Acute and subacute toxicity profile of ethanolic stem bark extract of Albizia coriaria Welw. ex Oliv. in Wistar albino rats

Albizia coriaria (Fabaceae) crude extracts are key ingredients of several licensed and unlicensed herbal products in East Africa. However, there is limited and often contradicting information regarding its toxicity. We therefore evaluated the acute and subacute toxicity of the ethanolic stem bark extract of A. coriaria in mature healthy Wistar albino rats following Lorke's method and OECD guidelines 407. The LD50 of the ethanolic stem bark extract of A. coriaria was 2000 mg/kg. The acute toxicity signs observed included piloerection, hyperventilation, lethargy, and loss of righting reflex. There was a significant increase in aspartate aminotransferase, alkaline phosphatase, red blood cells and haemoglobin in rats after 28 days at the dose of 500 mg/kg. Histological analyses revealed multifocal random parenchymal necrosis and scattered periportal mononuclear inflammatory cells infiltration in the liver, interstitial nephritis in the kidney and multifocal lymphoid accumulation in the peribronchiolar and perivascular lung tissue at 500 mg/kg. The ethanolic stem bark of A. coriaria was therefore moderately toxic to the rats when administered in a single high oral dose within 24 h. The extract caused a dose dependent toxicity with significant damage to the kidney, liver and lung tissues at a dose of 500 mg/kg after 28 days. Herbal medicines containing A. coriaria extracts should be consumed cautiously due to likelihood of toxicity particularly at higher doses greater than 500 mg/kg.

Can an integrated intervention package including peer support increase the proportion of health facility births? A cluster randomised controlled trial in Northern Uganda

OBJECTIVE

To assess the effect of an integrated intervention package compared with routine government health services on the frequency of health facility births.

SETTING

Three subcounties of Lira district in Northern Uganda.

DESIGN

A cluster randomised controlled trial where a total of 30 clusters were randomised in a ratio of 1:1 to intervention or standard of care.

PARTICIPANTS

Pregnant women at ≥28 weeks of gestation.

INTERVENTIONS

Participants in the intervention arm received an integrated intervention package of peer support, mobile phone messaging and birthing kits during pregnancy while those in the control arm received routine government health services ('standard of care').

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of women giving birth at a health facility in the intervention arm compared with the control arm. Secondary outcomes were perinatal and neonatal deaths.

RESULTS

In 2018-2019, 995 pregnant women were included in 15 intervention clusters and 882 in 15 control clusters. The primary outcome was ascertained for all except one participant who died before childbirth. In the intervention arm, 754/994 participants (76%) gave birth at a health facility compared with 500/882 (57%) in the control arm. Participants in the intervention arm were 35% more likely to give birth at a health facility compared with participants in the control arm, (risk ratio 1.35 (95% CI 1.20 to 1.51)) and (risk difference 0.20 (95% CI 0.13 to 0.27)). Adjusting for baseline differences generated similar results. There was no difference in secondary outcomes (perinatal or neonatal mortality or number of postnatal visits) between arms.

CONCLUSION

The intervention was successful in increasing the proportion of facility-based births but did not reduce perinatal or neonatal mortality.

TRIAL REGISTRATION NUMBER

NCT02605369.

Medicinal plants used for treatment of malaria by indigenous communities of Tororo District, Eastern Uganda

BACKGROUND

Malaria remains the leading cause of death in sub-Saharan Africa. Although recent developments such as malaria vaccine trials inspire optimism, the search for novel antimalarial drugs is urgently needed to control the mounting resistance of Plasmodium species to the available therapies. The present study was conducted to document ethnobotanical knowledge on the plants used to treat symptoms of malaria in Tororo district, a malaria-endemic region of Eastern Uganda.

METHODS

An ethnobotanical study was carried out between February 2020 and September 2020 in 12 randomly selected villages of Tororo district. In total, 151 respondents (21 herbalists and 130 non-herbalists) were selected using multistage random sampling method. Their awareness of malaria, treatment-seeking behaviour and herbal treatment practices were obtained using semi-structured questionnaires and focus group discussions. Data were analysed using descriptive statistics, paired comparison, preference ranking and informant consensus factor.

RESULTS

A total of 45 plant species belonging to 26 families and 44 genera were used in the preparation of herbal medicines for management of malaria and its symptoms. The most frequently mentioned plant species were Vernonia amygdalina, Chamaecrista nigricans, Aloe nobilis, Warburgia ugandensis, Abrus precatorius, Kedrostis foetidissima, Senna occidentalis, Azadirachta indica and Mangifera indica. Leaves (67.3%) were the most used plant part while maceration (56%) was the major method of herbal remedy preparation. Oral route was the predominant mode of administration with inconsistencies in the posology prescribed.

CONCLUSION

This study showed that the identified medicinal plants in Tororo district, Uganda, are potential sources of new antimalarial drugs. This provides a basis for investigating the antimalarial efficacy, phytochemistry and toxicity of the unstudied species with high percentage use values to validate their use in the management of malaria.

Incidence of home delivery among women living with HIV in Lira, Northern Uganda: a prospective cohort study

Background

Home delivery has been associated with mother-to-child transmission of HIV and remains high among HIV-infected women. Predictors for home delivery in the context of HIV have not been fully studied and understood in Northern Uganda. We therefore aimed to find out the incidence and risk factors for home delivery among women living with HIV in Lira, Northern Uganda.

