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Musanje K, Kasujja R, Camlin CS, Hooper N, Hope-Bell J, Sinclair DL, Kibanja GM, Mpirirwe R, Kalyango JN, Kamya MR. Effectiveness of a mindfulness and acceptance-based intervention for improving the mental health of adolescents with HIV in Uganda: An open-label trial. PLoS One 2024; 19:e0301988. [PMID: 38722926 PMCID: PMC11081388 DOI: 10.1371/journal.pone.0301988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 03/20/2024] [Indexed: 05/13/2024] Open
Abstract
Adolescents with HIV (AWH) face the double burden of dealing with challenges presented by their developmental phase while coping with stigma related to HIV, affecting their mental health. Poor mental health complicates adherence to daily treatment regimens, requiring innovative psychosocial support strategies for use with adolescents. We assessed the effectiveness of a mindfulness and acceptance-based intervention on the mental health of AWH in Uganda. One hundred and twenty-two AWH, mean age 17 ±1.59 (range 15 to 19 years), 57% female, receiving care at a public health facility in Kampala were enrolled in an open-label randomized trial (ClinicalTrials.gov: NCT05010317) with assessments at pre-and post-intervention. The mindfulness and acceptance-based intervention involved weekly 90-minute group sessions for four consecutive weeks facilitated by two experienced trainers. Sessions involved clarifying values, skillfully relating to thoughts, allowing and becoming aware of experiences non-judgmentally, and exploring life through trial and error. The control group received the current standard of care. Three mental health domains (depression, anxiety, and internalized stigma) were compared between the intervention and control groups. A linear mixed effects regression was used to analyze the effect of the intervention across the two time points. Results showed that the intervention was associated with a statistically significant reduction in symptoms of depression (β = -10.72, 95%CI: 6.25, -15.20; p < .0001), anxiety (β = -7.55, 95%CI: 2.66, -12.43; p = .0003) and stigma (β = -1.40, 95%CI: 0.66 to -2.15; p = .0004) over time. Results suggest that mindfulness and acceptance-based interventions have the potential to improve the mental health of AWH.
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Affiliation(s)
- Khamisi Musanje
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
- School of Psychology, Makerere University, Kampala, Uganda
| | - Rosco Kasujja
- School of Psychology, Makerere University, Kampala, Uganda
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, United States of America
| | - Nic Hooper
- School of Psychology, Cardiff University, Wales, United Kingdom
| | - Josh Hope-Bell
- School of Medicine, Cardiff University, Wales, United Kingdom
| | | | | | - Ruth Mpirirwe
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - Joan N. Kalyango
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - Moses R. Kamya
- School of Medicine, Makerere University, Kampala, Uganda
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Owino L, Johnson-Peretz J, Lee J, Getahun M, Coppock-Pector D, Maeri I, Onyango A, Cohen CR, Bukusi EA, Kabami J, Ayieko J, Petersen M, Kamya MR, Charlebois E, Havlir D, Camlin CS. Exploring HIV risk perception mechanisms among youth in a test-and-treat trial in Kenya and Uganda. PLOS Glob Public Health 2024; 4:e0002922. [PMID: 38696376 PMCID: PMC11065277 DOI: 10.1371/journal.pgph.0002922] [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] [Received: 11/21/2023] [Accepted: 03/24/2024] [Indexed: 05/04/2024]
Abstract
Understanding risk perception and risk-taking among youth can inform targeted prevention efforts. Using a health beliefs model-informed framework, we analysed 8 semi-structured, gender-specific focus group discussions with 93 youth 15-24 years old (48% male, 52% female), drawn from the SEARCH trial in rural Kenya and Uganda in 2017-2018, coinciding with the widespread introduction of PrEP. Highly connected social networks and widespread uptake of antiretrovirals shaped youth HIV risk perception. Amid conflicting information about HIV prevention methods, youth felt exposed to multiple HIV risk factors like the high prevalence of HIV, belief that people with HIV(PWH) purposefully infect others, dislike of condoms, and doubts about PrEP efficacy. Young women also reported minimal sexual autonomy in the context of economic disadvantages, the ubiquity of intergenerational and transactional sex, and peer pressure from other women to have many boyfriends. Young men likewise reported vulnerability to intergenerational sex, but also adopted a sexual conquest mentality. Comprehensive sexuality education and economic empowerment, through credible and trusted sources, may moderate risk-taking. Messaging should leverage youth's social networks to spread fact-based, gender- and age-appropriate information. PrEP should be offered alongside other reproductive health services to address both pregnancy concerns and reduce HIV risk.
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Affiliation(s)
- Lawrence Owino
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jason Johnson-Peretz
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Joi Lee
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Dana Coppock-Pector
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Maya Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Edwin Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
| | - Diane Havlir
- HIV, Infectious Disease and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
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Ishengoma DS, Gosling R, Martinez-Vega R, Beshir KB, Bailey JA, Chimumbwa J, Sutherland C, Conrad MD, Tadesse FG, Juliano JJ, Kamya MR, Mbacham WF, Ménard D, Rosenthal PJ, Raman J, Tatarsky A, Tessema SK, Fidock DA, Djimde AA. Urgent action is needed to confront artemisinin partial resistance in African malaria parasites. Nat Med 2024:10.1038/d41591-024-00028-y. [PMID: 38710833 DOI: 10.1038/d41591-024-00028-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
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Musoke D, Lubega GB, Niyongabo F, Nakalawa S, McMorrow S, Wanyenze RK, Kamya MR. Facilitators and barriers to integrated malaria prevention in Wakiso district, Uganda: A photovoice study. PLOS Glob Public Health 2024; 4:e0002469. [PMID: 38626091 PMCID: PMC11020531 DOI: 10.1371/journal.pgph.0002469] [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] [Received: 10/04/2023] [Accepted: 03/09/2024] [Indexed: 04/18/2024]
Abstract
Malaria continues to cause significant morbidity and mortality globally, particularly in sub-Saharan Africa. Appropriate combinations of non-chemical and chemical methods of malaria vector control in the context of integrated vector management have been recommended by the World Health Organization. The aim of the study was to explore facilitators and barriers to using integrated malaria prevention in Wakiso district, Uganda. This qualitative study employed photovoice among 20 community members in Kasanje Town Council, Wakiso District. The photos taken by participants for 5 months using smartphones were discussed during monthly meetings with the researchers. The discussions were audio-recorded, and resulting data analysed using thematic analysis with the support of NVivo (2020) QSR International. Findings indicated that various conventional and non-conventional measures were being used for preventing malaria such as: insecticide treated nets; clearing overgrown vegetation; draining stagnant water; mosquito coils; smouldering of cow dung; spraying insecticides; plant repellents near houses; eating of prophylactic herbs; as well as closing doors and windows on houses early in the evening. Facilitators supporting the use of several malaria prevention methods holistically included: low cost and accessibility of some methods such as slashing overgrown vegetation; and support provided for certain methods such as receiving free mosquito nets from the government. Barriers to using several malaria prevention methods holistically included: inadequate knowledge of some methods such as housing improvement; allergic reactions to chemical-based methods such as insecticide treated nets; unaffordability of some methods such as insecticide sprays; and inaccessibility of certain methods such as body repellents. These barriers to integrated malaria prevention need to be addressed to achieve greater impact from the combination of methods in endemic communities.
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Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Grace B. Lubega
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Filimin Niyongabo
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Suzan Nakalawa
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Shannon McMorrow
- School of Interdisciplinary Health Programs, Western Michigan University, Kalamazoo, Michigan, United States of America
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses R. Kamya
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Kabami J, Koss CA, Sunday H, Biira E, Nyabuti M, Balzer LB, Gupta S, Chamie G, Ayieko J, Kakande E, Bacon MC, Havlir D, Kamya MR, Petersen M. Randomized Trial of Dynamic Choice HIV Prevention at Antenatal and Postnatal Care Clinics in Rural Uganda and Kenya. J Acquir Immune Defic Syndr 2024; 95:447-455. [PMID: 38489493 PMCID: PMC10927304 DOI: 10.1097/qai.0000000000003383] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/30/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Pregnant and postpartum women in Sub-Saharan Africa are at high risk of HIV acquisition. We evaluated a person-centered dynamic choice intervention for HIV prevention (DCP) among women attending antenatal and postnatal care. SETTING Rural Kenya and Uganda. METHODS Women (aged 15 years or older) at risk of HIV acquisition seen at antenatal and postnatal care clinics were individually randomized to DCP vs. standard of care (SEARCH; NCT04810650). The DCP intervention included structured client choice of product (daily oral pre-exposure prophylaxis or postexposure prophylaxis), service location (clinic or out of facility), and HIV testing modality (self-test or provider-administered), with option to switch over time and person-centered care (phone access to clinician, structured barrier assessment and counseling, and provider training). The primary outcome was biomedical prevention coverage-proportion of 48-week follow-up with self-reported pre-exposure prophylaxis or postexposure prophylaxis use, compared between arms using targeted maximum likelihood estimation. RESULTS Between April and July 2021, we enrolled 400 women (203 intervention and 197 control); 38% were pregnant, 52% were aged 15-24 years, and 94% reported no pre-exposure prophylaxis or postexposure prophylaxis use for ≥6 months before baseline. Among 384/400 participants (96%) with outcome ascertained, DCP increased biomedical prevention coverage 40% (95% CI: 34% to 47%; P < 0.001); the coverage was 70% in intervention vs. 29% in control. DCP also increased coverage during months at risk of HIV (81% in intervention, 43% in control; 38% absolute increase; 95% CI: 31% to 45%; P < 0.001). CONCLUSION A person-centered dynamic choice intervention that provided flexibility in product, testing, and service location more than doubled biomedical HIV prevention coverage in a high-risk population already routinely offered access to biomedical prevention options.
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Affiliation(s)
- Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Helen Sunday
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Edith Biira
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Marilyn Nyabuti
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Laura B. Balzer
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
| | - Shalika Gupta
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
| | - Gabriel Chamie
- Department of Medicine, University of California, San Francisco, CA
| | - James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Melanie C. Bacon
- Department of Health and Human Services, National Institute of Health, Bethesda, MD
| | - Diane Havlir
- Department of Medicine, University of California, San Francisco, CA
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Maya Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA; and
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Lee JJ, Kakuru A, Jacobson KB, Kamya MR, Kajubi R, Ranjit A, Gaw SL, Parsonnet J, Benjamin-Chung J, Dorsey G, Jagannathan P, Roh ME. Monthly Sulfadoxine-Pyrimethamine During Pregnancy Prevents Febrile Respiratory Illnesses: A Secondary Analysis of a Malaria Chemoprevention Trial in Uganda. Open Forum Infect Dis 2024; 11:ofae143. [PMID: 38585183 PMCID: PMC10995957 DOI: 10.1093/ofid/ofae143] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/18/2024] [Indexed: 04/09/2024] Open
Abstract
Background Trials evaluating antimalarials for intermittent preventive treatment in pregnancy (IPTp) have shown that dihydroartemisinin-piperaquine (DP) is a more efficacious antimalarial than sulfadoxine-pyrimethamine (SP); however, SP is associated with higher birthweight, suggesting that SP demonstrates "nonmalarial" effects. Chemoprevention of nonmalarial febrile illnesses (NMFIs) was explored as a possible mechanism. Methods In this secondary analysis, we leveraged data from 654 pregnant Ugandan women without HIV infection who participated in a randomized controlled trial comparing monthly IPTp-SP with IPTp-DP. Women were enrolled between 12 and 20 gestational weeks and followed through delivery. NMFIs were measured by active and passive surveillance and defined by the absence of malaria parasitemia. We quantified associations among IPTp regimens, incident NMFIs, antibiotic prescriptions, and birthweight. Results Mean "birthweight for gestational age" Z scores were 0.189 points (95% CI, .045-.333) higher in women randomized to IPTp-SP vs IPTp-DP. Women randomized to IPTp-SP had fewer incident NMFIs (incidence rate ratio, 0.74; 95% CI, .58-.95), mainly respiratory NMFIs (incidence rate ratio, 0.69; 95% CI, .48-1.00), vs IPTp-DP. Counterintuitively, respiratory NMFI incidence was positively correlated with birthweight in multigravidae. In total 75% of respiratory NMFIs were treated with antibiotics. Although overall antibiotic prescriptions were similar between arms, for each antibiotic prescribed, "birthweight for gestational age" Z scores increased by 0.038 points (95% CI, .001-.074). Conclusions Monthly IPTp-SP was associated with reduced respiratory NMFI incidence, revealing a potential nonmalarial mechanism of SP and supporting current World Health Organization recommendations for IPTp-SP, even in areas with high-grade SP resistance. While maternal respiratory NMFIs are known risk factors of lower birthweight, most women in our study were presumptively treated with antibiotics, masking the potential benefit of SP on birthweight mediated through preventing respiratory NMFIs.
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Affiliation(s)
- Jordan John Lee
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Karen B Jacobson
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Kaiser Permanente Northern California Division of Research, Vaccine Study Center, Oakland, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Richard Kajubi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Anju Ranjit
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Stephanie L Gaw
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Julie Parsonnet
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Grant Dorsey
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Prasanna Jagannathan
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California, USA
- Department of Microbiology and Immunology, Stanford University, Stanford, California, USA
| | - Michelle E Roh
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
- Malaria Elimination Initiative, Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA
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Rosenthal PJ, Asua V, Bailey JA, Conrad MD, Ishengoma DS, Kamya MR, Rasmussen C, Tadesse FG, Uwimana A, Fidock DA. The emergence of artemisinin partial resistance in Africa: how do we respond? Lancet Infect Dis 2024:S1473-3099(24)00141-5. [PMID: 38552654 DOI: 10.1016/s1473-3099(24)00141-5] [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] [Received: 01/17/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 04/21/2024]
Abstract
Malaria remains one of the most important infectious diseases in the world, with the greatest burden in sub-Saharan Africa, primarily from Plasmodium falciparum infection. The treatment and control of malaria is challenged by resistance to most available drugs, but partial resistance to artemisinins (ART-R), the most important class for the treatment of malaria, was until recently confined to southeast Asia. This situation has changed, with the emergence of ART-R in multiple countries in eastern Africa. ART-R is mediated primarily by single point mutations in the P falciparum kelch13 protein, with several mutations present in African parasites that are now validated resistance mediators based on clinical and laboratory criteria. Major priorities at present are the expansion of genomic surveillance for ART-R mutations across the continent, more frequent testing of the efficacies of artemisinin-based regimens against uncomplicated and severe malaria in trials, more regular assessment of ex-vivo antimalarial drug susceptibilities, consideration of changes in treatment policy to deter the spread of ART-R, and accelerated development of new antimalarial regimens to overcome the impacts of ART-R. The emergence of ART-R in Africa is an urgent concern, and it is essential that we increase efforts to characterise its spread and mitigate its impact.
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Affiliation(s)
- Philip J Rosenthal
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - Victor Asua
- Infectious Diseases Research Collaboration, Kampala, Uganda; University of Tübingen, Tübingen, Germany
| | - Jeffrey A Bailey
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA; Departments of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Melissa D Conrad
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar es Salaam, Tanzania; Department of Biochemistry, Kampala International University in Tanzania, Dar es Salaam, Tanzania; School of Public Health, Harvard University, Boston, MA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Fitsum G Tadesse
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia; London School of Hygiene and Tropical Medicine, London, UK
| | - Aline Uwimana
- Rwanda Biomedical Center, Kigali, Rwanda; Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - David A Fidock
- Department of Microbiology and Immunology and Center for Malaria Therapeutics and Antimicrobial Resistance, Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Mpirirwe R, Mujugira A, Walusaga H, Ayebare F, Musanje K, Ndugga P, Muhumuza C, Nangendo J, Semitala FC, Kyambadde P, Kalyango J, Kiragga A, Karamagi C, Kamya MR, Armstrong-Hough M, Katahoire AR. Perspectives of female sex workers on HIV pre-exposure prophylaxis delivery in Uganda: A qualitative study. Res Sq 2024:rs.3.rs-4115528. [PMID: 38562811 PMCID: PMC10984088 DOI: 10.21203/rs.3.rs-4115528/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] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background HIV pre-exposure prophylaxis (PrEP) is underutilized by cisgender female sex workers (FSW) despite its proven effectiveness. This study aimed to understand the experiences of FSW with PrEP services in Uganda to inform HIV programming for this key population. Methods We conducted qualitative interviews with 19 FSW between June and July 2022 at the Most at Risk Populations Initiative clinic, Mulago Hospital, Kampala, to explore experiences with accessing PrEP Indepth interviews explored: (1) descriptions of where and how PrEP was obtained; (2) perspectives on current approaches for accessing PrEP; and (3) individual encounters with PrEP services. Data were analyzed through inductive thematic analysis. Results Three key themes emerged for FSW perspectives on PrEP service delivery. FSW highlighted the positive impact of a welcoming clinic environment, which motivated FSW to initiate PrEP and fostered a sense of connectedness within their community. They also reported feeling accepted, secure, and free from prejudice when accessing PrEP through facility-based services. The second explores the obstacles faced by FSW, such as lengthy wait times at clinics, inadequate provider support, and lack of sensitivity training which hindered their access to PrEP The third sheds light on how HIV-related stigma negatively impacted the delivery of community-based PrEP for FSW. While community-based distribution offered convenience and helped mitigate stigma, clinic-based care provided greater anonymity and was perceived as offering higher-quality care. Overall, FSWs emphasized the critical role of friendly healthcare providers, social support, and non-stigmatizing environments in promoting successful utilization of PrEP. Conclusion The study findings offer insights that can support HIV programs in optimizing PrEP delivery for FSW. Establishing easily accessible drug pick-up locations, prioritizing privacy, addressing and improving health workers' attitudes, and providing regular reminders could enhance PrEP access for FSW and decrease HIV acquisition.
