The pre-defined poor prognostic indicators were HIV co-infection, diabetes, heart failure, malignancy, psychiatric illness/symptoms, severe anaemia, alcohol use, cigarette smoking, low body mass index, elevated creatinine, hepatic dysfunction, hearing loss, resistance to fluoroquinolones and/or second-line aminoglycosides, previous exposure to second-line drugs (SLDs), and pregnancy. Tuberculosis treatment outcomes were treatment success, mortality, loss to follow up, and treatment failure as defined by the World Health Organisation. We used logistic and cox proportional hazards regression analysis to determine predictors of treatment success and mortality, respectively. RESULTS Of 1122 DR - TB patients, 709 (63.2%) were male and the median (interquartile range, IQR) age was 36.0 (28.0-45.0) years. A total of 925 (82.4%) had ≥2 poor prognostic indicators. Treatment success and mortality occurred among 806 (71.8%) and 207 (18.4%) patients whereas treatment loss-to-follow-up and failure were observed among 96 (8.6%) and 13 (1.2%) patients, respectively. Mild (OR: 0.57, 95% CI 0.39-0.84, p = 0.004), moderate (OR: 0.18, 95% CI 0.12-0.26, p < 0.001) and severe anaemia (OR: 0.09, 95% CI 0.05-0.17, p < 0.001) and previous exposure to SLDs (OR: 0.19, 95% CI 0.08-0.48, p < 0.001) predicted lower odds of treatment success while the number of poor prognostic indicators (HR: 1.62, 95% CI 1.30-2.01, p < 0.001), for every additional poor prognostic indicator) predicted mortality. CONCLUSION Among DR - TB patients with multiple poor prognostic indicators, mortality was the most frequent unsuccessful outcomes. Every additional poor prognostic indicator increased the risk of mortality while anaemia and previous exposure to SLDs were associated with lower odds of treatment success. The management of anaemia among DR - TB patients needs to be evaluated by prospective studies. DR - TB programs should also optimise DR - TB treatment the first time it is initiated.
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Affiliation(s)
- Joseph Baruch Baluku
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
- Mildmay Uganda, Wakiso, Uganda
- Makerere University Lung Institute, Kampala, Uganda
| | - Bridget Nakazibwe
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Joshua Naloka
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Martin Nabwana
- Makerere University – Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Sarah Mwanja
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Rose Mulwana
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Mike Sempiira
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | | | - Febronius Babirye
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Carol Namugenyi
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | - Samuel Ntambi
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
| | | | - Felix Bongomin
- Department of Medical Microbiology & Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Richard Katuramu
- National Tuberculosis and Leprosy Control Program, Ministry of Health, Kampala, Uganda
| | - Irene Andia-Biraro
- Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- MRC/UVRI & LSHTM Uganda Research Unit, Uganda
| | - William Worodria
- Division of Pulmonology, Mulago National Referral Hospital, Kampala, Uganda
- Makerere University Lung Institute, Kampala, Uganda
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Katuramu R, Kamya MR, Sanyu N, Armstrong-Hough M, Semitala FC. Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study. Implement Sci Commun 2020; 1:37. [PMID: 32885194 PMCID: PMC7427962 DOI: 10.1186/s43058-020-00025-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 02/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Despite increasing access to antiretroviral therapy (ART), the proportion of eligible patients initiated on treatment remains suboptimal. Only 64.6% of the people living with HIV (PLHIV) globally were initiated on ART by June 2019. The streamlined ART (START-ART) implementation study was based on the PRECEDE model, which suggests that "predisposing, enabling, and reinforcing" factors are needed to create behavior change. START-ART increased ART initiation within 2 weeks of eligibility by 42%. However, the gains from some implementation interventions erode over time. We evaluated facilitators and barriers to sustainability of this streamlined ART