Methods

This prospective cohort study was conducted between August 2018 and January 2020 in Lira district, Northern Uganda. A total of 505 HIV infected women receiving antenatal care at Lira regional referral hospital were enrolled consecutively and followed up at delivery. We used a structured questionnaire to obtain data on exposures which included: socio-demographic, reproductive-related and HIV-related characteristics. Data was analysed using Stata version 14.0 (StataCorp, College Station, Texas, U.S.A.). We estimated adjusted risk ratios using Poisson regression models to ascertain risk factors for the outcome of interest which was home delivery (which is delivering an infant outside a health facility setting under the supervision of a non-health worker).

Results

The incidence of home delivery among women living with HIV was 6.9% (95%CI: 4.9–9.5%). Single women were more likely to deliver at home (adjusted risk ratio = 4.27, 95%CI: 1.66–11). Women whose labour started in the night (night time onset of labour ARR = 0.39, 95%CI: 0.18–0.86) and those that were adherent to their ART (ARR = 0.33, 95%CI: 0.13–0.86) were less likely to deliver at home.

Conclusion

Home delivery remains high among women living with HIV especially those that do not have a partner. We recommend intensified counselling on birth planning and preparedness in the context of HIV and PMTCT especially for women who are: separated, divorced, widowed or never married and those that are not adherent to their ART.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04222-5.

Incidence and determinants of perinatal mortality among women with obstructed labour in eastern Uganda: a prospective cohort study

BACKGROUND

In Uganda, the incidence and determinants of perinatal death in obstructed labour are not well documented. We determined the incidence and determinants of perinatal mortality among women with obstructed labour in Eastern Uganda.

METHODS

Between July 2018 and September 2019, 584 with obstructed labour were recruited and followed up to the 7th day postnatal. Information on maternal characteristics, obstetric factors and laboratory parameters was collected. Each patient received the standard perioperative care. We used a generalized linear model for the Poisson family, with a log link and robust variance estimation to determine the association between the exposure variables and perinatal death.

RESULTS

Of the 623 women diagnosed with obstructed labour, 584 met the eligibility criteria. There were 24 fresh still births (FSB) and 32 early neonatal deaths (ENND) giving an FSB rate of 43.8 (95% CI 28.3-64.4) deaths per 1000 total births; early neonatal death rate of 58.4 (95% CI 40.3-81.4) deaths per 1000 and an overall perinatal mortality rate of 102.2 (95% CI 79.4-130.6) deaths in the first 7 days of life. A mother being referred in active labour adjusted risk ratio of 2.84 (95% CI: 1.35-5.96) and having high blood lactate levels at recruitment adjusted risk ratio 2.71 (95% CI: 1.26-4.24) were the determinants of perinatal deaths.

CONCLUSIONS

The incidence of perinatal death was four times the regional and national average. Babies to women referred in active labour and those with high maternal blood lactate were more likely to die.

Exclusive breastfeeding among HIV exposed infants from birth to 14 weeks of life in Lira, Northern Uganda: a prospective cohort study

Background

Breastfeeding is important for growth, development and survival of HIV exposed infants. Exclusive breastfeeding reduces the risk of morbidity, mortality and increases HIV free survival of infants. Evidence on risk factors for inappropriate breastfeeding in Northern Uganda is limited.

Objective

This study determined the risk factors for non-exclusivity of breastfeeding in the first 14 weeks of life.

Methods

This prospective cohort study was conducted among 466 mother-infant pairs between August 2018 and February 2020 in Lira district, Northern Uganda. HIV infected pregnant women were enrolled and followed up at delivery, 6- and 14- weeks postpartum. We used a structured questionnaire to obtain data on socio-demographic, reproductive-related, HIV-related characteristics and exclusive breastfeeding. Data were analysed using Stata version 14.0 (StataCorp, College Station, Texas, USA.). We estimated adjusted risk ratios using modified Poisson regression models.

Results

The proportion of HIV exposed infants that were exclusively breastfed reduced with increasing age. Risk factors for non-exclusive breastfeeding included infants being born to HIV infected women who: were in the highest socioeconomic strata (adjusted risk ratio = 1.5, 95%CI: 1.01– 2.1), whose delivery was supervised by a non-health worker (adjusted risk ratio = 1.6, 95%CI: 1.01– 2.7) and who had not adhered to their ART during pregnancy (adjusted risk ratio = 1.3, 95%CI: 1.01– 1.7).

Conclusions

HIV infected women: with highest socioeconomic status, whose delivery was not supervised by a health worker and who did not adhere to ART were less likely to practice exclusive breastfeeding. We recommend ART adherence and infant feeding counselling to be emphasised among HIV infected women who are at risk of having a home delivery, those with poor ART adherence and those of higher socioeconomic status. We also recommend integration of these services into other settings like homes, community and work places instead of limiting them to hospital settings.

Abbreviations

HIV: Human Immunodeficiency Virus; ART: Antiretroviral therapy; HEI: HIV exposed infant; PMTCT: Prevention of mother-to-child transmission of HIV; MTCT: Mother-to-child transmission of HIV; AFASS: Acceptable, Feasible, Affordable, Sustainable and Safe; LRRH: Lira regional referral hospital; CI: confidence interval; ARR: Adjusted risk ratio; SD: Standard deviation; PCA: Principal component analysis

Experiences and views of healthcare professionals on the prescription of antibiotics in Eastern Uganda: A qualitative study

OBJECTIVES

This study aimed to explore the experiences and views of healthcare professionals on antibiotic prescription in Eastern Uganda.