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Kamya MR, Nankabirwa JI, Arinaitwe E, Rek J, Zedi M, Maiteki-Sebuguzi C, Opigo J, Staedke SG, Oruni A, Donnelly MJ, Greenhouse B, Briggs J, Krezanoski PJ, Bousema T, Rosenthal PJ, Olwoch P, Jagannathan P, Rodriguez-Barraquer I, Dorsey G. Dramatic resurgence of malaria after 7 years of intensive vector control interventions in Eastern Uganda. medRxiv 2024:2024.03.15.24304352. [PMID: 38559091 PMCID: PMC10980127 DOI: 10.1101/2024.03.15.24304352] [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] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Tororo District, Uganda experienced a dramatic decrease in malaria burden from 2015-19 following 5 years of indoor residual spraying (IRS) with carbamate (Bendiocarb) and then organophosphate (Actellic) insecticides. However, a marked resurgence occurred in 2020, which coincided with a change to a clothianidin-based IRS formulations (Fludora Fusion/SumiShield). To quantify the magnitude of the resurgence, investigate causes, and evaluate the impact of a shift back to IRS with Actellic in 2023, we assessed changes in malaria metrics in regions within and near Tororo District. Methods Malaria surveillance data from Nagongera Health Center, Tororo District was included from 2011-2023. In addition, a cohort of 667 residents from 84 houses was followed from August 2020 through September 2023 from an area bordering Tororo and neighboring Busia District, where IRS has never been implemented. Cohort participants underwent passive surveillance for clinical malaria and active surveillance for parasitemia every 28 days. Mosquitoes were collected in cohort households every 2 weeks using CDC light traps. Female Anopheles were speciated and tested for sporozoites and phenotypic insecticide resistance. Temporal comparisons of malaria metrics were stratified by geographic regions. Findings At Nagongera Health Center average monthly malaria cases varied from 419 prior to implementation of IRS; to 56 after 5 years of IRS with Bendiocarb and Actellic; to 1591 after the change in IRS to Fludora Fusion/SumiShield; to 155 after a change back to Actellic. Among cohort participants living away from the border in Tororo, malaria incidence increased over 8-fold (0.36 vs. 2.97 episodes per person year, p<0.0001) and parasite prevalence increased over 4-fold (17% vs. 70%, p<0.0001) from 2021 to 2022 when Fludora Fusion/SumiShield was used. Incidence decreased almost 5-fold (2.97 vs. 0.70, p<0.0001) and prevalence decreased by 39% (70% vs. 43%, p<0.0001) after shifting back to Actellic. There was a similar pattern among those living near the border in Tororo, with increased incidence between 2021 and 2022 (0.93 vs. 2.40, p<0.0001) followed by a decrease after the change to Actellic (2.40 vs. 1.33, p<0.001). Among residents of Busia, malaria incidence did not change significantly over the 3 years of observation. Malaria resurgence in Tororo was temporally correlated with the replacement of An. gambiae s.s. by An. funestus as the primary vector, with a marked decrease in the density of An. funestus following the shift back to IRS with Actellic. In Busia, An. gambiae s.s. remained the primary vector throughout the observation period. Sporozoite rates were approximately 50% higher among An. funestus compared to the other common malaria vectors. Insecticide resistance phenotyping of An. funestus revealed high tolerance to clothianidin, but full susceptibility to Actellic. Conclusions A dramatic resurgence of malaria in Tororo was temporally associated with a change to clothianidin-based IRS formulations and emergence of An. funestus as the predominant vector. Malaria decreased after a shift back to IRS with Actellic. This study highlights the ability of malaria vectors to rapidly circumvent control efforts and the importance of high-quality surveillance systems to assess the impact of malaria control interventions and generate timely, actionable data.
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Affiliation(s)
- Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University Kampala, Uganda
| | - Joaniter I. Nankabirwa
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University Kampala, Uganda
| | | | - John Rek
- Infectious Diseases Research Collaboration, Kampala, Uganda
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Maato Zedi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Catherine Maiteki-Sebuguzi
- Infectious Diseases Research Collaboration, Kampala, Uganda
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Jimmy Opigo
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Sarah G. Staedke
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ambrose Oruni
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Martin J. Donnelly
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Bryan Greenhouse
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Jessica Briggs
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Paul J. Krezanoski
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Teun Bousema
- Department of Medical Microbiology, Radboud University Medical Center, Netherlands
| | - Philip J. Rosenthal
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Peter Olwoch
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Prasanna Jagannathan
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, USA
| | | | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Christian C, Kakande E, Nahurira V, Akatukwasa C, Atwine F, Bakanoma R, Itiakorit H, Owaraganise A, DiIeso W, Rast D, Kabami J, Peretz JJ, Shade SB, Kamya MR, Havlir DV, Chamie G, Camlin CS. Mid-level managers' perspectives on implementing isoniazid preventive therapy for people living with HIV in Ugandan health districts: a qualitative study. BMC Health Serv Res 2024; 24:313. [PMID: 38454501 PMCID: PMC10921742 DOI: 10.1186/s12913-024-10803-9] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 02/28/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Isoniazid preventive therapy (IPT) works to prevent tuberculosis (TB) among people living with HIV (PLHIV), but uptake remains low in Sub-Saharan Africa. In this analysis, we sought to identify barriers mid-level managers face in scaling IPT in Uganda and the mechanisms by which the SEARCH-IPT trial intervention influenced their abilities to increase IPT uptake. METHODS The SEARCH-IPT study was a cluster randomized trial conducted from 2017-2021. The SEARCH-IPT intervention created collaborative groups of district health managers, facilitated by local HIV and TB experts, and provided leadership and management training over 3-years to increase IPT uptake in Uganda. In this qualitative study we analyzed transcripts of annual Focus Group Discussions and Key Informant Interviews, from a subset of SEARCH-IPT participants from intervention and control groups, and participant observation field notes. We conducted the analysis using inductive and deductive coding (with a priori codes and those derived from analysis) and a framework approach for data synthesis. RESULTS When discussing factors that enabled positive outcomes, intervention managers described feeling ownership over interventions, supported by the leadership and management training they received in the SEARCH-IPT study, and the importance of collaboration between districts facilitated by the intervention. In contrast, when discussing factors that impeded their ability to make changes, intervention and control managers described external funders setting agendas, lack of collaboration in meetings that operated with more of a 'top-down' approach, inadequate supplies and staffing, and lack of motivation among frontline providers. Intervention group managers mentioned redistribution of available stock within districts as well as between districts, reflecting efforts of the SEARCH-IPT intervention to promote between-district collaboration, whereas control group managers mentioned redistribution within their districts to maximize the use of available IPT stock. CONCLUSIONS In Uganda, mid-level managers' perceptions of barriers to scaling IPT included limited power to set agendas and control over funding, inadequate resources, lack of motivation of frontline providers, and lack of political prioritization. We found that the SEARCH-IPT intervention supported managers to design and implement strategies to improve IPT uptake and collaborate between districts. This may have contributed to the overall intervention effect in increasing the uptake of IPT among PLHIV compared to standard practice. TRIAL REGISTRATION ClinicalTrials.gov, NCT03315962 , Registered 20 October 2017.
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Affiliation(s)
| | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | | | | | | | - William DiIeso
- Sustainable East Africa Research Collaboration (SEARCH)-IPT Trial, Mbarara, Uganda
| | - Derek Rast
- Sustainable East Africa Research Collaboration (SEARCH)-IPT Trial, Mbarara, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Starley B Shade
- University of California San Francisco, San Francisco, CA, USA
| | | | - Diane V Havlir
- University of California San Francisco, San Francisco, CA, USA
| | - Gabriel Chamie
- University of California San Francisco, San Francisco, CA, USA
| | - Carol S Camlin
- University of California San Francisco, San Francisco, CA, USA
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11
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Koss CA, Ayieko J, Kabami J, Balzer LB, Kakande E, Sunday H, Nyabuti M, Wafula E, Shade SB, Biira E, Opel F, Atuhaire HN, Okochi H, Ogachi S, Gandhi M, Bacon MC, Bukusi EA, Chamie G, Petersen ML, Kamya MR, Havlir DV. Dynamic choice HIV prevention intervention at outpatient departments in rural Kenya and Uganda. AIDS 2024; 38:339-349. [PMID: 37861683 DOI: 10.1097/qad.0000000000003763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVE HIV prevention service delivery models that offer product choices, and the option to change preferences over time, may increase prevention coverage. Outpatient departments in sub-Saharan Africa diagnose a high proportion of new HIV infections, but are an understudied entry point to biomedical prevention. DESIGN Individually randomized trial of dynamic choice HIV prevention (DCP) intervention vs. standard-of-care (SOC) among individuals with current/anticipated HIV exposure risk at outpatient departments in rural Kenya and Uganda (SEARCH; NCT04810650). METHODS Our DCP intervention included 1) product choice (oral preexposure prophylaxis [PrEP] or postexposure prophylaxis [PEP]) with an option to switch over time, 2) HIV provider- or self-testing, 3) service location choice (community vs. clinic-based), and 4) provider training on patient-centered care. Primary outcome was proportion of follow-up covered by PrEP/PEP over 48 weeks assessed via self-report. RESULTS We enrolled 403 participants (61% women; median 27 years, IQR 22-37). In the DCP arm, 86% ever chose PrEP, 15% ever chose PEP over 48 weeks; selection of HIV self-testing increased from 26 to 51% and of out-of-facility visits from 8 to 52%. Among 376 of 403 (93%) with outcomes ascertained, time covered by PrEP/PEP was higher in DCP (47.5%) vs. SOC (18.3%); difference = 29.2% (95% confidence interval: 22.7-35.7; P < 0.001). Effects were similar among women and men (28.2 and 31.0% higher coverage in DCP, respectively) and larger during periods of self-reported HIV risk (DCP 64.9% vs. SOC 26.3%; difference = 38.6%; 95% confidence interval: 31.0-46.2; P < 0.001). CONCLUSION A dynamic choice HIV prevention intervention resulted in two-fold greater time covered by biomedical prevention products compared to SOC in general outpatient departments in eastern Africa.
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Affiliation(s)
- Catherine A Koss
- University of California San Francisco, San Francisco California, USA
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Laura B Balzer
- University of California Berkeley, Berkeley, California, USA
| | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Helen Sunday
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Erick Wafula
- Global Programs for Research and Training, Kisumu, Kenya
| | - Starley B Shade
- University of California San Francisco, San Francisco California, USA
| | - Edith Biira
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Fred Opel
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Hideaki Okochi
- University of California San Francisco, San Francisco California, USA
| | | | - Monica Gandhi
- University of California San Francisco, San Francisco California, USA
| | - Melanie C Bacon
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | | | - Gabriel Chamie
- University of California San Francisco, San Francisco California, USA
| | - Maya L Petersen
- University of California Berkeley, Berkeley, California, USA
| | - Moses R Kamya
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- University of California San Francisco, San Francisco California, USA
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Corrêa GC, Uddin MJ, Wahed T, Oliveras E, Morgan C, Kamya MR, Kabatangare P, Namugaya F, Leab D, Adjakidje D, Nguku P, Attahiru A, Sequeira J, Vollmer N, Reynolds HW. Measuring Zero-Dose Children: Reflections on Age Cohort Flexibilities for Targeted Immunization Surveys at the Local Level. Vaccines (Basel) 2024; 12:195. [PMID: 38400178 PMCID: PMC10892624 DOI: 10.3390/vaccines12020195] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Zero-dose (ZD) children is a critical objective in global health, and it is at the heart of the Immunization Agenda 2030 (IA2030) strategy. Coverage for the first dose of diphtheria-tetanus-pertussis (DTP1)-containing vaccine is the global operational indicator used to estimate ZD children. When surveys are used, DTP1 coverage estimates usually rely on information reported from caregivers of children aged 12-23 months. It is important to have a global definition of ZD children, but learning and operational needs at a country level may require different ZD measurement approaches. This article summarizes a recent workshop discussion on ZD measurement for targeted surveys at local levels related to flexibilities in age cohorts of inclusion from the ZD learning Hub (ZDLH) initiative-a learning initiative involving 5 consortia of 14 different organizations across 4 countries-Bangladesh, Mali, Nigeria, and Uganda-and a global learning partner. Those considerations may include the need to generate insights on immunization timeliness and on catch-up activities, made particularly relevant in the post-pandemic context; the need to compare results across different age cohort years to better identify systematically missed communities and validate programmatic priorities, and also generate insights on changes under dynamic contexts such as the introduction of a new ZD intervention or for recovering from the impact of health system shocks. Some practical considerations such as the potential need for a larger sample size when including comparisons across multiple cohort years but a potential reduction in the need for household visits to find eligible children, an increase in recall bias when older age groups are included and a reduction in recall bias for the first year of life, and a potential reduction in sample size needs and time needed to detect impact when the first year of life is included. Finally, the inclusion of the first year of life cohort in the survey may be particularly relevant and improve the utility of evidence for decision-making and enable its use in rapid learning cycles, as insights will be generated for the population being currently targeted by the program. For some of those reasons, the ZDLH initiative decided to align on a recommendation to include the age cohort from 18 weeks to 23 months, with enough power to enable disaggregation of key results across the two different cohort years. We argue that flexibilities with the age cohort for inclusion in targeted surveys at the local level may be an important principle to be considered. More research is needed to better understand in which contexts improvements in timeliness of DTP1 in the first year of life will translate to improvements in ZD results in the age cohort of 12-23 months as defined by the global DTP1 indicator.
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Affiliation(s)
- Gustavo C. Corrêa
- Gavi, The Vaccine Alliance, Chemin du Pommier 40, Le Grand Saconnex, 1218 Geneva, Switzerland
| | - Md. Jasim Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh (T.W.)
| | - Tasnuva Wahed
- International Centre for Diarrhoeal Disease Research, Bangladesh, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh (T.W.)
| | - Elizabeth Oliveras
- Jhpiego, The Johns Hopkins University Affiliate, 1615 Thames Street, Baltimore, MD 21231, USA (C.M.)
| | - Christopher Morgan
- Jhpiego, The Johns Hopkins University Affiliate, 1615 Thames Street, Baltimore, MD 21231, USA (C.M.)
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala P.O. Box 7475, Uganda; (M.R.K.); (F.N.)
- Department of Medicine, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Patience Kabatangare
- Infectious Diseases Research Collaboration (IDRC), Kampala P.O. Box 7475, Uganda; (M.R.K.); (F.N.)
| | - Faith Namugaya
- Infectious Diseases Research Collaboration (IDRC), Kampala P.O. Box 7475, Uganda; (M.R.K.); (F.N.)
| | - Dorothy Leab
- GaneshAID, 143 Doc Ngu, Lieu Giai, Ba Dinh, Hanoi 152960, Vietnam
| | - Didier Adjakidje
- GaneshAID, 143 Doc Ngu, Lieu Giai, Ba Dinh, Hanoi 152960, Vietnam
| | - Patrick Nguku
- African Field Epidemiology Network (AFENET), 50 Haile Selassie St, Asokoro, Abuja 900103, Nigeria
| | - Adam Attahiru
- African Field Epidemiology Network (AFENET), 50 Haile Selassie St, Asokoro, Abuja 900103, Nigeria
| | - Jenny Sequeira
- The Geneva Learning Foundation (TGLF), Av. Louis-Casaï 18, 1209 Geneva, Switzerland
| | - Nancy Vollmer
- JSI Research & Training Institute, Inc. (JSI), 2733 Crystal Dr 4th Floor, Arlington, VA 22202, USA;
| | - Heidi W. Reynolds
- Gavi, The Vaccine Alliance, Chemin du Pommier 40, Le Grand Saconnex, 1218 Geneva, Switzerland
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Kawuma S, Katwesigye R, Walusaga H, Akatukunda P, Nangendo J, Kabugo C, Kamya MR, Semitala FC. Determinants to Continuation on Hiv Pre-exposure Propylaxis Among Female Sex Workers at a Referral Hospital in Uganda: a Mixed Methods Study Using Com-b Model. Res Sq 2024:rs.3.rs-3914483. [PMID: 38405703 PMCID: PMC10889058 DOI: 10.21203/rs.3.rs-3914483/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] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background Female sex workers (FSWs) have the highest HIV prevalence in Uganda. Pre exposure prophylaxis (PrEP) has been recommended as part of the HIV combination prevention strategy, with improved patient initiation, but continuation on the service is low. We evaluated PrEP continuation among FSWs and explored potential determinants of PrEP continuation within a public referral hospital in Urban Uganda. Methods An explanatory sequential mixed method study was conducted at Kiruddu National referral hospital in Uganda. Secondary data on social demographic characteristics and follow up outcomes of at least one year was collected for all FSWs who were initiated PrEP between May 2020 and April 2021.We used Kaplan-Meier survival analysis to evaluate continuation on PrEP from time of initiation and follow-up period. The capability, opportunity, and motivation to change behaviour model was used to explore perspectives and practices of FSWs (n = 24) and health care providers (n = 8) on continuation on PrEP among FSWs, using semi structured interviews. The qualitative data was deductively coded and analyzed thematically, categorizing the themes related to PrEP continuation as facilitators and barriers. Results Of the 292 FSWs initiated on PrEP during this period, 101 (34.6) % were active on PrEP, 137 (46.9%) were lost to follow-up, 45 (15.4%) were no longer eligible to continue PrEP, eight (2.7%) were transferred out and one (0.3%) had died. Median survival time on PrEP was 15 months (Interquartile range IQR, 3-21). The continuation rates on PrEP at six (6) and 12 months were, 61.1% and 53.1%, respectively. Facilitators of PrEP continuation included awareness of risk associated with sex work, integration of PrEP with other HIV prevention services, presence of PrEP Peer support and use of Drop-in centers. The barriers included low community awareness about PrEP, high mobility of sex workers, substance abuse, and the unfavorable daytime clinic schedules. Conclusion Continuation on PrEP remains low among FSWs. Interventions for PrEP continuation should address barriers such as low community awareness on PrEP, substance abuse and restrictive health facility policies for scale of the PrEP program among FSWs in Uganda. Integration of PrEP with other services and scale up of community PrEP delivery structures may improve its continuation.