initiation in the year following the implementation period. Methods We designed a mixed-methods explanatory sequential study to examine the sustainability of START-ART implementation. Quantitative component consisted of cross-sectional patient chart reviews of routinely collected data; qualitative component consisted of key informant interviews of health workers in START-ART facilities 2 years after conclusion of the implementation period. We analyzed data from 15 public health centers of Mbarara district, where the START-ART implementation was carried out. We included PLHIV aged > 18 years who initiated ART from June 2013 to July 2016. The START-ART implementation took place from June 2013 to June 2015 while the sustainability period was from August 2015 to July 2016. Results A total of 863 ART-eligible patients were sampled. The median CD4 count was 348 cells/ml (IQR 215-450). During the intervention, 338 (77.4%) eligible patients initiated on ART within 2 weeks compared with 375 (88.2%) during the sustainability period (risk difference 10.8%; 95% CI 5.9-15.8%). In 14 of the 15 health centers, the intervention was sustained. During key informant interviews, rapid ART initiation sustainability was attributed to counseling skills that were obtained during intervention and availability of point-of-care (POC) CD4 PIMA machine. Failure to sustain the intervention was attributed to three specific barriers: lack of training after the intervention, transfer of trained staff to other health facilities, and shortage of supplies like cartridges for POC CD4 PIMA machine. Conclusion Rapid ART initiation was sustained in most health centers. Skills acquired during the intervention and functional POC CD4 machine facilitated while staff transfers and irregular laboratory supplies were barriers to sustainability of rapid ART initiation.
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Affiliation(s)
- Richard Katuramu
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Moses R Kamya
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University Joint AIDS Program, Kampala, Uganda
| | - Naome Sanyu
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Fred C Semitala
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University Joint AIDS Program, Kampala, Uganda
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8
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Katuramu R, Wallenta J, Semitala FC, Amanyire G, Kampiire L, Namusobya J, Kamya MR, Havlir D, Glidden DV, Geng E. Closing the gap: A novel metric of change in performance. East Afr J Appl Health Monitor Eval 2019; 2019:http://eajahme.com/wp-content/uploads/2019/02/Katuramu_FINAL.pdf. [PMID: 32817932 PMCID: PMC7428843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Interventions to improve performance of global programs in the HIV cascade of care are widespread and increasing the focus of implementation science. At present, however, there is no clear consensus on how to conceptualize their improvement at the program level. The commonly used measures of association, based on ratios of probabilities (or odds), have well-known defects in public health applications. They yield large effect sizes even when the absolute effects, and therefore the public health impact, are small. On the other hand, risk differences create problems because settings with higher baseline values are penalized. We aim to examine ways of quantifying improvement in each health center of a cluster-randomized trial in Uganda to accelerate antiretroviral therapy initiation among HIV-infected adults. METHODS We formalize the concept of the 'improvement index,' defined as the fraction of gaps closed as a metric of improvement, and suggest that it has unique features and strengths when compared to risk ratios and risk differences. RESULTS Overall agreement between the different indices was not high, especially among health centers that were among the top 5 or 10. However, all ranking showed broad similarities at the far ends of the spectrum. On scatter plots, there was a positive linear relationship between the metrics, and the Bland Altman (B-A) plots were in agreement. CONCLUSION The improvement index can be used as an alternative measure of association in implementation science interventions. It can be useful for public health purposes as it demonstrates how much can be covered from the baseline.