METHODS

This was an exploratory qualitative study using semi-structured interviews. Participants included 16 healthcare professionals from Mbale and Soroti Regional Referral Hospitals. Additionally, two workshops were held (one in each hospital) with a total of 56 healthcare professionals to discuss the findings. Thematic analysis was used to analyse the data.

RESULTS

Healthcare professionals' prescriptions are influenced by (i) healthcare workers' perceptions and practices, (ii) patients' perceptions and beliefs, and (iii) contextual factors. Healthcare workers' prescriptions depend on the presence of bacterial infection and the severity of the condition, the availability and cost of medication, previous experience with antibiotic prescribing, patient characteristics, and trial and error. They also have limited knowledge and share little information on the use of antibiotics with patients. Patient factors included demand for a particular antibiotic, inability to afford expensive drugs, and limited knowledge about antibiotic use and resistance. Contextual factors that contributed to antibiotic prescribing were an overburdened healthcare system, the influence of pharmaceutical companies and pharmacies, the use of (treatment) guidelines, and difficulties with laboratory services.

CONCLUSION

This study showed that healthcare professionals are aware of the problem of antibiotic resistance but do not feel ownership of the problem. Instead, they rather blame the overburdened system, local drug shops, pharmacies, drug representatives and patients. There is a need for a multisectoral and holistic approach toward fighting antibiotic resistance.

Prevalence of antibiotic-resistant bacteria among patients in two tertiary hospitals in Eastern Uganda

OBJECTIVE

The aim of this study was to determine the prevalence and antibiotic resistance patterns of bacterial isolates from inpatients and outpatients in Mbale and Soroti regional referral hospitals in Eastern Uganda.

METHODS

A retrospective analysis of culture and antibiotic sensitivity test results from the microbiology laboratories of the two tertiary hospitals was conducted for a 3-year period (January 2016-December 2018).

RESULTS

Microbiology records of 3092 patients were reviewed and analysed, with 1305 (42.1%) samples yielding clinical isolates. The most prevalent isolates were Escherichia coli (n = 442; 33.9%), Staphylococcus aureus (n = 376; 28.8%), Klebsiella pneumoniae (n = 237; 18.2%), and Streptococcus pneumoniae (n = 76; 5.8%). High rates of antimicrobial resistance were detected across both Gram-negative and Gram-positive bacteria. Escherichia coli and K. pneumoniae were resistant to several agents such as amoxicillin/clavulanate (83.5%; 64.6%), cefotaxime (74.2%; 52.7%), ciprofloxacin (92.1%; 27.8%), gentamicin (51.8%; 76%), imipenem (3.2%; 10.5%), tetracycline (98%; 74.5%), and trimethoprim-sulfamethoxazole (74.1%; 74.3%), respectively. Staphylococcus aureus and S. pneumoniae exhibited the following resistance profile: cefoxitin (44.4%; 40.9%), chloramphenicol (69.1%; 27.6%) clindamycin (21.5%; 24.4%), gentamicin (83.2%; 66.9%), penicillin (46.5%; -) tetracycline (85.6%; 97.6%), trimethoprim-sulfamethoxazole (88%; 91.3%), and vancomycin (41.2%; -).

CONCLUSION

We observed high resistance rates to antibiotics among the majority of microorganisms that were isolated from the samples collected from patients in Eastern Uganda. Furthermore, measures should be undertaken locally to improve microbiology diagnostics and to prevent the spread of antibiotic-resistant strains as this impedes the optimal treatment of bacterial infections and narrows the choice of effective therapeutic options.

Effect of pre-operative bicarbonate infusion on maternal and perinatal outcomes among women with obstructed labour in Mbale hospital: A double blind randomized controlled trial

INTRODUCTION

Oral bicarbonate solution is known to improve both maternal and perinatal outcomes among women with abnormal labour (dystocia). Its effectiveness and safety among women with obstructed labour is not known.

OBJECTIVE

To determine the effect and safety of a single-dose preoperative infusion of sodium bicarbonate on maternal and fetal blood lactate and clinical outcomes among women with obstructed labour (OL) in Mbale hospital.

METHODS

We conducted a double blind, randomised controlled trial from July 2018 to September 2019. The participants were women with OL at term (≥37 weeks gestation), carrying a singleton pregnancy with no other obstetric emergency, medical comorbidity or laboratory derangements.

INTERVENTION

A total of 477 women with OL were randomized to receive 50ml of 8.4% sodium bicarbonate (238 women) or 50 mL of 0.9% sodium chloride (239 women). In both the intervention and controls arms, each participant was preoperatively given a single dose intravenous bolus. Every participant received 1.5 L of normal saline in one hour as part of standard preoperative care.

OUTCOME MEASURES

Our primary outcome was the mean difference in maternal venous blood lactate at one hour between the two arms. The secondary outcomes were umbilical cord blood lactate levels at birth, neonatal sepsis and early neonatal death upto 7 days postnatal, as well as the side effects of sodium bicarbonate, primary postpartum hemorrhage, maternal sepsis and mortality at 14 days postpartum.

RESULTS

The median maternal venous lactate was 6.4 (IQR 3.3-12.3) in the intervention and 7.5 (IQR 4.0-15.8) in the control group, with a statistically non-significant median difference of 1.2 mmol/L; p-value = 0.087. Vargha and Delaney effect size was 0.46 (95% CI 0.40-0.51) implying very little if any effect at all.

CONCLUSION

The 4.2g of preoperative intravenous sodium bicarbonate was safe but made little or no difference on blood lactate levels.

TRIAL REGISTRATION

PACTR201805003364421.