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14
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Semitala FC, Kadota JL, Musinguzi A, Welishe F, Nakitende A, Akello L, Kunihira Tinka L, Nakimuli J, Ritar Kasidi J, Bishop O, Nakasendwa S, Baik Y, Patel D, Sammann A, Nahid P, Belknap R, Kamya MR, Handley MA, Phillips PPJ, Katahoire A, Berger CA, Kiwanuka N, Katamba A, Dowdy DW, Cattamanchi A. Comparison of 3 optimized delivery strategies for completion of isoniazid-rifapentine (3HP) for tuberculosis prevention among people living with HIV in Uganda: A single-center randomized trial. PLoS Med 2024; 21:e1004356. [PMID: 38377166 PMCID: PMC10914279 DOI: 10.1371/journal.pmed.1004356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/05/2024] [Accepted: 02/02/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Expanding access to shorter regimens for tuberculosis (TB) prevention, such as once-weekly isoniazid and rifapentine taken for 3 months (3HP), is critical for reducing global TB burden among people living with HIV (PLHIV). Our coprimary hypotheses were that high levels of acceptance and completion of 3HP could be achieved with delivery strategies optimized to overcome well-contextualized barriers and that 3HP acceptance and completion would be highest when PLHIV were provided an informed choice between delivery strategies. METHODS AND FINDINGS In a pragmatic, single-center, 3-arm, parallel-group randomized trial, PLHIV receiving care at a large urban HIV clinic in Kampala, Uganda, were randomly assigned (1:1:1) to receive 3HP by facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), or informed choice between facilitated DOT and facilitated SAT using a shared decision-making aid. We assessed the primary outcome of acceptance and completion (≥11 of 12 doses of 3HP) within 16 weeks of treatment initiation using proportions with exact binomial confidence intervals (CIs). We compared proportions between arms using Fisher's exact test (two-sided α = 0.025). Trial investigators were blinded to primary and secondary outcomes by study arm. Between July 13, 2020, and July 8, 2022, 1,656 PLHIV underwent randomization, with equal numbers allocated to each study arm. One participant was erroneously enrolled a second time and was excluded in the primary intention-to-treat analysis. Among the remaining 1,655 participants, the proportion who accepted and completed 3HP exceeded the prespecified 80% target in the DOT (0.94; 97.5% CI [0.91, 0.96] p < 0.001), SAT (0.92; 97.5% CI [0.89, 0.94] p < 0.001), and Choice (0.93; 97.5% CI [0.91, 0.96] p < 0.001) arms. There was no difference in acceptance and completion between any 2 arms overall or in prespecified subgroup analyses based on sex, age, time on antiretroviral therapy, and history of prior treatment for TB or TB infection. Only 14 (0.8%) participants experienced an adverse event prompting discontinuation of 3HP. The main limitation of the study is that it was conducted in a single center. Multicenter studies are now needed to confirm the feasibility and generalizability of the facilitated 3HP delivery strategies in other settings. CONCLUSIONS Short-course TB preventive treatment was widely accepted by PLHIV in Uganda, and very high levels of treatment completion were achieved in a programmatic setting with delivery strategies tailored to address known barriers. TRIAL REGISTRATION ClinicalTrials.gov NCT03934931.
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Affiliation(s)
- Fred C. Semitala
- Makerere University, Department of Medicine, College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala Uganda
| | - Jillian L. Kadota
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | | | - Fred Welishe
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Anne Nakitende
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Lydia Akello
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Jane Nakimuli
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Opira Bishop
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Suzan Nakasendwa
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Yeonsoo Baik
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Devika Patel
- The Better Lab and Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Amanda Sammann
- The Better Lab and Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Payam Nahid
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Robert Belknap
- Denver Health and Hospital Authority and Division of Infectious Diseases, Department of Medicine, University of Colorado, Denver, Colorado, United States of America
| | - Moses R. Kamya
- Makerere University, Department of Medicine, College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Margaret A. Handley
- Center for Vulnerable Populations, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Patrick PJ Phillips
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Anne Katahoire
- Child Health and Development Center, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Christopher A. Berger
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Achilles Katamba
- Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - David W. Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Adithya Cattamanchi
- Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, California, United States of America
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Kamya MR, Kakuru A, Dorsey G. Dihydroartemisinin-piperaquine for prevention of malaria in pregnant women living with HIV. Lancet 2024; 403:327-330. [PMID: 38224711 DOI: 10.1016/s0140-6736(24)00048-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/09/2024] [Indexed: 01/17/2024]
Affiliation(s)
- Moses R Kamya
- Department of Medicine, Makerere University, PO Box 7072, Kampala, Uganda; Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Community and Public Health, Busitema University, Tororo, Uganda
| | - Grant Dorsey
- and Department of Medicine, University of California, San Francisco, CA, USA
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16
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Nangendo J, Wanyenze RK, Obeng-Amoako GO, Muwema M, Mukisa J, Okiring J, Kabami J, Karamagi CA, Semitala FC, Kalyango JN, Kamya MR, Katahoire AR. Health provider perspectives of Village Health Team-delivered oral HIV self-testing among men in Central Uganda: a qualitative evaluation using RE-AIM framework. Res Sq 2024:rs.3.rs-3816613. [PMID: 38343851 PMCID: PMC10854283 DOI: 10.21203/rs.3.rs-3816613/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] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Background HIV self-testing (HIVST) is a practical and effective way to provide HIV testing services to at-risk and underserved populations, particularly men. Utilizing Village Health Teams (VHTs) could enhance community-based delivery of oral HIVST to reach the last un-tested individuals who may be at-risk of infection. However, little is known about what VHTs and facility-based healthcare workers think about facilitating oral HIVST and delivery of subsequent HIV services. We investigated the views of health providers on oral HIVST delivered by VHTs among men in rural communities in Central Uganda. Methods We conducted a qualitative study in Mpigi district, interviewing 27 health providers who facilitated oral HIV self-testing among men. The providers consisting of 15 VHTs and 12 facility-based health workers were purposively selected. All interviews were audio-recorded, transcribed verbatim, and translated to English for a hybrid inductive-deductive thematic analysis. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Implementation Science framework to generate and categorize open codes. Results In terms of reaching men with HIV testing services, the providers considered HIVST to be a fast and convenient method, which could boost HIV testing. However, they also had concerns about its accuracy. In terms of effectiveness, HIVST was perceived as a reliable, user-friendly, and efficient approach to HIV testing. However, it depended on the user's preference for testing algorithms. Regarding adoption, HIVST was considered to enhance autonomy, well-suited for use in the community, and offered opportunities for linkage and re-linkage into care. However, at times HIVST faced hesitance. As for Implementation, VHTs had various support roles in HIVST but had concerns about social insecurities and delays in seeking subsequent facility-based services after HIVST. Regarding Maintenance, providers recommended several ways to improve oral HIVST including; optimizing tracking of HIVST distribution and use, improving linkage and retention in care after HIVST, diversifying HIVST for combined HIV prevention packages and including more languages, broadening sensitization among potential HIVST users and health providers, differentiating distribution models, and prioritizing targeted HIVST efforts. Conclusion HIVST has the potential to increase testing rates and engagement of men in HIV services. However, for it to be implemented on a population-wide scale, continuous sensitization of potential users and health providers is necessary, along with streamlined structures for tracking kit distribution, use, and reporting of results. Further implementation research may be necessary to optimize the role of health providers in facilitating HIVST.
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Affiliation(s)
| | | | | | | | - John Mukisa
- Makerere University College of Health Sciences
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Agaba BB, Smith D, Travis J, Pasay C, Nabatanzi M, Arinaitwe E, Ssewanyana I, Nabadda S, Cunningham J, Kamya MR, Cheng Q. Limited threat of Plasmodium falciparum pfhrp2 and pfhrp3 gene deletion to the utility of HRP2-based malaria RDTs in Northern Uganda. Malar J 2024; 23:3. [PMID: 38167003 PMCID: PMC10759665 DOI: 10.1186/s12936-023-04830-w] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Rapid diagnostic tests (RDTs) that detect Plasmodium falciparum histidine-rich protein-2 (PfHRP2) are exclusively deployed in Uganda, but deletion of the pfhrp2/3 target gene threatens their usefulness as malaria diagnosis and surveillance tools. METHODS A cross-sectional survey was conducted at 40 sites across four regions of Uganda in Acholi, Lango, W. Nile and Karamoja from March 2021 to June 2023. Symptomatic malaria suspected patients were recruited and screened with both HRP2 and pan lactate dehydrogenase (pLDH) detecting RDTs. Dried blood spots (DBS) were collected from all patients and a random subset were used for genomic analysis to confirm parasite species and pfhrp2 and pfhrp3 gene status. Plasmodium species was determined using a conventional multiplex PCR while pfhrp2 and pfhrp3 gene deletions were determined using a real-time multiplex qPCR. Expression of the HRP2 protein antigen in a subset of samples was further assessed using a ELISA. RESULTS Out of 2435 symptomatic patients tested for malaria, 1504 (61.8%) were positive on pLDH RDT. Overall, qPCR confirmed single pfhrp2 gene deletion in 1 out of 416 (0.2%) randomly selected samples that were confirmed of P. falciparum mono-infections. CONCLUSION These findings show limited threat of pfhrp2/3 gene deletions in the survey areas suggesting that HRP2 RDTs are still useful diagnostic tools for surveillance and diagnosis of P. falciparum malaria infections in symptomatic patients in this setting. Periodic genomic surveillance is warranted to monitor the frequency and trend of gene deletions and its effect on RDTs.
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Affiliation(s)
- Bosco B Agaba
- Faculty of Medicine, Department of Medical Laboratory Sciences, Mbarara University of Science and Technology, Mbarara, Uganda.
- National Malaria Control Division, Kampala, Uganda.
- London School of Hygiene and Tropical Medicine, London, UK.
- Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - David Smith
- QIMR Berghofer Medical Research Institute, Kelvin Grove, QLD, Australia
- Australian Defence Force Malaria and Infectious Disease Institute, Kelvin Grove, Australia
| | - Jye Travis
- QIMR Berghofer Medical Research Institute, Kelvin Grove, QLD, Australia
- Australian Defence Force Malaria and Infectious Disease Institute, Kelvin Grove, Australia
| | - Cielo Pasay
- QIMR Berghofer Medical Research Institute, Kelvin Grove, QLD, Australia
| | | | | | - Isaac Ssewanyana
- Infectious Diseases Research Collaboration, Kampala, Uganda
- National Health Laboratory Services/Central Public Health Laboratories, Kelvin Grove, Uganda
| | - Susan Nabadda
- National Health Laboratory Services/Central Public Health Laboratories, Kelvin Grove, Uganda
| | - Jane Cunningham
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Moses R Kamya
- Faculty of Medicine, Department of Medical Laboratory Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Qin Cheng
- QIMR Berghofer Medical Research Institute, Kelvin Grove, QLD, Australia
- Australian Defence Force Malaria and Infectious Disease Institute, Kelvin Grove, Australia
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Ayieko J, Balzer LB, Inviolata C, Kakande E, Opel F, Wafula EM, Kabami J, Owaraganise A, Mwangwa F, Nakato H, Bukusi EA, Camlin CS, Charlebois ED, Bacon MC, Petersen ML, Kamya MR, Havlir DV, Chamie G. Randomized Trial of a "Dynamic Choice" Patient-Centered Care Intervention for Mobile Persons With HIV in East Africa. J Acquir Immune Defic Syndr 2024; 95:74-81. [PMID: 38054932 PMCID: PMC10695335 DOI: 10.1097/qai.0000000000003311] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/04/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Persons with HIV (PWH) with high mobility face obstacles to HIV care engagement and viral suppression. We sought to understand whether a patient-centered intervention for mobile PWH would improve viral suppression and retention in care, and if so, which subgroups would benefit most. METHODS In a randomized trial, we evaluated the effect of an intervention designed to address barriers to care among mobile (≥2 weeks out of community in previous year) PWH with viral nonsuppression or recent missed visits in Kenya and Uganda (NCT04810650). The intervention included dynamic choice of a "travel pack" (emergency antiretroviral therapy [ART] supply, discrete ART packaging, and travel checklist), multimonth and offsite refills, facilitated transfer to out-of-community clinics, and hotline access to a mobility coordinator. The primary outcome was viral suppression (<400 copies/mL) at 48 weeks. Secondary outcomes included retention in care and ART possession. RESULTS From April 2021 to July 2022, 201 participants were enrolled and randomized (102 intervention, 99 control): 109 (54%) were female participants and 101 (50%) from Kenya; median age was 37 years (interquartile range: 29-43). At 48 weeks, there was no significant difference in viral suppression in intervention (85%) vs. control (86%). The intervention improved retention in care (risk ratio: 1.06[1.02-1.1]; P < 0.001) and ART possession (risk ratio: 1.07[1.03-1.11]; P < 0.001), with larger effect sizes among persons with baseline nonsuppression and high mobility (≥2 weeks out of community in previous 3 months). CONCLUSIONS Mobile PWH-centered care should be considered for high-risk mobile populations, including nonsuppressed and highly mobile PWH, to improve retention in care and sustain viral suppression over time. TRIAL REGISTRATION NCT04810650.
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Affiliation(s)
| | | | | | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Fred Opel
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Hellen Nakato
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Melanie C. Bacon
- National Institute of Allergy and Infectious Diseases, Bethesda, MD; and
| | | | - Moses R. Kamya
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Gabriel Chamie
- University of California San Francisco, San Francisco, CA
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Musanje K, Kamya MR, Kasujja R, Vanderplasschen W, Sinclair DL, Baluku MM, Odokonyero RF, Namisi CP, Mukisa J, White RG, Camlin CS. The Effect of a Group-Based Mindfulness and Acceptance Training on Psychological Flexibility and Adherence to Antiretroviral Therapy Among Adolescents in Uganda: An Open-Label Randomized Trial. J Int Assoc Provid AIDS Care 2024; 23:23259582241236260. [PMID: 38446992 PMCID: PMC10919136 DOI: 10.1177/23259582241236260] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
Adherence to antiretroviral therapy (ART) is lower in adolescents with HIV (AWH) than in any other age group, partly due to self-regulatory challenges during development. Mindfulness and acceptance training have been shown to support psychological flexibility, a self-regulatory skill that potentially improves adolescent adherence to medication. We assessed the effect of weekly group-based mindfulness and acceptance training sessions on ART adherence among older adolescents (15-19 years) in Kampala, Uganda. One hundred and twenty-two AWH (median age 17, range 15-19 years, 57% female) receiving care at a public health facility in Kampala were randomized 1:1 to receive 4 weekly 90-min group sessions facilitated by experienced trainers or standard-of-care ART services. The training involved (Session 1) clarifying values, (Session 2) skillfully relating to thoughts, (Session 3) allowing and becoming aware of experiences non-judgmentally, and (Session 4) exploring life through trial and error. At baseline, postintervention, and 3-month follow-up, psychological flexibility was measured using the Avoidance and Fusion Questionnaire for Youth (AFQ-Y8), and self-reported ART adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8). At baseline, the intervention and standard-of-care arms had similar psychological flexibility (AFQ-Y8 score:15.45 ± 0.82; 15.74 ± 0.84) and ART adherence (MMAS-8 score: 5.32 ± 0.24; 5.13 ± 0.23). Retention through the study was moderate (71%). Completion of mindfulness and acceptance training was associated with a significant reduction in psychological inflexibility at the 3-month follow-up (AFQ-Y8 score: 12.63 ± 1.06; 14.05 ± 1.07, P = .006). However, no significant differences were observed in self-reported adherence to ART at the 3-month follow-up (MMAS-8 score: 5.43 ± 0.23; 4.90 ± 0.33, P = .522). Group-based mindfulness and acceptance training improved psychological flexibility in this population of adolescents on ART in Uganda but did not significantly improve ART adherence. Future research should explore integrated approaches that combine behavioral management training with other empowerment aspects to improve ART adherence among AWH.