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Affiliation(s)
| | - Jeanna Wallenta
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - Fred C Semitala
- Makerere University, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | | | | | - Moses R. Kamya
- Makerere University, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Diane Havlir
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - David V. Glidden
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - Elvin Geng
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
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9
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Semitala FC, Camlin CS, Wallenta J, Kampiire L, Katuramu R, Amanyire G, Namusobya J, Chang W, Kahn JG, Charlebois ED, Havlir DV, Kamya MR, Geng EH. Understanding uptake of an intervention to accelerate antiretroviral therapy initiation in Uganda via qualitative inquiry. J Int AIDS Soc 2018; 20. [PMID: 29206357 PMCID: PMC5810312 DOI: 10.1002/jia2.25033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 11/10/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction The Streamlined Antiretroviral Therapy Initiation Strategy (START‐ART) study found that a theory‐based intervention using opinion leaders to inform and coach health care providers about the risks of treatment delay, provision of point of care (POC) CD4 testing machines (PIMA) and reputational incentives, led to rapid rise in ART initiation. We used qualitative research methods to explore mechanisms of provider behaviour change. Methods We conducted in‐depth interviews (IDIs) with 24 health care providers and nine study staff to understand perceptions, attitudes and the context of changes in ART initiation practices. Analyses were informed by the Theoretical Domains Framework. Results Rapid dissemination of new practices was enabled in the environmental context of an existing relationship based on communication, implementation and accountability between Makerere University Joint AIDS Program (MJAP), a Ugandan University‐affiliated organization that provided technical oversight for HIV service delivery at the health facilities where the intervention was implemented, and a network of health facilities operated by the Uganda Ministry of Health. Coaching carried out by field coordinators from MJAP strengthened influence and informal accountability for carrying out the intervention. Frontline health workers held a pre‐existing strong sense of professional identity. They were proud of attainment of new knowledge and skills and gratified by providing what they perceived to be higher quality care. Peer counsellors, who were not explicitly targeted in the intervention design, effectively substituted some functions of health care providers; as role models for successful ART uptake, they played a crucial role in creating demand for rapid ART initiation through interactions with patients. Point of care (POC) CD4 testing enabled immediate action and relieved providers from frustrations of lost or delayed laboratory results, and led to higher patient satisfaction (due to reduced costs because of ability to initiate ART right away, requiring fewer return trips to clinic). Conclusions Qualitative data revealed that a multicomponent intervention to change provider behaviour succeeded in the context of strong institutional and individual relationships between a University‐affiliated organization, government facilities, and peer health workers (who acted as a crucial link between stakeholders) and the community. Fostering stable institutional relationships between institutional actors (non‐governmental organization (NGOs) and ministry‐operated facilities) as well as between facilities and the community (through peer health workers) can enhance uptake of innovations targeting the HIV cascade in similar clinical settings.
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Affiliation(s)
- Fred C Semitala
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Makerere University Joint AIDS Program (MJAP), Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Carol S Camlin
- Division of HIV, ID and Global Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jeanna Wallenta
- Philip R. Lee Institute for Health Policy Studies, Department of Epidemiology and Biostatistics, and Global Health Sciences, University of California, San Francisco, CA, USA
| | | | | | - Gideon Amanyire
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Wei Chang
- Philip R. Lee Institute for Health Policy Studies, Department of Epidemiology and Biostatistics, and Global Health Sciences, University of California, San Francisco, CA, USA
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, Department of Epidemiology and Biostatistics, and Global Health Sciences, University of California, San Francisco, CA, USA
| | - Edwin D Charlebois
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Diane V Havlir
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Makerere University Joint AIDS Program (MJAP), Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Elvin H Geng
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
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10
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Kekitiinwa A, Szubert AJ, Spyer M, Katuramu R, Musiime V, Mhute T, Bakeera-Kitaka S, Senfuma O, Walker AS, Gibb DM. Virologic Response to First-line Efavirenz- or Nevirapine-based Antiretroviral Therapy in HIV-infected African Children. Pediatr Infect Dis J 2017; 36:588-594. [PMID: 28505015 PMCID: PMC5533213 DOI: 10.1097/inf.0000000000001505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Poorer virologic response to nevirapine- versus efavirenz-based antiretroviral therapy (ART) has been reported in adult systematic reviews and pediatric studies. METHODS We compared drug discontinuation and viral load (VL) response in ART-naïve Ugandan/Zimbabwean children ≥3 years of age initiating ART with clinician-chosen nevirapine versus efavirenz in the ARROW trial. Predictors of suppression <80, <400 and <1000 copies/mL at 36, 48 and 144 weeks were identified using multivariable logistic regression with backwards elimination (P = 0.1). RESULTS A total of 445 (53%) children received efavirenz and 391 (47%) nevirapine. Children receiving efavirenz were older (median age, 8.6 vs. 7.5 years nevirapine, P < 0.001) and had higher CD4% (12% vs. 10%, P = 0.05), but similar pre-ART VL (P = 0.17). The initial non-nucleoside-reverse-transcriptase-inhibitor (NNRTI) was permanently discontinued for adverse events in 7 of 445 (2%) children initiating efavirenz versus 9 of 391 (2%) initiating nevirapine (P = 0.46); at switch to second line in 17 versus 23, for tuberculosis in 0 versus 26, for pregnancy in 6 versus 0 and for other reasons in 15 versus 5. Early (36-48 weeks) virologic suppression <80 copies/mL was superior with efavirenz, particularly in children with higher pre-ART VL (P = 0.0004); longer-term suppression was superior with nevirapine in older children (P = 0.05). Early suppression was poorer in the youngest and oldest children, regardless of NNRTI (P = 0.02); longer-term suppression was poorer in those with higher pre-ART VL regardless of NNRTI (P = 0.05). Results were broadly similar for <400 and <1000 copies/mL. CONCLUSION Short-term VL suppression favored efavirenz, but long-term relative performance was age dependent, with better suppression in older children with nevirapine, supporting World Health Organization recommendation that nevirapine remains an alternative NNRTI.