Detectable HIV-RNA Viral Load Among HIV-Infected Pregnant Women on Treatment in Northern Uganda

BACKGROUND / OBJECTIVES

Detectable HIV viral load among HIV-infected pregnant women remains a public health threat. We aimed to determine factors associated with detectable viral load among HIV-infected pregnant women in Lira, Northern Uganda.

METHODS

We conducted a cross-sectional survey among 420 HIV-infected pregnant women attending Lira Regional Referral Hospital using a structured questionnaire and combined it with viral load tests from Uganda National Health Laboratories. We conducted multivariable logistic regression while adjusting for confounders to determine the factors associated with detectable viral load and we report adjusted odds ratios and proportion of women with viral load less than 50 copies/ml and above 1000 copies, respectively.

RESULTS

The prevalence of detectable viral load (>50 copies/ml) was 30.7% (95%CI: 26.3% - 35.4%) and >1000 copies/ml was 8.1% (95% CI: 5.7% - 11.1%). Factors associated with detectable viral load were not belonging to the Lango ethnicity (adjusted odds ratio = 1.92, 95%CI: 1.05 - 3.90) and taking a second-line (protease inhibitor-based) regimen (adjusted odds ratio = 4.41, 95%CI: 1.13 - 17.22).

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

HIV-infected pregnant women likely to have detectable viral load included those taking a protease inhibitor-based regimen and those who were not natives of Lira. We recommend intensified clinical and psychosocial monitoring for medication compliance among HIV-infected pregnant women that are likely to have a detectable viral load to significantly lower the risk of vertical transmission of HIV in Lira specifically those taking a protease inhibitor-based regimen and those who are non-natives to the study setting. Much as the third 90% of the global UNAIDS 90-90-90 target has been achieved, the national implementation of PMTCT guidelines should be tailored to its contextual needs.

Three year survival among patients with aids-related Kaposi sarcoma treated with chemotherapy and combination antiretroviral therapy at Moi teaching and referral hospital, Kenya

Background

AIDS-related Kaposi sarcoma (AIDS-KS), a common malignancy in Kenya is associated with high morbidity and mortality. AIDS-KS is treated using bleomycin and vincristine (BV) plus or minus doxorubicin in most low resource settings, with response rates ranging from 24.8 to 87%. Survival in low resource settings has not been well documented. We report the three-year survival in a cohort of seventy patients referred to Moi Teaching and Referral Hospital (MTRH).

Methods

Study participants are part of a randomized phase IIA trial on the use of gemcitabine compared to bleomycin plus vincristine for the treatment of Kaposi sarcoma after combination antiretroviral therapy (cART) in Western Kenya. All patients were followed for three years in MTRH. Survival was determined by three monthly physical examination and analysed using Kaplan-Meier method, while possible determinants of survival such as baseline characteristics, type of chemotherapy, initial CD4 counts, age at enrolment, gender and early response to chemotherapy were analysed using univariate and multivariate Cox regression.

Results

Participants were aged between 19 and 70 years with 56% being male. The median CD4 count was 224 cells/μl, median duration of HIV diagnosis was 12.0 months and median duration of KS lesions after histology diagnosis before initiating chemotherapy was 4.8 weeks. At three years, 60 (85.7%) patients were alive. Six of those who died were under treatment with BV while four with gemcitabine. There was no difference in the probability of survival between the patients on either treatment arm (HR = 0.573 [95% C. I 0.143, 2.292; p = 0.4311]). Additionally, the hazard ratio (HR) for response after six weeks, age at enrolment and gender indicated that they were not significant determinants of survival. Patients with normal CD4 cell counts (> = 500/μl), had a HR of 0.401(0.05,3.23; p = 0.391), suggesting better survival.

Conclusions

Patients with AIDS-KS treated with combined antiretroviral drugs had excellent three-year survival regardless of whether they were treated with BV or gemcitabine as first line therapy. An initial CD4 cell count of > = 500/μl appeared to improve survival while gender, age and early response to chemotherapy were not predictors of survival after three years.

Trial registration

Number PACTR201510001.

Electronic supplementary material

The online version of this article (10.1186/s13027-019-0242-9) contains supplementary material, which is available to authorized users.

Oil-Fortified Maize Porridge Increases Absorption of Lumefantrine in Children with Uncomplicated Falciparum Malaria

Artemether-lumefantrine (AL) is a first-line treatment for uncomplicated malaria. Absorption of lumefantrine (LUM) is fat dependent, and in children, intake is recommended with milk. We investigated whether oil-fortified maize porridge can be an alternative when milk is not available. In an open-label pharmacokinetic study, Ugandan children <5 years with uncomplicated Plasmodium falciparum malaria were randomized to receive standard six-dose AL treatment [one tablet (20 mgA/120 mg LUM) if <15 kg and two tablets if >15 kg] with milk (A) or maize porridge plus oil (B). Parametric two-sample t-test was used to compare relative oral LUM bioavailability. The primary end-point was LUM exposure till 8 hr after the first dose (AUC_{0-8 hr} ). Secondary outcome included day 7 concentrations (d7_LUM ), LUM exposure between days 7 and 28 (AUC_d7-28 ) and day 28 PCR-adjusted parasitological response. Evaluable children (n = 33) included 16 in arm A and 17 in arm B. The AUC_{0-8 hr} was comparable between A and B [geometric mean (95% CI): 6.01 (3.26-11.1) versus 6.26 (4.5-8.43) hr*μg/mL, p = 0.9]. Less interindividual variability in AUC_{0-8 hr} was observed in B (p = 0.01), but d7_LUM and AUC_d7-28 were comparable. Children receiving two tablets had significantly higher exposure than those receiving one tablet [median d7_LUM (505 versus 289 ng/mL, p = 0.02) and AUC_d7-28 (108 versus 41 hr*μg/mL, p = 0.006)]. One parasitological failure (d28 recrudescence) was observed. Our findings suggest that oil-fortified maize porridge can be an alternative to milk in augmenting absorption of LUM. The lower LUM exposure observed in children dosed with one AL tablet needs further attention.