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Affiliation(s)
- Khamisi Musanje
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
- Department of Educational, Social and Organizational Psychology, Makerere University, Kampala, Uganda
| | - Moses R. Kamya
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Rosco Kasujja
- Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda
| | | | | | - Martin M. Baluku
- Department of Educational, Social and Organizational Psychology, Makerere University, Kampala, Uganda
| | | | - Charles P. Namisi
- Department of Epidemiology and Biostatistics, Makerere University, Kampala, Uganda
| | - John Mukisa
- Department of Epidemiology and Biostatistics, Makerere University, Kampala, Uganda
| | - Ross G. White
- School of Psychology, Queens University, Belfast, Northern Ireland
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, USA
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20
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Kakande ER, Ayieko J, Sunday H, Biira E, Nyabuti M, Agengo G, Kabami J, Aoko C, Atuhaire HN, Sang N, Owaranganise A, Litunya J, Mugoma EW, Chamie G, Peng J, Schrom J, Bacon MC, Kamya MR, Havlir DV, Petersen ML, Balzer LB. A community-based dynamic choice model for HIV prevention improves PrEP and PEP coverage in rural Uganda and Kenya: a cluster randomized trial. J Int AIDS Soc 2023; 26:e26195. [PMID: 38054535 PMCID: PMC10698808 DOI: 10.1002/jia2.26195] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 11/17/2023] [Indexed: 12/07/2023] Open
Abstract
INTRODUCTION Optimizing HIV prevention may require structured approaches for providing client-centred choices as well as community-based entry points and delivery. We evaluated the effect of a dynamic choice model for HIV prevention, delivered by community health workers (CHWs) with clinician support, on the use of biomedical prevention among persons at risk of HIV in rural East Africa. METHODS We conducted a cluster randomized trial among persons (≥15 years) with current or anticipated HIV risk in 16 villages in Uganda and Kenya (SEARCH; NCT04810650). The intervention was a client-centred HIV prevention model, including (1) structured client choice of product (pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP]), service location (clinic or out-of-clinic) and HIV testing modality (self-test or rapid test), with the ability to switch over time; (2) a structured assessment of patient barriers and development of a personalized support plan; and (3) phone access to a clinician 24/7. The intervention was delivered by CHWs and supported by clinicians who oversaw PrEP and PEP initiation and monitoring. Participants in control villages were referred to local health facilities for HIV prevention services, delivered by Ministry of Health staff. The primary outcome was biomedical prevention coverage: a proportion of 48-week follow-up with self-reported PrEP or PEP use. RESULTS From May to July 2021, we enrolled 429 people (212 intervention; 217 control): 57% women and 35% aged 15-24 years. Among intervention participants, 58% chose PrEP and 58% chose PEP at least once over follow-up; self-testing increased from 52% (baseline) to 71% (week 48); ≥98% chose out-of-facility service delivery. Among 413 (96%) participants with the primary outcome ascertained, average biomedical prevention coverage was 28.0% in the intervention versus 0.5% in the control: a difference of 27.5% (95% CI: 23.0-31.9%, p<0.001). Impact was larger during periods of self-reported HIV risk: 36.6% coverage in intervention versus 0.9% in control, a difference of 35.7% (95% CI: 27.5-43.9, p<0.001). Intervention effects were seen across subgroups defined by sex, age group and alcohol use. CONCLUSIONS A client-centred dynamic choice HIV prevention intervention, including the option to switch between products and CHW-based delivery in the community, increased biomedical prevention coverage by 27.5%. However, substantial person-time at risk of HIV remained uncovered.
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Affiliation(s)
| | | | - Helen Sunday
- Infectious Diseases Research CollaborationKampalaUganda
| | - Edith Biira
- Infectious Diseases Research CollaborationKampalaUganda
| | | | | | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
- Department of MedicineMakerere University College of Health SciencesKampalaUganda
| | | | | | - Norton Sang
- Kenya Medical Research InstituteNairobiKenya
| | | | | | | | - Gabriel Chamie
- Division of HIVInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - James Peng
- Department of BiostatisticsUniversity of WashingtonSeattleWashingtonUSA
| | - John Schrom
- Division of HIVInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Melanie C. Bacon
- Department of Health and Human ServicesNational Institute of HealthBethesdaMarylandUSA
| | - Moses R. Kamya
- Infectious Diseases Research CollaborationKampalaUganda
- Department of MedicineMakerere University College of Health SciencesKampalaUganda
| | - Diane V. Havlir
- Division of HIVInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Maya L. Petersen
- Division of BiostatisticsUniversity of California BerkeleyBerkeleyCaliforniaUSA
| | - Laura B. Balzer
- Division of BiostatisticsUniversity of California BerkeleyBerkeleyCaliforniaUSA
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21
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Johnson-Peretz J, Chamie G, Kakande E, Christian C, Kamya MR, Akatukwasa C, Atwine F, Havlir DV, Camlin CS. Geographical, social, and political contexts of tuberculosis control and intervention, as reported by mid-level health managers in Uganda: 'The activity around town'. Soc Sci Med 2023; 338:116363. [PMID: 37944344 PMCID: PMC10878310 DOI: 10.1016/j.socscimed.2023.116363] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/29/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
Training district-level health officers and other mid-level health system managers revealed multiple contextual factors across political, administrative, and social axes affecting tuberculosis (TB) and TB control in Uganda. Individual relationships between local health, political, and media leaders affect efforts to inform the public and provide services, yet greater administrative coordination between national-level logistics, implementing partner funding, and local needs is required. Social challenges to TB control include high population mobility, local industries, poverty with high-density living and social venues, and misinformation about TB. Capitalizing on implementation knowledge and sharing data can overcome social geographic challenges to TB-prevention planning through strategic healthcare capacity-building at the district level.
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Affiliation(s)
- Jason Johnson-Peretz
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), ANSIRH Program, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA.
| | - Gabriel Chamie
- Department of Medicine, Division of HIV, Infectious Diseases & Global Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.
| | - Elijah Kakande
- Infectious Diseases Research Collaboration (IDRC), 2C Nakasero Hill Road, Kampala, Uganda.
| | - Canice Christian
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - Moses R Kamya
- Infectious Diseases Research Collaboration (IDRC), 2C Nakasero Hill Road, Kampala, Uganda; Department of Medicine, Makerere University College of Health Sciences, Old Mulago Hill Road, New Mulago Hospital Complex, P.O Box 7051, Kampala, Uganda.
| | - Cecilia Akatukwasa
- Infectious Diseases Research Collaboration (IDRC), 2C Nakasero Hill Road, Kampala, Uganda.
| | - Fred Atwine
- Infectious Diseases Research Collaboration (IDRC), 2C Nakasero Hill Road, Kampala, Uganda.
| | - Diane V Havlir
- Department of Medicine, Division of HIV, Infectious Diseases & Global Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.
| | - Carol S Camlin
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco (UCSF), ANSIRH Program, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA; Department of Medicine, University of California, San Francisco (UCSF), Center for AIDS Prevention Studies, San Francisco, CA, USA.
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22
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Chamie G, Hahn JA, Kekibiina A, Emenyonu NI, Beesiga B, Marson K, Fatch R, Lodi S, Adong J, Thirumurthy H, McDonell MG, Gandhi M, Bryant K, Havlir DV, Kamya MR, Muyindike WR. Financial incentives for reduced alcohol use and increased isoniazid adherence during tuberculosis preventive therapy among people with HIV in Uganda: an open-label, factorial randomised controlled trial. Lancet Glob Health 2023; 11:e1899-e1910. [PMID: 37973340 PMCID: PMC11005200 DOI: 10.1016/s2214-109x(23)00436-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Alcohol use is common among people with HIV and is a risk factor for tuberculosis disease and non-adherence to isoniazid preventive therapy (IPT). Few interventions exist to reduce alcohol use and increase IPT adherence in sub-Saharan Africa. The aim of this study was to test the hypothesis that financial incentives conditional on point-of-care negative urine alcohol biomarker testing and positive urine isoniazid testing would reduce alcohol use and increase isoniazid adherence, respectively, in people with HIV who have latent tuberculosis infection and hazardous alcohol use. METHODS We conducted an open-label, 2×2 factorial randomised controlled trial in Uganda. Eligible for the study were non-pregnant HIV-positive adults (aged ≥18 years) prescribed antiretroviral therapy for at least 6 months, with current heavy alcohol use confirmed by urine ethyl glucuronide (biomarker of recent alcohol use) and a positive Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; ≥3 for women, ≥4 for men) for the past 3 months' drinking, no history of active tuberculosis, tuberculosis treatment, or tuberculosis preventive therapy, and a positive tuberculin skin test. We randomly assigned participants (1:1:1:1) initiating 6 months of IPT to: no incentives (group 1); or incentives for recent alcohol abstinence (group 2), isoniazid adherence (group 3), or both (group 4). Escalating incentives were contingent on monthly point-of-care urine tests negative for ethyl glucuronide (groups 2 and 4), or positive on IsoScreen (biomarker of recent isoniazid use; groups 3 and 4). The primary alcohol outcome was non-hazardous use by self-report (AUDIT-C <3 for women, <4 for men) and phosphatidylethanol (PEth; past-month alcohol biomarker) <35 ng/mL at 3 months and 6 months. The primary isoniazid adherence outcome was more than 90% bottle opening of days prescribed. We performed intention-to-treat analyses. This trial is registered with ClinicalTrials.gov (NCT03492216), and is complete. FINDINGS From April 16, 2018, to Aug 2, 2021, 5508 people were screened, of whom 680 were randomly assigned: 169 to group 1, 169 to group 2, 170 to group 3, and 172 to group 4. The median age of participants was 39 years (IQR 32-47), 470 (69%) were male, 598 (90%) of 663 had HIV RNA viral loads of less than 40 copies per mL, median AUDIT-C score was 6 (IQR 4-8), and median PEth was 252 ng/mL (IQR 87-579). Among 636 participants who completed the trial with alcohol use endpoint measures (group 1: 152, group 2: 159, group 3: 161, group 4: 164), non-hazardous alcohol use was more likely in the groups with incentives for alcohol abstinence (groups 2 and 4) versus no alcohol incentives (groups 1 and 3): 57 (17·6%) of 323 versus 31 (9·9%) of 313, respectively; adjusted risk difference (aRD) 7·6% (95% CI 2·7 to 12·5, p=0·0025). Among 656 participants who completed the trial with isoniazid adherence endpoint measures (group 1: 158, group 2: 163, group 3: 168, group 4: 167), incentives for isoniazid adherence did not increase adherence: 244 (72·8%) of 335 in the isoniazid incentive groups (groups 3 and 4) versus 234 (72·9%) of 321 in the no isoniazid incentive groups (groups 1 and 2); aRD -0·2% (95% CI -7·0 to 6·5, p=0·94). Overall, 53 (8%) of 680 participants discontinued isoniazid due to grade 3 or higher adverse events. There was no significant association between randomisation group and hepatotoxicity resulting in isoniazid discontinuation, after adjusting for sex and site. INTERPRETATION Escalating financial incentives contingent on recent alcohol abstinence led to significantly lower biomarker-confirmed alcohol use versus control, but incentives for recent isoniazid adherence did not lead to changes in adherence. The alcohol intervention was efficacious despite less intensive frequency of incentives and clinic visits than traditional programmes for substance use, suggesting that pragmatic modifications of contingency management for resource-limited settings can have efficacy and that further evaluation of implementation is merited. FUNDING National Institute on Alcohol Abuse and Alcoholism. TRANSLATION For the Runyankole translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Judith A Hahn
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Allen Kekibiina
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nneka I Emenyonu
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Brian Beesiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Kara Marson
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Robin Fatch
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Julian Adong
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Harsha Thirumurthy
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael G McDonell
- Department of Community and Behavioral Health, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | - Winnie R Muyindike
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda; Mbarara Regional Referral Hospital, Mbarara, Uganda
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Ayieko J, Charlebois ED, Maeri I, Owino L, Thorp M, Bukusi EA, Petersen ML, Kamya MR, Havlir DV, Camlin CS. Improving care engagement for mobile people living with HIV in rural western Kenya. PLoS One 2023; 18:e0288087. [PMID: 37992063 PMCID: PMC10664942 DOI: 10.1371/journal.pone.0288087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/20/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) assures major gains in health outcomes among people living with HIV, however, this benefit may not be realized by all due to care interruptions. Mobile populations comprise a subgroup that is likely to have sub-optimal care engagement, resulting in discontinuation of ART. We sought to evaluate the barriers to care engagement among highly mobile individuals living with HIV and explore options aimed at improving engagement in care for this group. METHODS Qualitative in-depth interviews were conducted in 2020 among a purposive sample of twelve persons living with HIV and eight health care providers in western Kenya, within a mixed methods study of mobility in communities participating in the SEARCH trial (NCT01864603). We explored the barriers to care engagement among mobile individuals living with HIV and explored different options aimed at enhancing care engagement. These included options such as a coded card containing treatment details, alternative drug packaging to conceal drug identity, longer refills to cover travel period, wrist bands with data storage capability to enable data transfer and "warm handoff" by providers to new clinics upon transfer. Data were inductively analyzed to understand the barriers and acceptability of potential interventions to address them. RESULTS Stigma and lack of disclosure, rigid work schedules, and unpredictability of travel were major barriers to care engagement for highly mobile individuals living with HIV. Additionally, lack of flexibility in clinic schedules and poor provider attitude were identified as health-system-associated barriers to care engagement. Options that enhance flexibility, convenience and access to care were viewed as the most effective means of addressing the barriers to care by both patients and providers. The most preferred option was a coded card with treatment details followed by alternative drug packaging to conceal drug identity due to stigma and longer refills to cover travel periods. CONCLUSION Highly mobile individuals living with HIV desire responsive, flexible, convenient and patient-centered care delivery models to enhance care engagement. They embraced simple health delivery improvements such as coded cards, alternative drug packaging and longer refills to address challenges of mobility.
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Affiliation(s)
- James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Edwin D. Charlebois
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Irene Maeri
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lawrence Owino
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Marguerite Thorp
- Department of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L. Petersen
- School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Diane V. Havlir
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
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Ayieko J, Thorp M, Getahun M, Gandhi M, Maeri I, Gutin SA, Okiring J, Kamya MR, Bukusi EA, Charlebois ED, Petersen M, Havlir DV, Camlin CS, Murnane PM. Geographic Mobility and HIV Care Engagement among People Living with HIV in Rural Kenya and Uganda. Trop Med Infect Dis 2023; 8:496. [PMID: 37999615 PMCID: PMC10675546 DOI: 10.3390/tropicalmed8110496] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/31/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Human mobility is a critical aspect of existence and survival, but may compromise care engagement among people living with HIV (PLHIV). We examined the association between various forms of human mobility with retention in HIV care and antiretroviral treatment (ART) interruptions. METHODS In a cohort of adult PLHIV in Kenya and Uganda, we collected surveys in 2016 about past 6-month travel and lifetime migration histories, including reasons and locations, and engagement in HIV care defined as (1) discontinuation of care, and (2) history of a treatment interruption among those who remained in care. We estimated associations between mobility and these care engagement outcomes via logistic regression, adjusted for sex, prior mobility, age, region, marital status, household wealth, and education. RESULTS Among 1081 participants, 56 (5%) reported having discontinued care; among those in care, 104 (10%) reported treatment interruption. Past-year migration was associated with a higher risk of discontinuation of care (adjusted odds ratio [aOR] 1.98, 95% CI 1.08-3.63). In sex-stratified models, the association was somewhat attenuated in women, but remained robust among men. Past-year migration was associated with reduced odds of having a treatment interruption among men (aOR 0.51, 95% CI 0.34-0.77) but not among women (aOR 2.67, 95% CI 0.78, 9.16). Travel in the past 6 months was not associated with discontinuation of care or treatment interruptions. CONCLUSIONS We observed both negative and protective effects of recent migration on care engagement and ART use that were most pronounced among men in this cohort. Migration can break ties to ongoing care, but for men, who have more agency in the decision to migrate, may foster new care and treatment strategies. Strategies that enable health facilities to support individuals throughout the process of transferring care could alleviate the risk of care disengagement.