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Affiliation(s)
- Adeodata Kekitiinwa
- Baylor-Uganda, Paediatric Infectious Diseases Clinic, Mulago
Hospital, Kampala, Uganda
| | | | - Moira Spyer
- MRC Clinical Trials Unit at University College London, London,
UK
| | - Richard Katuramu
- Medical Research Council/Uganda Virus Research Institute Uganda
Research Unit on AIDS, Entebbe, Uganda
| | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda,Makerere University College of Health Sciences, Kampala,
Uganda
| | - Tawanda Mhute
- University of Zimbabwe College of Health Sciences, Harare,
Zimbabwe
| | - Sabrina Bakeera-Kitaka
- Baylor-Uganda, Paediatric Infectious Diseases Clinic, Mulago
Hospital, Kampala, Uganda,Makerere University College of Health Sciences, Kampala,
Uganda
| | | | - Ann Sarah Walker
- MRC Clinical Trials Unit at University College London, London,
UK
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London,
UK
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11
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Amanyire G, Semitala FC, Namusobya J, Katuramu R, Kampiire L, Wallenta J, Charlebois E, Camlin C, Kahn J, Chang W, Glidden D, Kamya M, Havlir D, Geng E. Effects of a multicomponent intervention to streamline initiation of antiretroviral therapy in Africa: a stepped-wedge cluster-randomised trial. Lancet HIV 2016; 3:e539-e548. [PMID: 27658873 DOI: 10.1016/s2352-3018(16)30090-x] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND In Africa, up to 30% of HIV-infected patients who are clinically eligible for antiretroviral therapy (ART) do not start timely treatment. We assessed the effects of an intervention targeting prevalent health systems barriers to ART initiation on timing and completeness of treatment initiation. METHODS In this stepped-wedge, non-blinded, cluster-randomised controlled trial, 20 clinics in southwestern Uganda were randomly assigned in groups of five clinics every 6 months to the intervention by a computerised random number generator. This procedure continued until all clinics had crossed over from control (standard of care) to the intervention, which consisted of opinion-leader-led training and coaching of front-line health workers, a point-of-care CD4 cell count testing platform, a revised counselling approach without mandatory multiple pre-initiation sessions, and feedback to the facilities on their ART initiation rates and how they compared with other facilities. Treatment-naive, HIV-infected adults (aged ≥18 years) who were clinically eligible for ART during the study period were included in the study population. The primary outcome was ART initiation 14 days after first clinical eligibility for ART. This study is registered with ClinicalTrials.gov, number NCT01810289. FINDINGS Between April 11, 2013, and Feb 2, 2015, 12 024 eligible patients visited one of the 20 participating clinics. Median CD4 count was 310 cells per μL (IQR 179-424). 3753 of 4747 patients (weighted proportion 80%) in the intervention group had started ART by 2 weeks after eligibility compared with 2585 of 7066 patients (38%) in the control group (risk difference 41·9%, 95% CI 40·1-43·8). Vital status was ascertained in a random sample of 208 patients in the intervention group and 199 patients in the control group. Four deaths (2%) occurred in the intervention group and five (3%) occurred in the control group. INTERPRETATION A multicomponent intervention targeting health-care worker behaviour increased the probability of ART initiation 14 days after eligibility. This intervention consists of widely accessible components and has been tested in a real-world setting, and is therefore well positioned for use at scale. FUNDING National Institute of Allergy and Infectious Diseases (NIAID) and the President's Emergency Fund for AIDS Relief (PEPFAR).