Potential of Zanthoxylum leprieurii as a source of active compounds against drug resistant Mycobacterium tuberculosis

BACKGROUND

Tuberculosis (TB) is still a global health problem mainly due to development of resistance and co-infection with the Human immune Virus (HIV). Treatment of multi and extensively drug resistant TB requires use of second line drugs which are less efficacious, expensive and very toxic. This has necessitated a need to search for new treatment regimens especially from medicinal plants. Zanthoxylum leprieurii, a plant species from Rutaceae is used locally in the treatment of tuberculosis in Uganda. The aim of the study was to isolate, identify and characterize bio active compounds from Z. leprieurii stem bark with antimycobacterial activity.

METHODS

Crude extracts, fractions and compounds from air dried stem bark of Z. leprieurii were tested against pan sensitive (H37rv), isoniazid resistant (TMC 301) and rifampicin resistant (TMC 331) strains of M. tuberculosis using micro plate alamar blue assay. Isolation of active compounds was done by using column chromatography and thin layer chromatography. They were analysed using nuclear magnetic resonance spectroscopy and mass spectroscopy.

RESULTS

The methanol extract had minimum inhibitory concentrations (MIC) of 47.5, 75.3 and 125.0 μg/ml on the pan sensitive strain, rifampicin resistant and isozianid resistant strains of M. tuberculosis respectively. The chloroform extract had MIC values of 260 μg/ml agnaist the pan sensitive strain and 156 μg/ml on the rifampicin resistant strain. Of the sixteen fractions from the methanol extract, fraction Za₄ (MIC = 6.3 μg/mL, 23.0 μg/mL, 11.7 μg/mL) and Za₆ (MIC = 11.7 μg/mL 31.2 μg/ml, 31.2 μg/ml) were the most active. Three acridone alkaloids; hydroxy-1, 3-dimethoxy-10-methyl-9-acridone (1), 1-hydroxy-3-methoxy-10-methyl-9-acridone (2) and 3-hydroxy-1, 5, 6-trimethoxy-9-acridone (3) were isolated from Za₄ and Za₆. The MIC of compound 3 was found to be 5.1 μg/ml, 4.5 μg/ml and 3.9 μg/ml on H37rv, TMC 331 and TMC 301 while that of 1 was found to be 1.5 μg/ml, 8.3 μg/ml and 3.5 μg/ml respectively.

CONCLUSION

The results of this study suggest that Z. leprieurii is active on resistant strains of M. tuberculosis and could be a potential source of new leads against resistant tuberculosis. It also verifies the local use of the plant in treatment of tuberculosis.

CYP2B6 genotype, but not rifampicin-based anti-TB cotreatments, explains variability in long-term efavirenz plasma exposure

AIM

We investigated the effects of rifampicin-based anti-TB treatment on plasma efavirenz exposure and the implications of CYP2B6 genotype.

PATIENTS & METHODS

Antiretroviral therapy-naive Ugandan HIV patients without (n = 157) or with TB coinfection (n = 106) were enrolled and treated with efavirenz-based highly active antiretroviral therapy alone or with rifampicin-based anti-TB therapy, respectively. Efavirenz plasma concentration was determined on day 3 and weeks 1, 2, 8, 12, 16, 20, 24, 28 and 32.

RESULTS

Rifampicin-based anti-TB cotreatment reduced plasma efavirenz exposure during the first 2 weeks (p < 0.05), but no significant effect was observed afterwards. Although not significant, rifampicin-based anti-TB cotreatment inconsistently increased efavirenz exposure over time, which was reduced immediately after completing anti-TB therapy. CYP2B6*6, *11 and ABCB1 c.4036A>G genotypes were significant predictors of efavirenz plasma exposure.

CONCLUSION

Plasma efavirenz exposure is mainly influenced by CYP2B6 genotype, but not by rifampicin cotreatment. Therefore, no efavirenz dosage adjustment during rifampicin cotreatment is required in Ugandans.

Medication Error Disclosure and Attitudes to Reporting by Healthcare Professionals in a Sub-Saharan African Setting: A Survey in Uganda

Background

Medication errors (MEs) are largely under-reported, which undermines quality improvement and medication risk management in healthcare.

Objectives

To assess attitudes of Ugandan healthcare professionals (HCPs) towards ME reporting, and identify characteristics of HCPs who endorsed integration of ME and adverse drug reaction (ADR) reporting, valued patient involvement in ME reporting, disclosed having ever made potentially harmful MEs, or observed possibly harmful MEs committed by other HCPs.

Methods

Healthcare professionals self-completed a questionnaire on their attitudes towards the occurrence and reporting of MEs in purposively selected Ugandan health facilities (public/private) including the national referral and six regional referral hospitals representative of all regions.