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Affiliation(s)
- James Ayieko
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Marguerite Thorp
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90024, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Irene Maeri
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Sarah A. Gutin
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, CA 94143, USA
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Moses R. Kamya
- School of Medicine, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Elizabeth A. Bukusi
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Maya Petersen
- Division of Biostatistics, University of California, Berkeley, CA 94720, USA
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Pamela M. Murnane
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA 94143, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA 94143, USA
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Tugume L, Semitala FC, Owachi D, Kagimu E, Kamya MR, Meya DB. Clinical characteristics and morbidity among hospitalized adults with advanced HIV disease in Uganda during 'test and treat' era. PLOS Glob Public Health 2023; 3:e0002457. [PMID: 37851597 PMCID: PMC10584089 DOI: 10.1371/journal.pgph.0002457] [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] [Received: 01/31/2023] [Accepted: 09/13/2023] [Indexed: 10/20/2023]
Abstract
Nearly four decades after the first case of AIDS was described, the global number of AIDS-related deaths has steadily declined but falls short of the elimination targets, especially in sub-Saharan Africa. Despite interventions to promote early HIV diagnosis and treatment, hospitalization and mortality related to advanced HIV disease (AHD) remains a significant public health problem in Uganda. We assessed the HIV treatment history and causes of hospitalization among in-patients with AHD at a tertiary hospital in Uganda. In this cross-sectional study, pre-hospitalization HIV treatment history and clinical characteristics of HIV-positive in-patients with CD4<200 cells/μL or WHO stage 3 or 4 clinical events were assessed. Descriptive data were summarized using percentages and medians. Among hospitalized adults with AHD from November 2021 to June 2022, 74% (260/353) knew their HIV status prior to hospitalization and 62% (219/353) were ART experienced at presentation. The median time since ART initiation was 28 months (IQR; 2-97). Overall, 73% (258/353) had at least two etiological diagnoses and the majority (non-mutually exclusive) were diagnosed with tuberculosis (61.2%), cryptococcal meningitis (20.7%), mucosal candidiasis (16.1%) and bacterial infections (15%). In conclusion, nearly two-thirds of in-patients with advanced HIV disease were ART experienced prior to hospitalization and tuberculosis was the most common cause of hospitalization. Innovative strategies to strengthen HIV diagnosis, linkage, and retention in HIV care and to increase coverage of TB preventive therapy are urgently needed.
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Affiliation(s)
- Lillian Tugume
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred C. Semitala
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Kiruddu National Referral Hospital, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Enock Kagimu
- Department of Research, Infectious Diseases Institute Makerere University, Kampala, Uganda
| | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B. Meya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Research, Infectious Diseases Institute Makerere University, Kampala, Uganda
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Beesiga B, Marson K, Fatch R, Emenyonu NI, Adong J, Kekibiina A, Puryear S, Lodi S, McDonell MG, Muyindike WR, Kamya MR, Hahn JA, Chamie G. Effects of a COVID-19 Public Health Lockdown on Drinking and Health Behavior Among Persons with HIV and with Unhealthy Alcohol use in Uganda. AIDS Behav 2023; 27:3213-3222. [PMID: 37000383 PMCID: PMC10063928 DOI: 10.1007/s10461-023-04042-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/01/2023]
Abstract
To better understand the impact of Uganda's initial COVID-19 lockdown on alcohol use, we conducted a cross-sectional survey (August 2020-September 2021) among persons with HIV (PWH) with unhealthy alcohol use (but not receiving an alcohol intervention), enrolled in a trial of incentives to reduce alcohol use and improve isoniazid preventive therapy. We examined associations between bar-based drinking and decreased alcohol use, and decreased alcohol use and health outcomes (antiretroviral therapy [ART] access, ART adherence, missed clinic visits, psychological stress and intimate partner violence), during lockdown. Of 178 adults surveyed whose data was analyzed, (67% male, median age: 40), 82% reported bar-based drinking at trial enrollment; 76% reported decreased alcohol use during lockdown. In a multivariate analysis, bar-based drinking was not associated with greater decreases in alcohol use during lockdown compared to non-bar-based drinking (OR = 0.81, 95% CI: 0.31-2.11), adjusting for age and sex. There was a significant association between decreased alcohol use and increased stress during lockdown (adjusted β = 2.09, 95% CI: 1.07-3.11, P < 0.010), but not other health outcomes.
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Affiliation(s)
- Brian Beesiga
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Kara Marson
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Robin Fatch
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Nneka I Emenyonu
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Julian Adong
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Allen Kekibiina
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sarah Puryear
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sara Lodi
- Boston University School of Public Health, Boston, MA, USA
| | - Michael G McDonell
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Winnie R Muyindike
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Moses R Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Judith A Hahn
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Gabriel Chamie
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA.
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Ozarslan N, Robinson JF, Buarpung S, Kim MY, Ansbro MR, Akram J, Montoya DJ, Kamya MR, Kakuru A, Dorsey G, Rosenthal PJ, Cheng G, Feeney ME, Fisher SJ, Gaw SL. Distinct transcriptional profiles of maternal and fetal placental macrophages at term are associated with gravidity. bioRxiv 2023:2023.09.25.559419. [PMID: 37808856 PMCID: PMC10557660 DOI: 10.1101/2023.09.25.559419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Maternal intervillous monocytes (MIMs) and fetal Hofbauer cells (HBCs) are myeloid-derived immune cells at the maternal-fetal interface. Little is known regarding the molecular phenotypes and roles of these distinct monocyte/macrophage populations. Here, we used RNA sequencing to investigate the transcriptional profiles of MIMs and HBCs in six normal term pregnancies. Our analyses revealed distinct transcriptomes of MIMs and HBCs. Genes involved in differentiation and cell organization pathways were more highly expressed in MIMs vs. HBCs. In contrast, HBCs had higher expression of genes involved in inflammatory responses and cell surface receptor signaling. Maternal gravidity influenced monocyte programming, as expression of pro-inflammatory molecules was significantly higher in MIMs from multigravidas compared to primigravidas. In HBCs, multigravidas displayed enrichment of gene pathways involved in cell-cell signaling and differentiation. In summary, our results demonstrated that MIMs and HBCs have highly divergent transcriptional signatures, reflecting their distinct origins, locations, functions, and roles in inflammatory responses. Our data further suggested that maternal gravidity influences the gene signatures of MIMs and HBCs, potentially modulating the interplay between tolerance and trained immunity. The phenomenon of reproductive immune memory may play a novel role in the differential susceptibility of primigravidas to pregnancy complications.
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28
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Puryear SB, Ayieko J, Hahn JA, Mucunguzi A, Owaraganise A, Schwab J, Balzer LB, Kwarisiima D, Charlebois ED, Cohen CR, Bukusi EA, Petersen ML, Havlir DV, Kamya MR, Chamie G. Universal HIV Testing and Treatment With Patient-Centered Care Improves ART Uptake and Viral Suppression Among Adults Reporting Hazardous Alcohol Use in Uganda and Kenya. J Acquir Immune Defic Syndr 2023; 94:37-45. [PMID: 37220015 PMCID: PMC10524467 DOI: 10.1097/qai.0000000000003226] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 04/28/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Determine whether patient-centered, streamlined HIV care achieves higher antiretroviral therapy (ART) uptake and viral suppression than the standard treatment model for people with HIV (PWH) reporting hazardous alcohol use. DESIGN Community cluster-randomized trial. METHODS The Sustainable East Africa Research in Community Health trial (NCT01864603) compared an intervention of annual population HIV testing, universal ART, and patient-centered care with a control of baseline population testing with ART by country standard in 32 Kenyan and Ugandan communities. Adults (15 years or older) completed a baseline Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and were classified as no/nonhazardous (AUDIT-C 0-2 women/0-3 men) or hazardous alcohol use (≥3 women/≥4 men). We compared year 3 ART uptake and viral suppression of PWH reporting hazardous use between intervention and control arms. We compared alcohol use as a predictor of year 3 ART uptake and viral suppression among PWH, by arm. RESULTS Of 11,070 PWH with AUDIT-C measured, 1723 (16%) reported any alcohol use and 893 (8%) reported hazardous use. Among PWH reporting hazardous use, the intervention arm had higher ART uptake (96%) and suppression (87%) compared with control (74%, adjusted risk ratio [aRR] = 1.28, 95% CI: 1.19 to 1.38; and 72%, aRR = 1.20, 95% CI: 1.10 to 1.31, respectively). Within arm, hazardous alcohol use predicted lower ART uptake in control (aRR = 0.86, 95% CI: 0.78 to 0.96), but not intervention (aRR = 1.02, 95% CI: 1.00 to 1.04); use was not predictive of suppression in either arm. CONCLUSIONS The Sustainable East Africa Research in Community Health intervention improved ART uptake and viral suppression among PWH reporting hazardous alcohol use and eliminated gaps in ART uptake between PWH with hazardous and no/nonhazardous use. Patient-centered HIV care may decrease barriers to HIV care for PWH with hazardous alcohol use.
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Affiliation(s)
- Sarah B Puryear
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | - James Ayieko
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Judith A Hahn
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | | | | | - Joshua Schwab
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | - Laura B Balzer
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | | | - Edwin D Charlebois
- Division of Prevention Sciences, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; and
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maya L Petersen
- Division of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, CA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, CA
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29
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Kayendeke M, Nabirye C, Nayiga S, Westercamp N, Gonahasa S, Katureebe A, Kamya MR, Staedke SG, Hutchinson E. House modifications as a malaria control tool: how does local context shape participants' experience and interpretation in Uganda? Malar J 2023; 22:244. [PMID: 37626312 PMCID: PMC10463640 DOI: 10.1186/s12936-023-04669-1] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Evidence that house design can provide protection from malaria is growing. Housing modifications such as screening windows, doors, and ceilings, and attaching insecticide-impregnated materials to the eaves (the gap between the top of the wall and bottom of the roof), can protect against malaria. To be effective at scale, however, these modifications must be adopted by household residents. There is evidence that housing modifications can be acceptable, but in-depth knowledge on the experiences and interpretation of modifications is lacking. This qualitative study was carried out to provide a holistic account of the relationship between experiences and interpretations of four types of piloted housing modifications and the local context in Jinja, Uganda. METHODS Qualitative research was conducted between January to June 2021, before and during the installation of four types of housing modifications. The methods included nine weeks of participant observations in two study villages, nine focus group discussions with primary caregivers and heads of households (11-12 participants each), and nine key informant interviews with stakeholders and study team members. RESULTS Most residents supported the modifications. Experiences and interpretation of the housing modifications were shaped by the different types of housing in the area and the processes through which residents finished their houses, local forms of land and property ownership, and cultural and spiritual beliefs about houses. CONCLUSIONS To maximize the uptake and benefit of housing modifications against malaria, programme development needs to take local context into account. Forms of local land and house ownership, preferences, the social significance of housing types, and religious and spiritual ideas shape the responses to housing modifications in Jinja. These factors may be important in other setting. Trial registration Trial registration number is NCT04622241. The first draft was posted on November 9th 2020.
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Affiliation(s)
| | - Christine Nabirye
- Infectious Diseases Research Collaboration, Kampala, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Nelli Westercamp
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
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30
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Conrad MD, Asua V, Garg S, Giesbrecht D, Niaré K, Smith S, Namuganga JF, Katairo T, Legac J, Crudale RM, Tumwebaze PK, Nsobya SL, Cooper RA, Kamya MR, Dorsey G, Bailey JA, Rosenthal PJ. Evolution of Partial Resistance to Artemisinins in Malaria Parasites in Uganda. N Engl J Med 2023; 389:722-732. [PMID: 37611122 PMCID: PMC10513755 DOI: 10.1056/nejmoa2211803] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Partial resistance of Plasmodium falciparum to the artemisinin component of artemisinin-based combination therapies, the most important malaria drugs, emerged in Southeast Asia and now threatens East Africa. Partial resistance, which manifests as delayed clearance after therapy, is mediated principally by mutations in the kelch protein K13 (PfK13). Limited longitudinal data are available on the emergence and spread of artemisinin resistance in Africa. METHODS We performed annual surveillance among patients who presented with uncomplicated malaria at 10 to 16 sites across Uganda from 2016 through 2022. We sequenced the gene encoding kelch 13 (pfk13) and analyzed relatedness using molecular methods. We assessed malaria metrics longitudinally in eight Ugandan districts from 2014 through 2021. RESULTS By 2021-2022, the prevalence of parasites with validated or candidate resistance markers reached more than 20% in 11 of the 16 districts where surveillance was conducted. The PfK13 469Y and 675V mutations were seen in far northern Uganda in 2016-2017 and increased and spread thereafter, reaching a combined prevalence of 10 to 54% across much of northern Uganda, with spread to other regions. The 469F mutation reached a prevalence of 38 to 40% in one district in southwestern Uganda in 2021-2022. The 561H mutation, previously described in Rwanda, was first seen in southwestern Uganda in 2021, reaching a prevalence of 23% by 2022. The 441L mutation reached a prevalence of 12 to 23% in three districts in western Uganda in 2022. Genetic analysis indicated local emergence of mutant parasites independent of those in Southeast Asia. The emergence of resistance was observed predominantly in areas where effective malaria control had been discontinued or transmission was unstable. CONCLUSIONS Data from Uganda showed the emergence of partial resistance to artemisinins in multiple geographic locations, with increasing prevalence and regional spread over time. (Funded by the National Institutes of Health.).
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Affiliation(s)
- Melissa D Conrad
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Victor Asua
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Shreeya Garg
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - David Giesbrecht
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Karamoko Niaré
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Sawyer Smith
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Jane F Namuganga
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Thomas Katairo
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Jennifer Legac
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Rebecca M Crudale
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Patrick K Tumwebaze
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Samuel L Nsobya
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Roland A Cooper
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Moses R Kamya
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Grant Dorsey
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Jeffrey A Bailey
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
| | - Philip J Rosenthal
- From the University of California, San Francisco, San Francisco (M.D.C., S.G., J.L., G.D., P.J.R.); the Infectious Diseases Research Collaboration (V.A., J.F.N., T.K., P.K.T., S.L.N., M.R.K.) and Makerere University (M.R.K.) - both in Kampala, Uganda; the University of Tübingen, Tübingen, Germany (V.A.); Brown University, Providence, RI (D.G., K.N., S.S., R.M.C., J.A.B.); and Dominican University of California, San Rafael (R.A.C.)
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Kabami J, Owaraganise A, Beesiga B, Okiring J, Kakande E, Chen YH, Mwangwa F, Akatukwasa C, Nangendo J, Muyindike W, Semitala FC, Roh ME, Kamya MR. Effect of the COVID-19 lockdown on the HIV care continuum in Southwestern Uganda: A time series analysis. PLoS One 2023; 18:e0289000. [PMID: 37561727 PMCID: PMC10414556 DOI: 10.1371/journal.pone.0289000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 07/09/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION In Uganda, COVID-19 lockdown policies curbed the spread of SARS-CoV-2, but their effect on HIV care is poorly understood. OBJECTIVES We examined the effects of COVID-19 lockdown policies on ART initiation, missed visits, and viral suppression in Uganda. METHODS We conducted a time series analysis using data from a dynamic cohort of persons with HIV enrolled between March 2017 and September 2021 at HIV clinics in Masaka and Mbarara Regional Referral Hospitals in Southwestern Uganda. Poisson and fractional probit regression were used to predict expected monthly antiretroviral therapy initiations, missed visits, and viral suppression based on pre-lockdown trends. Observed and expected trends were compared across three policy periods: April 2020-September 2021 (overall), April-May 2020 (1st lockdown), and June-August 2021 (2nd lockdown). RESULTS We enrolled 7071 Persons living with HIV (PWH) (nMasaka = 4150; nMbarara = 2921). Average ART duration was 34 and 30 months in Masaka and Mbarara, respectively. During the 18-month post-lockdown period, monthly ART initiations were lower than expected in both Masaka (51 versus 63 visits; a decrease of 12 [95% CI: -2, 31] visits) and Mbarara (42 versus 55 visits; a decrase of 13 [95% CI: 0, 27] visits). Proportion of missed visits was moderately higher than expected post-lockdown in Masaka (10% versus 7%; 4% [95% CI: 1%, 7%] absolute increase), but not in Mbarara (13% versus 13%; 0% [95% CI: -4%, 6%] absolute decrease). Viral suppression rates were moderate-to-high in Masaka (64.7%) and Mbarara (92.5%) pre-lockdown and remained steady throughout the post-lockdown period. CONCLUSION The COVID-19 lockdown in Uganda was associated with reductions in ART initiation, with minimal effects on retention and viral suppression, indicating a resilient HIV care system.