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Affiliation(s)
| | | | | | | | | | - Jeanna Wallenta
- University of California San Francisco, San Francisco, CA, USA
| | | | - Carol Camlin
- University of California San Francisco, San Francisco, CA, USA
| | - James Kahn
- University of California San Francisco, San Francisco, CA, USA
| | - Wei Chang
- University of California San Francisco, San Francisco, CA, USA
| | - David Glidden
- University of California San Francisco, San Francisco, CA, USA
| | | | - Diane Havlir
- University of California San Francisco, San Francisco, CA, USA
| | - Elvin Geng
- University of California San Francisco, San Francisco, CA, USA.
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12
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Nahirya-Ntege P, Cook A, Vhembo T, Opilo W, Namuddu R, Katuramu R, Tezikyabbiri J, Naidoo-James B, Gibb D. Young HIV-infected children and their adult caregivers prefer tablets to syrup antiretroviral medications in Africa. PLoS One 2012; 7:e36186. [PMID: 22567139 PMCID: PMC3342167 DOI: 10.1371/journal.pone.0036186] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 04/02/2012] [Indexed: 11/18/2022] Open
Abstract
Background Provision of anti-retroviral therapy (ART) for HIV-infected children is complicated using syrup formulations, which are costlier than tablets, harder to transport and store and difficult for health-workers to prescribe and caregivers to administer. Dispersible/crushable tablets may be more appropriate. We studied the acceptability of syrups and scored tablets among young children who used both in the AntiRetroviral Research fOr Watoto (ARROW) trial. Methods ARROW is an ongoing randomized trial of paediatric ART monitoring and treatment strategies in 1206 children in Uganda and Zimbabwe. 405 children initially received syrups of combination ART including Nevirapine, Zidovudine, Abacavir and Lamivudine before changing, when reaching the 12-<15 kg weightband, to scored adult-dose tablets prescribed according to WHO weightband tables. Caregiver expectations and experiences were collected in questionnaires at their last visit on syrups and after 8 and 24 weeks on tablets. Results Questionnaires were completed by caregivers of 267 children (median age 2.9 years (IQR 2.5, 3.4)). At last visit on syrups, 79% caregivers reported problems with syrups, mostly related to number, weight, transportation and conspicuousness of bottles. Difficulties taking tablets were expected by 127(48%) caregivers; however, after 8 and 24 weeks, only 26% and 18% reported their children had problems with tablets and no problems were reported with transportation/conspicuousness. Taste, swallowing or vomiting were reported as problems ‘sometimes/often’ for 14%, 9%, 22% children on syrups and 16%, 9%, 8% on tablets. At last visit on syrups, 74% caregivers expected to prefer tablets but only 27% thought their child would. After 8/24 weeks, 94%/97% caregivers preferred tablets and 57%/59% reported their child did. Conclusions Most children at about 3 years can take tablets; caregivers and children themselves generally prefer tablets to liquid formulations of HIV medications above this age. Preferences of caregivers and children should be considered when designing and licensing paediatric drug formulations.
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Affiliation(s)
| | - Adrian Cook
- MRC Clinical Trials Unit, London, United Kingdom
- * E-mail:
| | | | | | - Rachel Namuddu
- Baylor-Uganda Paediatric Infectious Disease Clinic, Mulago Hospital, Kampala, Uganda
| | | | | | | | - Diana Gibb
- MRC Clinical Trials Unit, London, United Kingdom
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