Results

Response rate was 67 % (1345/2000). Most HCPs (91 %; 1174/1289) approved a national ME reporting system for Uganda and 58 % (734/1261) endorsed integration of ME and ADR reporting. Two-thirds (65 %; 819/1267) of HCPs valued patient involvement in ME reporting, one-fifth (18 %; 235/1310) disclosed that they had ever made potentially harmful MEs, while two-fifths (41 %; 542/1323) had ever identified possibly harmful MEs committed by other HCPs. Endorsing patient involvement in ME reporting was more likely by HCPs who valued root-cause analysis and reporting of both actual and potential MEs, or who conceded inadequate communication and lack of time. Self-disclosure of having ever committed potentially harmful MEs was more likely with the need for confidentiality, working in stressful conditions, and willingness to report ADRs. Identifying possibly harmful MEs committed by other HCPs was more likely by non-nurses and those who reported blame culture, stressful conditions, ever encountered a fatal ADR, or attachment to hospital-level health facility.

Conclusion

A non-punitive healthcare environment and patient involvement may promote ME disclosure and reporting in Uganda and possibly other African countries.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0032-7) contains supplementary material, which is available to authorized users.

The availability of six tracer medicines in private medicine outlets in Uganda

Objectives

Many low income countries struggle to provide safe and effective medicines due to poor public health care infrastructure, budgetary constraints, and lack of human resource capacity. Private sector pharmacies and drug shops are used by a majority of the population as an alternative to public pharmacies. This study looks at the availability of six essential medicines in private drug outlets across Uganda.

Methods

A standardised medicines availability survey developed by the World Health Organization and Health Action International was adapted for use in this project to collect availability data for six tracer medicines in 126 private medicine outlets across four districts in Uganda from September 2011 to October 2012.

Results

Artemisinin-based combination treatments and metformin were the most commonly found medicines in the private medicine outlets surveyed. Ninty-nine percent of all outlets carried artemisinin-based combinations while 93% of pharmacies and 53% of drug shops stocked metformin. Oxytocin was found in one third of outlets surveyed. Fluoxetine was in 70% of pharmacies yet was not found in any drug shops. Rifampicin and lamivudine were found infrequently in outlets across all districts; 10% and 2%, respectively. Not all brands found in surveyed outlets were listed on the Ugandan National Drug Register. In particular, five unlisted brands of rifampicin were found in private medicine outlets.

Conclusions

The regulatory process should be improved through the enforcement of outlet licensing and medicine registration. Additional studies to elucidate the reasons behind the use of private medicine outlets over the public sector would assist the government in implementing interventions to increase use of public sector medicine outlets.

Recognition and reporting of suspected adverse drug reactions by surveyed healthcare professionals in Uganda: key determinants

OBJECTIVE

To assess extent and determinants of past-month recognition of suspected adverse drug reactions (ADR) and past-year ADR reporting among healthcare professionals (HCPs) in Uganda.

SETTING

Geographically diverse health facilities (public, private for-profit, private not-for-profit).

PARTICIPANTS

Of 2000 questionnaires distributed, 1345 were completed: return rate of 67%.

PRIMARY AND SECONDARY OUTCOME MEASURES

Per cent HCPs who suspected ADR in the past month; reported ADR in the past year.

RESULTS

Nurses were the majority (59%, 792/1345). Only half the respondents had heard about pharmacovigilance: 39% of nurses (295/763; 95% CI 35% to 42%), 70% otherwise (383/547; 95% CI 66% to 74%). One fifth (268/1289 or 21%; 95% CI 19% to 23%) had suspected an ADR in the previous 4 weeks, 111 of them were nurses; 15% (190/1296) had reported a suspected ADR in the past year, 103 of them were nurses. Past-month ADR suspicion was more likely by non-nurses (OR=1.7, 95% CI 1.16 to 2.40) and with medical research involvement (OR=1.5, 95% CI 1.05 to 2.15) but past-month receipt of patient ADR-complaint predominated (OR=19, 95% CI 14 to 28). Past-year ADR reporting was higher by hospital staff (OR=1.9, 95% CI 1.18 to 3.10), especially in medicine (OR=2.3, 95% CI 1.08 to 4.73); but lower from private for-profit health facilities (OR=0.5, 95% CI 0.28 to 0.77) and by older staff (OR=0.6, 95% CI 0.43 to 0.91); more likely by HCPs who had ever encountered a fatal ADR (OR=2.9, 95% CI 1.94 to 4.25), knew to whom to report (OR=1.7, 95% CI 1.18 to 2.46), or suggested how to improve ADR reporting (OR=1.6, 95% CI 1.04 to 2.49). Two attitudinal factors were important: diffidence and lethargy.

CONCLUSIONS

One in five HCPs suspected an ADR in the past-month and one in seven reported ADR in the previous year. Empowering patients could strengthen ADR detection and reporting in Africa.

Factors predicting home storage of medicines in Northern Uganda

BACKGROUND

Medicines are kept in households Worldwide for first aid, treatment of chronic or acute disease conditions. This promotes inappropriate use of medicines and hence the associated risks. The study explored the factors which predict availability and utilization of medicines in households of Northern Uganda.

METHOD

A cross sectional survey of 892 households was performed from November-to-December 2012. Five data collectors administered the questionnaires, respondents were requested to bring out any medicines present in their households. Demographic characteristics, drug name, quantity, source, formulation, legibility of drug labels and reasons why the medicines were being kept at home was collected. Data was analyzed using STATA 12.0 at 95% level of significance.