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Affiliation(s)
- Jane Kabami
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Brian Beesiga
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Jaffer Okiring
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Elijah Kakande
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Yea-Hung Chen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Florence Mwangwa
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | | | | | - Winnie Muyindike
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred C. Semitala
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Michelle E. Roh
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
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Lynd A, Gonahasa S, Staedke SG, Oruni A, Maiteki-Sebuguzi C, Hancock P, Knight E, Dorsey G, Opigo J, Yeka A, Katureebe A, Kyohere M, Hemingway J, Kamya MR, McDermott D, Lucas ER, Donnelly MJ. LLIN Evaluation in Uganda Project (LLINEUP) - Plasmodium infection prevalence and genotypic markers of insecticide resistance in Anopheles vectors from 48 districts of Uganda. medRxiv 2023:2023.07.31.23293323. [PMID: 37577716 PMCID: PMC10418296 DOI: 10.1101/2023.07.31.23293323] [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] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Background In 2017-2019, we conducted a large-scale, cluster-randomised trial (LLINEUP) to evaluate long-lasting insecticidal nets (LLINs) treated with a pyrethroid insecticide plus the synergist piperonyl butoxide (PBO LLINs), as compared to conventional, pyrethroid-only LLINs across 104 health sub-districts (HSDs) in Uganda. In LLINEUP, and similar trials in Tanzania, PBO LLINs were found to provide greater protection against malaria than conventional LLINs, reducing parasitaemia and vector density. In the LLINEUP trial, cross-sectional entomological surveys were carried out at baseline and then every 6 months for two years. In each survey, ten households per HSD were randomly selected for indoor household entomological collections. Results Overall, 5395 female Anopheles mosquitoes were collected from 5046 households. The proportion of mosquitoes infected with Plasmodium falciparum did not change significantly over time, while infection with non-falciparum malaria decreased in An. gambiae s.s, but not An. funestus. The frequency of genetic markers associated with pyrethroid resistance increased significantly over time, but the rate of change was not different between the two LLIN types. The knock-down resistance (kdr) mutation Vgsc-995S declined over time as Vgsc-995F, the alternative resistance mutation at this codon, increased. Vgsc-995F appears to be spreading into Uganda. Conclusions Distribution of LLINs in Uganda was associated with reductions in parasite prevalence and vector density, but the proportion of infective mosquitoes remained stable, suggesting that the potential for transmission persisted. The increased frequency of markers of pyrethroid resistance indicates that LLIN distribution favoured the evolution of resistance within local vectors and highlights the potential benefits of resistance management strategies.Trial registration:: This study is registered with ISRCTN, ISRCTN17516395. Registered 14 February 2017, http://www.isrctn.com/ISRCTN17516395.
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Affiliation(s)
- Amy Lynd
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Samuel Gonahasa
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Sarah G Staedke
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Ambrose Oruni
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | | | | | - Erin Knight
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Grant Dorsey
- University of California, San Francisco, San Francisco, CA 94110 USA
| | | | - Adoke Yeka
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Agaba Katureebe
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Mary Kyohere
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Janet Hemingway
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Moses R Kamya
- Makerere University College of Health Sciences
- Infectious Diseases Research Collaboration, 2C Nakasero Hill Road, Kampala, Uganda
| | - Daniel McDermott
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Eric R Lucas
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Martin J Donnelly
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
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Ruel T, Mwangwa F, Balzer LB, Ayieko J, Nyabuti M, Mugoma WE, Kabami J, Kamugisha B, Black D, Nzarubara B, Opel F, Schrom J, Agengo G, Nakigudde J, Atuhaire HN, Schwab J, Peng J, Camlin C, Shade SB, Bukusi E, Kapogiannis BG, Charlebois E, Kamya MR, Havlir D. A multilevel health system intervention for virological suppression in adolescents and young adults living with HIV in rural Kenya and Uganda (SEARCH-Youth): a cluster randomised trial. Lancet HIV 2023; 10:e518-e527. [PMID: 37541706 DOI: 10.1016/s2352-3018(23)00118-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/11/2023] [Accepted: 05/17/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Social and cognitive developmental events can disrupt care and medication adherence among adolescents and young adults living with HIV in sub-Saharan Africa. We hypothesised that a dynamic multilevel health system intervention helping adolescents and young adults and their providers navigate life-stage related events would increase virological suppression compared with standard care. METHODS We did a cluster randomised, open-label trial of young individuals aged 15-24 years with HIV and receiving care in eligible clinics (operated by the government and with ≥25 young people receiving care) in rural Kenya and Uganda. After clinic randomisation stratified by region, patient population, and previous participation in the SEARCH trial, participants in intervention clinics received life-stage-based assessment at routine visits, flexible clinic access, and rapid viral load feedback. Providers had a secure mobile platform for interprovider consultation. The control clinics followed standard practice. The primary, prespecified endpoint was virological suppression (HIV RNA <400 copies per mL) at 2 years of follow-up among participants who enrolled before Dec 1, 2019, and received care at the study clinics. This trial is registered with ClinicalTrials.gov, NCT03848728, and is closed to recruitment. FINDINGS 28 clinics were enrolled and randomly assigned (14 control, 14 intervention) in January, 2019. Between March 14, 2019, and Nov 26, 2020, we recruited 1988 participants at the clinics, of whom 1549 were included in the analysis (785 at intervention clinics and 764 at control clinics). The median participant age was 21 years (IQR 19-23) and 1248 (80·6%) of 1549 participants were female. The mean proportion of participants with virological suppression at 2 years was 88% (95% CI 85-92) for participants in intervention clinics and 80% (77-84) for participants in control clinics, equivalent to a 10% beneficial effect of the intervention (risk ratio [RR] 1·10, 95% CI 1·03-1·16; p=0·0019). The intervention resulted in increased virological suppression within all subgroups of sex, age, and care status at baseline, with greatest improvement among those re-engaging in care (RR 1·60, 95% CI 1·00-2·55; p=0·025). INTERPRETATION Routine and systematic life-stage-based assessment, prompt adherence support with rapid viral load testing, and patient-centred, flexible clinic access could help bring adolescents and young adults living with HIV closer towards a goal of universal virological suppression. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development, US National Institutes of Health.
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Affiliation(s)
- Theodore Ruel
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
| | | | - Laura B Balzer
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Fred Opel
- Kenya Medical Research Institute, Kisumu, Kenya
| | - John Schrom
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Janet Nakigudde
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Josh Schwab
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - James Peng
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Carol Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Starley B Shade
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Bill G Kapogiannis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Edwin Charlebois
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Larmarange J, Bachanas P, Skalland T, Balzer LB, Iwuji C, Floyd S, Mills LA, Pillay D, Havlir D, Kamya MR, Ayles H, Wirth K, Dabis F, Hayes R, Petersen M. Population-level viremia predicts HIV incidence at the community level across the Universal Testing and Treatment Trials in eastern and southern Africa. PLOS Glob Public Health 2023; 3:e0002157. [PMID: 37450436 PMCID: PMC10348573 DOI: 10.1371/journal.pgph.0002157] [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] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
Universal HIV testing and treatment (UTT) strategies aim to optimize population-level benefits of antiretroviral treatment. Between 2012 and 2018, four large community randomized trials were conducted in eastern and southern Africa. While their results were broadly consistent showing decreased population-level viremia reduces HIV incidence, it remains unclear how much HIV incidence can be reduced by increasing suppression among people living with HIV (PLHIV). We conducted a pooled analysis across the four UTT trials. Leveraging data from 105 communities in five countries, we evaluated the linear relationship between i) population-level viremia (prevalence of non-suppression-defined as plasma HIV RNA >500 or >400 copies/mL-among all adults, irrespective of HIV status) and HIV incidence; and ii) prevalence of non-suppression among PLHIV and HIV incidence, using parametric g-computation. HIV prevalence, measured in 257 929 persons, varied from 2 to 41% across the communities; prevalence of non-suppression among PLHIV, measured in 31 377 persons, from 3 to 70%; population-level viremia, derived from HIV prevalence and non-suppression, from < 1% to 25%; and HIV incidence, measured over 345 844 person-years (PY), from 0.03/100PY to 3.46/100PY. Decreases in population-level viremia were strongly associated with decreased HIV incidence in all trials (between 0.45/100PY and 1.88/100PY decline in HIV incidence per 10 percentage points decline in viremia). Decreases in non-suppression among PLHIV were also associated with decreased HIV incidence in all trials (between 0.06/100PY and 0.17/100PY decline in HIV incidence per 10 percentage points decline in non-suppression). Our results support both the utility of population-level viremia as a predictor of incidence, and thus a tool for targeting prevention interventions, and the ability of UTT approaches to reduce HIV incidence by increasing viral suppression. Implementation of universal HIV testing approaches, coupled with interventions to leverage linkage to treatment, adapted to local contexts, can reduce HIV acquisition at population level.
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Affiliation(s)
- Joseph Larmarange
- Centre Population et Développement, Université Paris Cité, IRD, Inserm, Paris, France
| | - Pamela Bachanas
- Division of Global HIV/AIDS and TB, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Timothy Skalland
- Fred Hutchinson Cancer Center, Seattle, WA, United States of America
| | - Laura B. Balzer
- Division of Biostatistics, School of Public Health, University of California, Berkeley, California, United States of America
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lisa A. Mills
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Deenan Pillay
- Division of Infection & Immunity, University College London, London, United Kingdom
| | - Diane Havlir
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Moses R. Kamya
- Department of Medicine, Makerere University Kampala, Uganda and the Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Helen Ayles
- Clinical Research Department London School of Hygiene & Tropical Medicine, London, United Kingdom
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | - Kathleen Wirth
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - François Dabis
- Université Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Maya Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, California, United States of America
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Kabami J, Kakande E, Chamie G, Balzer LB, Petersen ML, Camlin CS, Nyabuti M, Koss CA, Bukusi EA, Kamya MR, Havlir DV, Ayieko J. Uptake of a patient-centred dynamic choice model for HIV prevention in rural Kenya and Uganda: SEARCH SAPPHIRE study. J Int AIDS Soc 2023; 26 Suppl 1:e26121. [PMID: 37408473 PMCID: PMC10323314 DOI: 10.1002/jia2.26121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/15/2023] [Indexed: 07/07/2023] Open
Abstract
INTRODUCTION Person-centred HIV prevention delivery models that offer structured choices in product, testing and visit location may increase coverage. However, data are lacking on the actual uptake of choices among persons at risk of HIV in southern Africa. In an ongoing randomized study (SEARCH; NCT04810650) in rural East Africa, we evaluated the uptake of choices made when offered in a person-centred, dynamic choice model for HIV prevention. METHODS Using the PRECEDE framework, we developed a persont-centred, Dynamic Choice HIV Prevention (DCP) intervention for persons at risk of HIV in three settings in rural Kenya and Uganda: antenatal clinic (ANC), outpatient department (OPD) and in the community. Components include: provider training on product choice (predisposing); flexibility and responsiveness to client desires and choices (pre-exposure prophylaxis [PrEP]/post-exposure prophylaxis [PEP], clinic vs. off-site visits and self- or clinician-based HIV testing) (enabling); and client and staff feedback (reinforcing). All clients received a structured assessment of barriers with personalized plans to address them, mobile phone access to clinicians (24 hours/7 days/week) and integrated reproductive health services. In this interim analysis, we describe the uptake of choices of product, location and testing during the first 24 weeks of follow-up (April 2021-March 2022). RESULTS A total of 612 (203 ANC, 197 OPD and 212 community) participants were randomized to the person-centred DCP intervention. We delivered the DCP intervention in all three settings with diverse populations: ANC: 39% pregnant; median age: 24 years; OPD: 39% male, median age 27 years; and community: 42% male, median age: 29 years. Baseline choice of PrEP was highest in ANC (98%) vs. OPD (84%) and community (40%); whereas the proportion of adults selecting PEP was higher in the community (46%) vs. OPD (8%) and ANC (1%). Personal preference for off-site visits increased over time (65% at week 24 vs. 35% at baseline). Interest in alternative HIV testing modalities grew over time (38% baseline self-testing vs. 58% at week 24). CONCLUSIONS A person-centred model incorporating structured choice in biomedical prevention and care delivery options in settings with demographically diverse groups, in rural Kenya and Uganda, was responsive to varying personal preferences over time in HIV prevention programmes.
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Affiliation(s)
- Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
- Department of MedicineMakerere UniversityKampalaUganda
| | | | - Gabriel Chamie
- Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Laura B. Balzer
- Department of BiostatisticsUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Maya L. Petersen
- Department of BiostatisticsUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive SciencesUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Marilyn Nyabuti
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | - Catherine A. Koss
- Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Elizabeth A. Bukusi
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
| | | | - Diane V. Havlir
- Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - James Ayieko
- Center for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
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Musanje K, Kamya MR, Kasujja R, Hooper N, Katahoire AR, White RG, Kimera E, Getahun M, Sinclair DL, Ojiambo D, Camlin CS. Acceptability of an adapted mindfulness and acceptance-based intervention to support adolescents with HIV: A qualitative study with Ugandan health care providers. J Contextual Behav Sci 2023; 29:160-168. [PMID: 37519920 PMCID: PMC10373499 DOI: 10.1016/j.jcbs.2023.07.002] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
While the adaptation of evidence-based psychosocial support tailors the intervention components to the targeted context, minimizing the associated costs of developing new interventions for low-income contexts, the acceptability of such adapted interventions is important for augmenting successful implementation and sustainability. Given that psychosocial support to persons living with HIV is mostly rendered by healthcare providers, their acceptance of adapted interventions before implementation is crucial. This study explored healthcare providers' acceptance of an adapted mindfulness and acceptance-based intervention supporting adolescents with HIV. Ten healthcare providers at two urban clinics in Kampala, Uganda attended a three-day training on using the adapted intervention and gave feedback on its appropriateness during in-depth interviews conducted thereafter. Semi-structured interviews were based on the Theoretical Framework of Acceptability and findings were analyzed abductively within the seven components of the framework. Overall, the adapted intervention was perceived to be acceptable and appropriate for use with adolescents. Benefits included the intervention offering support beyond a focus on adherence to drugs, refocusing adolescents on aspects in their lives that matter most, and being easy to integrate into providers' work processes. Providers however expressed concern about the time the intervention requires and the possibility of increasing their workload. These findings will support further adaptation and implementation.
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Affiliation(s)
- Khamisi Musanje
- Department of Educational, Social and Organizational Psychology, Makerere University, Uganda
- Clinical Epidemiology Unit, Makerere University, Uganda
| | | | - Rosco Kasujja
- Department of Mental Health and Community Psychology, Makerere University, Uganda
| | - Nic Hooper
- School of Psychology, Cardiff University, Wales, UK
| | | | - Ross G. White
- School of Psychology, Queens University, Belfast, Northern Ireland
| | - Emanuel Kimera
- Department of Public Health, Mountain of the Moon University, Uganda
| | - Monica Getahun
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | | | - Deborah Ojiambo
- Department of Mental Health and Community Psychology, Makerere University, Uganda
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences. University of California, San Francisco, USA
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Nangendo J, Katahoire AR, Karamagi CA, Obeng-Amoako GO, Muwema M, Okiring J, Kabami J, Semitala FC, Kalyango JN, Wanyenze RK, Kamya MR. Uptake and perceptions of oral HIV self-testing delivered by village health teams among men in Central Uganda: A concurrent parallel mixed methods analysis. PLOS Glob Public Health 2023; 3:e0002019. [PMID: 37315008 PMCID: PMC10266653 DOI: 10.1371/journal.pgph.0002019] [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] [Received: 03/02/2023] [Accepted: 05/12/2023] [Indexed: 06/16/2023]
Abstract
The World Health Organization (WHO) recommends HIV self-testing (HIVST) to increase access to and utilization of HIV services among underserved populations. We assessed the uptake and perceptions of oral HIVST delivered by Village Health Teams (VHTs) among men in a peri-urban district in Central Uganda. We used a concurrent parallel mixed methods study design and analyzed data from 1628 men enrolled in a prospective cohort in Mpigi district, Central Uganda between October 2018 and June 2019. VHTs distributed HIVST kits and linkage-to-care information leaflets to participants in 30 study villages allowing up-to 10 days each to self-test. At baseline, we collected data on participant socio-demographics, testing history and risk behavior for HIV. During follow-up, we measured HIVST uptake (using self-reports and proof of a used kit) and conducted in-depth interviews to explore participants' perceptions of using HIVST. We used descriptive statistics to analyze the quantitative data and a hybrid inductive, and deductive thematic analysis for the qualitative data and integrated the results at interpretation. The median age of men was 28 years, HIVST uptake was 96% (1564/1628), HIV positivity yield was 4% (63/1564) and reported disclosure of HIVST results to sexual partners and significant others was 75.6% (1183/1564). Men perceived HIVST as a quick, flexible, convenient, and more private form of testing; allowing disclosure of HIV test results to sexual partners, friends and family, and receiving social support. Others perceived it as an opportunity for knowing or re-confirming their sero-status and subsequent linkage or re-linkage to care and prevention. Utilizing VHT networks for community-based delivery of HIVST is effective in reaching men with HIV testing services. Men perceived HIVST as highly beneficial but needed more training on performing the test and the integrating post-test counseling support to optimize use of the test for diagnosing HIV.