RESULTS

Of the households visited, 35.1% (313/892) had drugs. Paracetamol (11.8%), coartem (11.3%), cotrimoxazole (10%), amoxicillin (9.2%) and metronidazole (8.2%) were the major medicines found. Antibacterial drugs were the most commonly (40.1%) kept type of drugs. The medicines present in households were for on-going treatment (48%); 'leftover' (30.5%) and anticipated future use (21.6%). Symptoms of malaria (34.1%) were common in households which had drugs. The medicines kept in homes were mainly from the private sector 60.5% (497/821). The rate of home drug storage was higher 85.3% (267/313) amongst the educated individuals. There was high prevalence 76% (238/313) of self-medication among respondents in households which stored drugs. The average number of medicines in each household was 6 ± 5 with majority (68.1%) having between 1-10 drugs. Previous successful treatment (OR: 1.3; 95% CI: 0.95-1.77), regular income (OR: 1.8; 95% CI: 1.2-2.6) and sex (OR: 0.63; 95% CI: 0.5-0.9) predicted storage of medicines in households in northern Uganda.

CONCLUSION

Over a third of households in Northern Uganda store medicines with antibacterial agents being the most common. Self-medication is common among individuals in households which keep drugs. Past successful treatment, regular income and sex predict community home drug storage.

Improving adherence to antiretroviral treatment in Uganda with a low-resource facility-based intervention

Objective

To assess the effects of facility-based interventions using existing resources to improve overall patient attendance and adherence to antiretroviral therapy (ART) at ART-providing facilities in Uganda.

Methods

This was an interventional study which tracked attendance and treatment adherence of two distinct cohorts: experienced patients who had been on treatment for at least 12 months prior to the intervention and patients newly initiated on ART before or during the intervention. The interventions included instituting appointment system, fast-tracking, and giving longer prescriptions to experienced stable patients. Mixed-effects models were used to examine intervention effects on the experienced patients, while Cox proportional hazards models were used to determine the intervention effects on time until newly treated patients experienced gaps in medication availability.

Results

In all, 1481 patients’ files were selected for follow-up from six facilities – 720 into the experienced cohort, and 761 into the newly treated cohort. Among patients in the experienced cohort, the interventions were associated with a significant reduction from 24.4 to 20.3% of missed appointments (adjusted odds ratio (AOR): 0.67; 95% confidence interval (CI): 0.59–0.77); a significant decrease from 20.2 to 18.4% in the medication gaps of three or more days (AOR: 0.69; 95% CI: 0.60–0.79); and a significant increase from 4.3 to 9.3% in the proportion of patients receiving more than 30 days of dispensed medication (AOR: 2.35; 95% CI: 1.91–2.89). Among newly treated patients, the interventions were associated with significant reductions of 44% (adjusted hazard rate (AHR): 0.56, 95% CI: 0.42–0.74) and 38% (AHR: 0.62; 95% CI: 0.45–0.85) in the hazards of experiencing a medication gap of 7 and 14 days or more, respectively.

Conclusions

Patients’ adherence was improved with low-cost and easily implemented interventions using existing health facilities’ resources. We recommend that such interventions be considered for scale-up at national levels as measures to improve clinic attendance and ART adherence among patients in Uganda and other low-resource settings in sub-Saharan Africa.

A consortium approach to competency-based undergraduate medical education in Uganda: process, opportunities and challenges

BACKGROUND

Uganda, like the rest of Africa, is faced with serious health challenges including human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), other infectious diseases and increasing non-communicable diseases, yet it has a significant shortage of health workers. Even the few health workers available may lack desired competencies required to address current and future health challenges. Reducing Uganda's disease burden and addressing health challenges requires Ugandan medical schools to produce health workers with the necessary competencies. This study describes the process which a consortium of Ugandan medical schools and the Medical Education Partnership for Equitable Services to all Ugandans (MESAU) undertook to define the required competencies of graduating doctors in Uganda and implement competency-based medical education (CBME).

METHODS

A retrospective qualitative study was conducted in which document analysis was used to collect data employing pre-defined checklists, in a desktop or secondary review of various documents. These included reports of MESAU meetings and workshops, reports from individual institutions as well as medical undergraduate curricula of the different institutions. Thematic analysis was used to extract patterns from the collected data.

RESULTS

MESAU initiated the process of developing competencies for medical graduates in 2011 using a participatory approach of all stakeholders. The process involved consultative deliberations to identify priority health needs of Uganda and develop competencies to address these needs. Nine competence domain areas were collaboratively identified and agreed upon, and competencies developed in these domains.

DISCUSSION

Key successes from the process include institutional collaboration, faculty development in CBME and initiating the implementation of CBME. The consortium approach strengthened institutional collaboration that led to the development of common competencies desired of all medical graduates to address priority health challenges in Uganda. It is important that the MESAU consortium continues engaging all stakeholders in medical education to support the implementation and sustainability of CBME in Uganda.

Knowledge on plants used traditionally in the treatment of tuberculosis in Uganda

ETHNOPHARMACOLOGICAL RELEVANCE

Tuberculosis (TB) is one of the leading causes of morbidity and mortality globally. The disease is especially important because of increasing drug resistant strains and co infection with human immune virus (HIV) and acquired immune disease syndrome (AIDS). Because of this there is need to identify new leads that can be developed into new drugs. The objectives of this study were to (1) document plant species commonly used by traditional medicine practitioners (TMPs) to treat TB, methods of preparation and administration of drugs (2) document disease recognition by TMPs and (3) document medicine preservation and packaging practices by TMPs.

MATERIALS AND METHODS

We interviewed 40 TMPs from Mpigi and Butambala districts using a guided questionnaire.

RESULTS

A total of 90 plant species, distributed within 44 families were documented. Priority plants identified include Zanthoxylum leprieurii, Piptadeniastrum africanum, Albizia coriaria and Rubia cordifolia which were most mentioned by TMPs. TMPs had knowledge of how TB is transmitted and they admitted that it is closely associated with HIV. Decoctions of multiple plant species were commonly used. Plant parts frequently used were leaves followed by the stem bark and root bark. The TMPs had insufficient knowledge about packaging and preservation techniques.