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Affiliation(s)
- Joanita Nangendo
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Anne R. Katahoire
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Charles A. Karamagi
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gloria O. Obeng-Amoako
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- International Centre for Evaluation and Development, Tema, Ghana
| | - Mercy Muwema
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jaffer Okiring
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jane Kabami
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Fred C. Semitala
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Joan N. Kalyango
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda K. Wanyenze
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses R. Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
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Sung J, Musinguzi A, Kadota JL, Baik Y, Nabunje J, Welishe F, Bishop O, Berger CA, Katahoire A, Nakitende A, Nakimuli J, Akello L, Kasidi JR, Kunihira Tinka L, Kamya MR, Sohn H, Kiwanuka N, Katamba A, Cattamanchi A, Dowdy DW, Semitala FC. Understanding patient-level costs of weekly isoniazid-rifapentine (3HP) among people living with HIV in Uganda. Int J Tuberc Lung Dis 2023; 27:458-464. [PMID: 37231600 DOI: 10.5588/ijtld.22.0679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND: Twelve weeks of weekly isoniazid and rifapentine (3HP) prevents TB disease among people with HIV (PWH), but the costs to people of taking TB preventive treatment is not well described.METHODS: We surveyed PWH who initiated 3HP at a large urban HIV/AIDS clinic in Kampala, Uganda, as part of a larger trial. We estimated the cost of one 3HP visit from the patient perspective, including both out-of-pocket costs and estimated lost wages. Costs were reported in 2021 Ugandan shillings (UGX) and US dollars (USD; USD1 = UGX3,587)RESULTS: The survey included 1,655 PWH. The median participant cost of one clinic visit was UGX19,200 (USD5.36), or 38.5% of the median weekly income. Per visit, the cost of transportation was the largest component (median: UGX10,000/USD2.79), followed by lost income (median: UGX4,200/USD1.16) and food (median: UGX2,000/USD0.56). Men reported greater income loss than women (median: UGX6,400/USD1.79 vs. UGX3,300/USD0.93), and participants who lived further than a 30-minute drive to the clinic had higher transportation costs than others (median: UGX14,000/USD3.90 vs. UGX8,000/USD2.23).CONCLUSION: Patient-level costs to receive 3HP accounted for over one-third of weekly income. Patient-centered approaches to averting or defraying these costs are needed.
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Affiliation(s)
- J Sung
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Musinguzi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - J L Kadota
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Y Baik
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - J Nabunje
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - F Welishe
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - O Bishop
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - C A Berger
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - A Katahoire
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - A Nakitende
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - J Nakimuli
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - L Akello
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - J R Kasidi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - L Kunihira Tinka
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - M R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda, Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - H Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - N Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - A Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda, Department of Internal Medicine Clinical Epidemiology Unit, Makerere University College of Health Science, Kampala, Uganda
| | - A Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda, Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - D W Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - F C Semitala
- Infectious Diseases Research Collaboration, Kampala, Uganda, Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda, Makerere University Joint AIDS Program, Kampala, Uganda
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Tukwasibwe S, Mboowa G, Sserwadda I, Nankabirwa JI, Arinaitwe E, Ssewanyana I, Taremwa Y, Tumusiime G, Kamya MR, Jagannathan P, Nakimuli A. Impact of high human genetic diversity in Africa on immunogenicity and efficacy of RTS,S/AS01 vaccine. Immunogenetics 2023; 75:207-214. [PMID: 37084013 PMCID: PMC10119520 DOI: 10.1007/s00251-023-01306-8] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/06/2023] [Indexed: 04/22/2023]
Abstract
In modern medicine, vaccination is one of the most effective public health strategies to prevent infectious diseases. Indisputably, vaccines have saved millions of lives by reducing the burden of many serious infections such as polio, tuberculosis, measles, pneumonia, and tetanus. Despite the recent recommendation by the World Health Organization (WHO) to roll out RTS,S/AS01, this malaria vaccine still faces major challenges of variability in its efficacy partly due to high genetic variation in humans and malaria parasites. Immune responses to malaria vary between individuals and populations. Human genetic variation in immune system genes is the probable cause for this heterogeneity. In this review, we will focus on human genetic factors that determine variable responses to vaccination and how variation in immune system genes affect the immunogenicity and efficacy of the RTS,S/AS01 vaccine.
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Affiliation(s)
- Stephen Tukwasibwe
- Infectious Diseases Research Collaboration, Kampala, Uganda.
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
- School of Medicine, Uganda Christian University, Kampala, Uganda.
| | - Gerald Mboowa
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ivan Sserwadda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | | | - Yoweri Taremwa
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Gerald Tumusiime
- School of Medicine, Uganda Christian University, Kampala, Uganda
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Annettee Nakimuli
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Chaisson LH, Semitala FC, Nangobi F, Steinmetz S, Marquez C, Armstrong DT, Opira B, Kamya MR, Phillips PPJ, Dowdy DW, Yoon C. Viral suppression among adults with HIV receiving routine dolutegravir-based antiretroviral therapy and 3 months weekly isoniazid-rifapentine. AIDS 2023; 37:1097-1101. [PMID: 36779500 PMCID: PMC10164049 DOI: 10.1097/qad.0000000000003508] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
OBJECTIVE We aimed to evaluate safety of 3 months weekly isoniazid-rifapentine (3HP) for tuberculosis (TB) prevention when co-administered with dolutegravir-based antiretroviral therapy (TLD), and compare viral suppression among those initiating TLD + 3HP vs. TLD alone. DESIGN/METHODS We analyzed data from an ongoing Phase 3 randomized trial comparing TB screening strategies among adults with CD4 + ≤350 cells/μl initiating routine antiretroviral therapy (ART) in Kampala, Uganda. TB screen-negative participants without contraindications are referred for self-administered 3HP. HIV viral load is routinely measured at 6 and 12 months. Here, we included TB-negative participants who initiated TLD with or without 3HP. We determined the number who discontinued 3HP due to drug toxicity. In addition, we assessed viral suppression at 6 and 12 months and used log-binomial regression to assess risk of viremia at 6 months for participants who initiated TLD + 3HP vs. TLD alone. RESULTS Of 453 participants initiating TLD (287 [63.4%] female, median age 30 years [interquartile range (IQR) 25-37], median pre-ART CD4 + cell count 188 cells/μl [IQR 86-271]), 163 (36.0%) initiated 3HP. Of these, 154 (94.5%) completed 3HP and one (0.6%) had treatment permanently discontinued due to a possible 3HP-related adverse event. At 6 months, for participants who received TLD + 3HP, risk of viremia >50 copies/ml was 1.51 [95% confidence interval (CI) 1.07-2.14] times that of participants who received TLD alone. There was no difference in viral suppression between those who received TLD + 3HP vs. TLD alone at 12 months. CONCLUSIONS Co-administration of TLD + 3HP was well tolerated. However, those who received TLD + 3HP were less likely to achieve viral suppression within six-months compared to those who received TLD alone.
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Affiliation(s)
- Lelia H Chaisson
- Division of Infectious Diseases, Department of Medicine
- Center for Global Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Fred C Semitala
- Department of Medicine, Makerere University College of Health Sciences
- Infectious Diseases Research Collaboration
- Makerere University Joint AIDS Program, Kampala Uganda
| | | | | | - Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA
| | | | | | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences
- Infectious Diseases Research Collaboration
| | - Patrick P J Phillips
- Division of Pulmonary and Critical Care Medicine
- Center for Tuberculosis, University of California San Francisco, San Francisco, CS
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD
- Departments of International Health and Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Christina Yoon
- Division of Pulmonary and Critical Care Medicine
- Center for Tuberculosis, University of California San Francisco, San Francisco, CS
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Epstein A, Namuganga JF, Nabende I, Kamya EV, Kamya MR, Dorsey G, Sturrock H, Bhatt S, Rodríguez-Barraquer I, Greenhouse B. Mapping malaria incidence using routine health facility surveillance data in Uganda. BMJ Glob Health 2023; 8:bmjgh-2022-011137. [PMID: 37208120 DOI: 10.1136/bmjgh-2022-011137] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Maps of malaria risk are important tools for allocating resources and tracking progress. Most maps rely on cross-sectional surveys of parasite prevalence, but health facilities represent an underused and powerful data source. We aimed to model and map malaria incidence using health facility data in Uganda. METHODS Using 24 months (2019-2020) of individual-level outpatient data collected from 74 surveillance health facilities located in 41 districts across Uganda (n=445 648 laboratory-confirmed cases), we estimated monthly malaria incidence for parishes within facility catchment areas (n=310) by estimating care-seeking population denominators. We fit spatio-temporal models to the incidence estimates to predict incidence rates for the rest of Uganda, informed by environmental, sociodemographic and intervention variables. We mapped estimated malaria incidence and its uncertainty at the parish level and compared estimates to other metrics of malaria. To quantify the impact that indoor residual spraying (IRS) may have had, we modelled counterfactual scenarios of malaria incidence in the absence of IRS. RESULTS Over 4567 parish-months, malaria incidence averaged 705 cases per 1000 person-years. Maps indicated high burden in the north and northeast of Uganda, with lower incidence in the districts receiving IRS. District-level estimates of cases correlated with cases reported by the Ministry of Health (Spearman's r=0.68, p<0.0001), but were considerably higher (40 166 418 cases estimated compared with 27 707 794 cases reported), indicating the potential for underreporting by the routine surveillance system. Modelling of counterfactual scenarios suggest that approximately 6.2 million cases were averted due to IRS across the study period in the 14 districts receiving IRS (estimated population 8 381 223). CONCLUSION Outpatient information routinely collected by health systems can be a valuable source of data for mapping malaria burden. National Malaria Control Programmes may consider investing in robust surveillance systems within public health facilities as a low-cost, high benefit tool to identify vulnerable regions and track the impact of interventions.
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Affiliation(s)
- Adrienne Epstein
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Isaiah Nabende
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Hugh Sturrock
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Malaria Elimination Initiative, University of California San Francisco, San Francisco, California, USA
| | - Samir Bhatt
- Department of Public Health, University of Copenhagen, Kobenhavn, Denmark
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | | | - Bryan Greenhouse
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Gutin SA, Neilands TB, Charlebois ED, Getahun M, Okiring J, Akullian A, Maeri I, Eyul P, Ssali S, Cohen CR, Kamya MR, Bukusi EA, Camlin CS. Mobility is Associated with Higher-risk Sexual Partnerships Among Both Men and Women in Co-resident Couples in Rural Kenya and Uganda: A Longitudinal Cohort Study. AIDS Behav 2023; 27:1418-1429. [PMID: 36318427 PMCID: PMC10129962 DOI: 10.1007/s10461-022-03878-0] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 11/06/2022]
Abstract
Population mobility is associated with higher-risk sexual behaviors in sub-Saharan Africa and is a key driver of the HIV epidemic. We conducted a longitudinal cohort study to estimate associations between recent mobility (overnight travel away from home in past six months) or migration (changes of residence over defined geopolitical boundaries) and higher-risk sexual behavior among co-resident couples (240 couples aged ≥ 16) from 12 rural communities in Kenya and Uganda. Data on concurrent mobility and sexual risk behaviors were collected every 6-months between 2015 and 2020. We used sex-pooled and sex-stratified multilevel models to estimate associations between couple mobility configurations (neither partner mobile, male mobile/female not mobile, female mobile/male not mobile, both mobile) and the odds of higher-risk (casual, commercial sex worker/client, one night stand, inherited partner, stranger) and concurrent sexual partnerships based on who was mobile. On average across all time points and subjects, mobile women were more likely than non-mobile women to have a higher-risk partner; similarly, mobile men were more likely than non-mobile men to report a higher-risk partnership. Men with work-related mobility versus not had higher odds of higher-risk partnerships. Women with work-related mobility versus not had higher odds of higher-risk partnerships. Couples where both members were mobile versus neither had greater odds of higher-risk partnerships. In analyses using 6-month lagged versions of key predictors, migration events of men, but not women, preceded higher-risk partnerships. Findings demonstrate HIV risks for men and women associated with mobility and the need for prevention approaches attentive to the risk-enhancing contexts of mobility.
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Affiliation(s)
- Sarah A Gutin
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA.
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), Oakland, CA, USA
| | - Jaffer Okiring
- The Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Adam Akullian
- Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Patrick Eyul
- The Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), Oakland, CA, USA
| | - Moses R Kamya
- The Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Carol S Camlin
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), Oakland, CA, USA
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Andolina C, Ramjith J, Rek J, Lanke K, Okoth J, Grignard L, Arinaitwe E, Briggs J, Bailey J, Aydemir O, Kamya MR, Greenhouse B, Dorsey G, Staedke SG, Drakeley C, Jonker M, Bousema T. Plasmodium falciparum gametocyte carriage in longitudinally monitored incident infections is associated with duration of infection and human host factors. Sci Rep 2023; 13:7072. [PMID: 37127688 PMCID: PMC10150352 DOI: 10.1038/s41598-023-33657-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/17/2023] [Indexed: 05/03/2023] Open
Abstract
Malaria transmission depends on the presence of Plasmodium gametocytes that are the only parasite life stage that can infect mosquitoes. Gametocyte production varies between infections and over the course of infections. Infection duration is highly important for gametocyte production but poorly quantified. Between 2017 and 2019 an all-age cohort of individuals from Tororo, eastern Uganda was followed by continuous passive and routine assessments. We longitudinally monitored 104 incident infections from 98 individuals who were sampled once every 28 days and on any day of symptoms. Among infections that lasted ≥ 3 months, gametocyte appearance was near-universal with 96% of infections having detectable gametocytes prior to clearance. However, most infections were of much shorter duration; 55.7% of asymptomatic infections were detected only once. When considering all asymptomatic infections, regardless of their duration, only 36.3% had detectable gametocytes on at least one time-point prior to parasite clearance. Infections in individuals with sickle-cell trait (HbAS) were more likely to have gametocytes detected (Hazard Rate (HR) = 2.68, 95% CI 1.12, 6.38; p = 0.0231) and had gametocytes detected at higher densities (Density Ratio (DR) = 9.19, 95% CI 2.79, 30.23; p = 0.0002) compared to infections in wildtype (HbAA) individuals. Our findings suggest that a large proportion of incident infections is too short in duration and of too low density to contribute to onward transmission.
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Affiliation(s)
- Chiara Andolina
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jordache Ramjith
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - John Rek
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Kjerstin Lanke
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Joseph Okoth
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Lynn Grignard
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Jessica Briggs
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, USA
| | - Jeffrey Bailey
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, USA
| | - Ozkan Aydemir
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Bryan Greenhouse
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, USA
| | - Grant Dorsey
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, USA
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Drakeley
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Marianne Jonker
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Teun Bousema
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK.
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Musanje K, Camlin CS, Kamya MR, Vanderplasschen W, Louise Sinclair D, Getahun M, Kirabo H, Nangendo J, Kiweewa J, White RG, Kasujja R. Culturally adapting a mindfulness and acceptance-based intervention to support the mental health of adolescents on antiretroviral therapy in Uganda. PLOS Glob Public Health 2023; 3:e0001605. [PMID: 36963093 PMCID: PMC10021405 DOI: 10.1371/journal.pgph.0001605] [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] [Received: 09/19/2022] [Accepted: 01/24/2023] [Indexed: 03/09/2023]
Abstract
The dual burden of living with HIV and negotiating life stage changes has been identified as a contributing factor to lapsed adherence among adolescents with HIV in sub-Saharan Africa. While psychosocial support can promote medication adherence, most interventions in use with adolescents were originally developed for the general population creating a gap in appropriate support. Life-stage-appropriate, evidence-based psychosocial support interventions have been used with young people in high-income contexts, prompting interest in their use in low-income contexts. However, many interventions are less effective when implemented outside of their original settings, hence the need for modifications before implementation. We aimed to culturally adapt an evidence-based psychosocial support intervention designed to improve the mental health of young people for use among adolescents with HIV in a sub-Saharan African context and to explore the acceptability of the adapted intervention among adolescents. We engaged thirty stakeholders (n = 30) in Kampala, Uganda including psychologists, psychiatrists, social workers, HIV counselors, religious leaders and adolescent peers from December 2021 to April 2022 to modify an evidence-based intervention for adolescents. Key adaptations included simplifying the language, adding local practices, integrating locally relevant slang and stories into therapy, introducing racially-congruent visuals and cards representing emotions, and adjusting therapy materials for use in resource-constrained settings. We then tested the acceptability of the intervention in a small sample of service users using a qualitative approach. We recruited nine adolescents with HIV from a participating clinic in Kampala, delivered six 90-minute sessions of the adapted intervention across three weeks and conducted in-depth interviews to assess the acceptability of the intervention. We used thematic analysis to analyze the qualitative data. The adapted intervention was perceived as acceptable among adolescents with HIV, with many stating that it helped them overcome fears, increased their self-acceptance, and gave them the confidence to make careful health-enhancing decisions.
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Affiliation(s)
- Khamisi Musanje
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
- Department of Educational, Social and Organizational Psychology, Makerere University, Kampala, Uganda
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Moses R. Kamya
- Department of Medicine, Makerere University, Kampala, Uganda
| | | | | | - Monica Getahun
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
| | - Hope Kirabo
- Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda
| | - Joan Nangendo
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - John Kiweewa
- Fairfield University, Fairfield, Connecticut, United States of America
| | - Ross G. White
- School of Psychology, Queens University, Belfast, Northern Ireland, United Kingdom
| | - Rosco Kasujja
- Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda
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45
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Musoke D, Atusingwize E, Namata C, Ndejjo R, Wanyenze RK, Kamya MR. Integrated malaria prevention in low- and middle-income countries: a systematic review. Malar J 2023; 22:79. [PMID: 36879237 PMCID: PMC9987134 DOI: 10.1186/s12936-023-04500-x] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 02/16/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND As many countries aim to eliminate malaria, use of comprehensive approaches targeting the mosquito vector and environment are needed. Integrated malaria prevention advocates the use of several malaria prevention measures holistically at households and in the community. The aim of this systematic review was to collate and summarize the impact of integrated malaria prevention in low- and middle-income countries on malaria burden. METHODS Literature on integrated malaria prevention, defined as the use of two or more malaria prevention methods holistically, was searched from 1st January 2001 to 31st July 2021. The primary outcome variables were malaria incidence and prevalence, while the secondary outcome measures were human biting and entomological inoculation rates, and mosquito mortality. RESULTS A total of 10,931 studies were identified by the search strategy. After screening, 57 articles were included in the review. Studies included cluster randomized controlled trials, longitudinal studies, programme evaluations, experimental hut/houses, and field trials. Various interventions were used, mainly combinations of two or three malaria prevention methods including insecticide-treated nets (ITNs), indoor residual spraying (IRS), topical repellents, insecticide sprays, microbial larvicides, and house improvements including screening, insecticide-treated wall hangings, and screening of eaves. The most common methods used in integrated malaria prevention were ITNs and IRS, followed by ITNs and topical repellents. There was reduced incidence and prevalence of malaria when multiple malaria prevention methods were used compared to single methods. Mosquito human biting and entomological inoculation rates were significantly reduced, and mosquito mortality increased in use of multiple methods compared to single interventions. However, a few studies showed mixed results or no benefits of using multiple methods to prevent malaria. CONCLUSION Use of multiple malaria prevention methods was effective in reducing malaria infection and mosquito density in comparison with single methods. Results from this systematic review can be used to inform future research, practice, policy and programming for malaria control in endemic countries.
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Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Edwinah Atusingwize
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Carol Namata
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses R Kamya
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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46
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Bangirana P, Conroy AL, Opoka RO, Semrud-Clikeman M, Jang JH, Apayi C, Kakuru A, Muhindo MK, Georgieff MK, Dorsey GM, Kamya MR, Havlir D, John CC. Effect of Malaria and Malaria Chemoprevention Regimens in Pregnancy and Childhood on Neurodevelopmental and Behavioral Outcomes in Children at 12, 24, and 36 Months: A Randomized Clinical Trial. Clin Infect Dis 2023; 76:600-608. [PMID: 36219705 PMCID: PMC10169410 DOI: 10.1093/cid/ciac815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malaria in pregnancy has been associated with worse cognitive outcomes in children, but its association with behavioral outcomes and the effectiveness of malaria chemoprevention on child neurodevelopment are not well characterized. METHODS To determine if more effective malaria chemoprevention in mothers and their children results in better neurodevelopment, 305 pregnant women were randomly assigned to 3 doses of sulfadoxine-pyrimethamine, 3 doses of dihydroartemisinin-piperaquine (DP), or monthly DP during pregnancy, and their 293 children were assigned to DP every 3 months or monthly DP from 2 to 24 months of age. Cognition, language, and motor function were assessed at 12, 24. and 36 months of age, and attention, memory, behavior, and executive function were assessed at 24 and 36 months of age. RESULTS Children of mothers with versus without malaria in pregnancy had worse scores on cognitive, behavioral, and executive function outcomes at 24 months. Clinical malaria in children within the first 12 months was similarly associated with poorer scores in behavior and executive function at 24 months, language at 24 and 36 months, and motor function scores at 36 months. However, more effective malaria chemoprevention in the mothers and children was not associated with better outcomes. CONCLUSIONS Malaria in pregnancy was associated with worse cognitive, behavioral, and executive function scores in affected children, but more effective malaria chemoprevention measures did not result in better outcomes. Malaria chemoprevention prior to and early in gestation and with even higher efficacy in mothers and children may be required to prevent neurodevelopmental impairment in children. Clinical Trials Registration. NCT02557425.
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Affiliation(s)
- Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis
| | - Robert O Opoka
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Jeong H Jang
- Underwood International College and Department of Applied Statistics, Yonsei University, Seoul, Korea
| | - Claire Apayi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Mary K Muhindo
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Grant M Dorsey
- Department of Medicine, University of California, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane Havlir
- Department of Medicine, University of California, California, USA
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis
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47
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Ivanochko D, Fabra-García A, Teelen K, van de Vegte-Bolmer M, van Gemert GJ, Newton J, Semesi A, de Bruijni M, Bolscher J, Ramjith J, Szabat M, Vogt S, Kraft L, Duncan S, Lee SM, Kamya MR, Feeney ME, Jagannathan P, Greenhouse B, Sauerwein RW, Richter King C, MacGill RS, Bousema T, Jore MM, Julien JP. Potent transmission-blocking monoclonal antibodies from naturally exposed individuals target a conserved epitope on Plasmodium falciparum Pfs230. Immunity 2023; 56:420-432.e7. [PMID: 36792575 PMCID: PMC9942874 DOI: 10.1016/j.immuni.2023.01.013] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/04/2022] [Accepted: 01/12/2023] [Indexed: 02/16/2023]
Abstract
Pfs230 is essential for Plasmodium falciparum transmission to mosquitoes and is the protein targeted by the most advanced malaria-transmission-blocking vaccine candidate. Prior understanding of functional epitopes on Pfs230 is based on two monoclonal antibodies (mAbs) with moderate transmission-reducing activity (TRA), elicited from subunit immunization. Here, we screened the B cell repertoire of two naturally exposed individuals possessing serum TRA and identified five potent mAbs from sixteen Pfs230 domain-1-specific mAbs. Structures of three potent and three low-activity antibodies bound to Pfs230 domain 1 revealed four distinct epitopes. Highly potent mAbs from natural infection recognized a common conformational epitope that is highly conserved across P. falciparum field isolates, while antibodies with negligible TRA derived from natural infection or immunization recognized three distinct sites. Our study provides molecular blueprints describing P. falciparum TRA, informed by contrasting potent and non-functional epitopes elicited by natural exposure and vaccination.
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Affiliation(s)
- Danton Ivanochko
- Program in Molecular Medicine, the Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | | | - Karina Teelen
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | | | | | - Jocelyn Newton
- Program in Molecular Medicine, the Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Anthony Semesi
- Program in Molecular Medicine, the Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | | | | | - Jordache Ramjith
- Radboud Institute for Health Sciences, Department for Health Evidence, Biostatistics Section, Radboudumc, Nijmegen, the Netherlands
| | | | | | - Lucas Kraft
- AbCellera Biologics Inc., Vancouver, BC, Canada
| | | | - Shwu-Maan Lee
- PATH's Malaria Vaccine Initiative, Washington, DC 20001, USA
| | - Moses R Kamya
- Infectious Disease Research Collaboration, Kampala, Uganda
| | - Margaret E Feeney
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Prasanna Jagannathan
- Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Bryan Greenhouse
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - C Richter King
- PATH's Malaria Vaccine Initiative, Washington, DC 20001, USA
| | | | - Teun Bousema
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands.
| | - Matthijs M Jore
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands.
| | - Jean-Philippe Julien
- Program in Molecular Medicine, the Hospital for Sick Children Research Institute, Toronto, ON, Canada; Departments of Biochemistry and Immunology, University of Toronto, Toronto, ON, Canada.
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48
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Fabra-García A, Hailemariam S, de Jong RM, Janssen K, Teelen K, van de Vegte-Bolmer M, van Gemert GJ, Ivanochko D, Semesi A, McLeod B, Vos MW, de Bruijni MHC, Bolscher JM, Szabat M, Vogt S, Kraft L, Duncan S, Kamya MR, Feeney ME, Jagannathan P, Greenhouse B, Dechering KJ, Sauerwein RW, King CR, MacGill RS, Bousema T, Julien JP, Jore MM. Highly potent, naturally acquired human monoclonal antibodies against Pfs48/45 block Plasmodium falciparum transmission to mosquitoes. Immunity 2023; 56:406-419.e7. [PMID: 36792574 PMCID: PMC9942873 DOI: 10.1016/j.immuni.2023.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/05/2022] [Accepted: 01/11/2023] [Indexed: 02/16/2023]
Abstract
Malaria transmission-blocking vaccines (TBVs) aim to induce antibodies that interrupt malaria parasite development in the mosquito, thereby blocking onward transmission, and provide a much-needed tool for malaria control and elimination. The parasite surface protein Pfs48/45 is a leading TBV candidate. Here, we isolated and characterized a panel of 81 human Pfs48/45-specific monoclonal antibodies (mAbs) from donors naturally exposed to Plasmodium parasites. Genetically diverse mAbs against each of the three domains (D1-D3) of Pfs48/45 were identified. The most potent mAbs targeted D1 and D3 and achieved >80% transmission-reducing activity in standard membrane-feeding assays, at 10 and 2 μg/mL, respectively. Co-crystal structures of D3 in complex with four different mAbs delineated two conserved protective epitopes. Altogether, these Pfs48/45-specific human mAbs provide important insight into protective and non-protective epitopes that can further our understanding of transmission and inform the design of refined malaria transmission-blocking vaccine candidates.
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Affiliation(s)
| | - Sophia Hailemariam
- Program in Molecular Medicine, The Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | - Roos M de Jong
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - Kirsten Janssen
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - Karina Teelen
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | | | | | - Danton Ivanochko
- Program in Molecular Medicine, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Anthony Semesi
- Program in Molecular Medicine, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Brandon McLeod
- Program in Molecular Medicine, The Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | - Lucas Kraft
- AbCellera Biologics Inc., Vancouver, BC, Canada
| | | | - Moses R Kamya
- Infectious Disease Research Collaboration, Kampala, Uganda
| | - Margaret E Feeney
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Prasanna Jagannathan
- Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Bryan Greenhouse
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - C Richter King
- PATH's Malaria Vaccine Initiative, Washington, DC 20001, USA
| | | | - Teun Bousema
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands.
| | - Jean-Philippe Julien
- Program in Molecular Medicine, The Hospital for Sick Children Research Institute, Toronto, ON, Canada; Department of Biochemistry, University of Toronto, Toronto, ON, Canada; Department of Immunology, University of Toronto, Toronto, ON, Canada.
| | - Matthijs M Jore
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands.
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49
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Marquez C, Chen Y, Atukunda M, Chamie G, Balzer LB, Kironde J, Ssemmondo E, Mwangwa F, Kabami J, Owaraganise A, Kakande E, Abbott R, Ssekyanzi B, Koss C, Kamya MR, Charlebois ED, Havlir DV, Petersen ML. The Association Between Social Network Characteristics and Tuberculosis Infection Among Adults in 9 Rural Ugandan Communities. Clin Infect Dis 2023; 76:e902-e909. [PMID: 35982635 PMCID: PMC10169405 DOI: 10.1093/cid/ciac669] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/02/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Social network analysis can elucidate tuberculosis transmission dynamics outside the home and may inform novel network-based case-finding strategies. METHODS We assessed the association between social network characteristics and prevalent tuberculosis infection among residents (aged ≥15 years) of 9 rural communities in Eastern Uganda. Social contacts named during a census were used to create community-specific nonhousehold social networks. We evaluated whether social network structure and characteristics of first-degree contacts (sex, human immunodeficiency virus [HIV] status, tuberculosis infection) were associated with revalent tuberculosis infection (positive tuberculin skin test [TST] result) after adjusting for individual-level risk factors (age, sex, HIV status, tuberculosis contact, wealth, occupation, and Bacillus Calmette-Guérin [BCG] vaccination) with targeted maximum likelihood estimation. RESULTS Among 3 335 residents sampled for TST, 32% had a positive TST results and 4% reported a tuberculosis contact. The social network contained 15 328 first-degree contacts. Persons with the most network centrality (top 10%) (adjusted risk ratio, 1.3 [95% confidence interval, 1.1-1.1]) and the most (top 10%) male contacts (1.5 [1.3-1.9]) had a higher risk of prevalent tuberculosis, than those in the remaining 90%. People with ≥1 contact with HIV (adjusted risk ratio, 1.3 [95% confidence interval, 1.1-1.6]) and ≥2 contacts with tuberculosis infection were more likely to have tuberculosis themselves (2.6 [ 95% confidence interval: 2.2-2.9]). CONCLUSIONS Social networks with higher centrality, more men, contacts with HIV, and tuberculosis infection were positively associated with tuberculosis infection. Tuberculosis transmission within measurable social networks may explain prevalent tuberculosis not associated with a household contact. Further study on network-informed tuberculosis case finding interventions is warranted.
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Affiliation(s)
- Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Yiqun Chen
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Laura B Balzer
- Division of Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Joel Kironde
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Rachel Abbott
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Bob Ssekyanzi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Catherine Koss
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - Maya L Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, California, USA
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50
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Maiteki-Sebuguzi C, Gonahasa S, Kamya MR, Katureebe A, Bagala I, Lynd A, Mutungi P, Kigozi SP, Opigo J, Hemingway J, Dorsey G, Donnelly MJ, Staedke SG. Effect of long-lasting insecticidal nets with and without piperonyl butoxide on malaria indicators in Uganda (LLINEUP): final results of a cluster-randomised trial embedded in a national distribution campaign. Lancet Infect Dis 2023; 23:247-258. [PMID: 36174592 DOI: 10.1016/s1473-3099(22)00469-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Long-lasting insecticidal nets (LLINs) are the foundation of malaria control but resistance of mosquito vectors to pyrethroids threatens their effectiveness. We embedded a cluster-randomised trial into Uganda's 2017-18 campaign to distribute LLINs. LLINs with piperonyl butoxide (PBO) reduced parasite prevalence more effectively than conventional LLINs (without PBO) for 18 months. Here, we report the final 25-month survey results. METHODS LLINEUP was a cluster-randomised trial conducted in 48 districts in eastern and western Uganda. 104 health subdistricts (clusters) without ongoing or planned indoor residual spraying with pirimiphos-methyl (Actellic, Basel, Switzerland) were eligible for inclusion in the trial. Clusters were randomly assigned to PBO LLINs (PermaNet 3.0 or Olyset Plus) and conventional LLINs (PermaNet 2.0 or Olyset Net) with proportionate randomisation using STATA version 14.2. LLINs were delivered from March 25, 2017, to March 18, 2018. Between April 23, 2019, and Sept 13, 2019, community surveys were conducted in 50 randomly selected households per cluster; ten households per cluster were randomly selected for entomology surveys. Mosquitoes were collected in the morning from indoor surfaces of households using Prokopack aspirators. Due to COVID-19 restrictions, only 90 of the 104 clusters were surveyed at 25 months. The primary outcome was parasite prevalence by microscopy in children aged 2-10 years, assessed in the as-treated population, determined using the results from the 6-month household survey on the type of LLINs received in each cluster. This trial is registered with ISRCTN, ISRCTN17516395, and is now completed. FINDINGS In the as-treated analysis, two clusters were excluded (no predominant LLIN received) and four were reassigned; 40 PBO LLIN clusters (30 PermaNet 3.0, ten Olyset Plus) and 48 non-PBO LLIN (36 PermaNet 2.0, 12 Olyset Net) were included. Parasite prevalence was 17·1% (506 of 2958 participants) in the PBO group and 19·8% (701 of 3534) in the non-PBO group (prevalence ratio adjusted for baseline 0·80 [95% CI 0·69-0·93], p=0·0048). Comparing within-treatment group parasite prevalence to baseline, parasite prevalence ratios were lower in the PBO groups at all timepoints, but the difference was greatest at 6 months (PBO LLINs parasite prevalence at baseline 28·8% [1001 of 3472, 95% CI 27·3-30·4] vs at 6 months 12·0% [361 of 3009, 10·9-13·2], prevalence ratio [PR] 0·43 [95% CI 0·36-0·52], p<0·0001; non-PBO LLINs parasite prevalence at baseline 25·4% [1015 of 4004, 24·0-26·7] vs 6 months 14·8% [526 of 3551, 13·7-16·0], PR 0·60 [0·54-0·68], p<0·0001) and 25 months (PBO LLINs parasite prevalence at 25 months 17·1% [506 of 2958, 15·8-18·5], PR 0·63 [95% CI 0·57-0·71], p<0·0001; non-PBO LLINs parasite prevalence at 25 months 19·8% [701 of 3534, 18·5-21·2], PR 0·79 [0·73-0·86], p<0·0001). INTERPRETATION In Uganda, PBO LLINs outperformed pyrethroid-only LLINs for 25 months. WHO concluded that PBO LLINs are more effective against malaria than non-PBO LLINs when resistance to pyrethroids is high and issued a conditional recommendation suggesting PBO LLINs should be deployed in areas of pyrethroid resistance. FUNDING The Against Malaria Foundation, UK Department for International Development, Innovative Vector Control Consortium, and Bill and Melinda Gates Foundation.
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Affiliation(s)
- Catherine Maiteki-Sebuguzi
- Infectious Diseases Research Collaboration, Kampala, Uganda; National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Irene Bagala
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Amy Lynd
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter Mutungi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Simon P Kigozi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jimmy Opigo
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | - Janet Hemingway
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Martin J Donnelly
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, UK; Wellcome Sanger Institute, Hinxton, UK
| | - Sarah G Staedke
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK.
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