CONCLUSION

Plant based therapies for treating TB have been identified in this study and further investigation of these plants is appropriate as these, may be developed into new drugs to curb the resistant strains of TB.

Poor immunological recovery among severely immunosuppressed antiretroviral therapy-naïve Ugandans

Introduction

CD4 T lymphocytes remain the surrogate measure for monitoring HIV progress in resource-limited settings. The absolute CD4 cell counts form the basis for antiretroviral therapy (ART) initiation and monitoring among HIV-infected adults. However, the rate of CD4 cell change differs among patients, and the factors responsible are inadequately documented.

Objective

This study investigated the relationship between HIV severity and ART outcomes among ART-naïve Ugandans, with the primary outcome of complete immunological recovery among patients of different baseline CD4 counts.

Methods

Patients’ records at two HIV/ART sites – the Joint Clinic Research Centre (JCRC) in the Kampala region and Mbarara Hospital in Western Uganda – were reviewed. Records of 426 patients – 68.3% female and 63.2% from JCRC – who initiated ART between 2002 and 2007 were included. HIV severity was based on baseline CD4 cell counts, with low counts considered as severe immunosuppression, while attaining 418 CD4 cells/μL signified complete immunological recovery. Incidence rates of complete immunological recovery were calculated for, and compared between baseline CD4 cell categories: <50 with ≥50, <100 with ≥100, <200 with ≥200, and ≥200 with ≥250 cells/μL.

Results

The incidence of complete immunological recovery was 158 during 791.9 person-years of observation, and patients with baseline CD4 ≥ 200 cells/μL reached the end point of immunological recovery 1.89 times faster than the patients with baseline CD4 < 200 cells/μL. CD4 cell change also differed by time, sex, and site, with a faster increase observed during the first year of treatment. CD4 cell increase was faster among females, and among patients from Mbarara.

Conclusion

Initiating ART at an advanced HIV stage was the main reason for poor immunological recovery among Ugandans. Earlier ART initiation might lead to better immunological responses.

Influence of efavirenz pharmacokinetics and pharmacogenetics on neuropsychological disorders in Ugandan HIV-positive patients with or without tuberculosis: a prospective cohort study

Background

HIV infection, anti-tuberculosis and efavirenz therapy are associated with neuropsychological effects. We evaluated the influence of rifampicin cotreatment, efavirenz pharmacokinetics and pharmacogenetics on neuropsychiatric disorders in Ugandan HIV patients with or without tuberculosis coinfection.

Methods

197 treatment naïve Ugandan HIV patients, of whom 138 were TB co-infected, enrolled prospectively and received efavirenz based HAART. TB-HIV confected patients received concomitant rifampicin based anti-TB therapy. Genotypes for CYP2B6 (*6, *11), CYP3A5 (*3, *6, *7), ABCB1 (c.3435C>T and c.4036 A/G rs3842), CYP2A6 (*9, *17) and NR1I3 rs3003596 T/C were determined. Efavirenz plasma concentrations were serially quantified at 3rd day, 1st, 2nd, 4th, 6th, 8th and 12th weeks during therapy. Efavirenz neuropsychiatric symptoms were evaluated in terms of sleep disorders, hallucinations and cognitive effects at baseline, at two and twelve weeks of efavirenz treatment using a modified Mini Mental State Examination (MMSE) score.

Results

During the first twelve weeks of ART, 73.6% of the patients experienced at least one efavirenz related neuropsychiatric symptom. Commonest symptoms experienced were sleep disorders 60.5% (n=124) and hallucination 30.7% (n=63). Neuropsychiatric symptoms during HAART were significantly predicted by efavirenz plasma concentrations consistently. Rifampicin cotreatment reduced plasma efavirenz concentrations significantly only during the first week but not afterwards. There was no significant difference in the incidence of neuropsychiatric symptoms between patients receiving efavirenz with or without rifampicin cotreatment. CYP2B6*6 and ABCB1 c.4036 A/G genotype significantly predicted efavirenz concentrations. The tendency of CYP2B6*6 genotype association with higher incidence of having vivid dream (p=0.05), insomnia (p=0.19) and tactile hallucination (p=0.09) was observed mainly at week-2.

Conclusions

Efavirenz related neuropsychiatric symptoms are common among Ugandan HIV patients receiving ART and is mainly predicted by higher efavirenz plasma concentrations and CYP2B6 genotype but not by rifampicin based anti-TB co-treatment.

Naturalistic outcome of treatment of psychosis by traditional healers in Jinja and Iganga districts, Eastern Uganda - a 3- and 6 months follow up

OBJECTIVE

To determine the naturalistic outcome of treatment of psychosis by traditional healers in Jinja and Iganga districts of Eastern Uganda.

METHOD

A cohort of patients with psychosis receiving treatment from traditional healers' shrines were recruited between January and March 2008 and followed up at three and six months. The Mini International Neuropsychiatry Interview (MINI Plus) was used for making specific diagnosis at the point of contact. For specific symptoms, Positive and Negative Symptom Scale (PANSS), Young Mania Rating Scale (YMRS) and Montgomery Asberg Depression Rating Scale (MADRS) were used to measure severity of schizophrenia, mania and psychotic depression, respectively. The Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) were used for objective assessments. The Compass Mental Health Index measured well being. Mean scores of the scales were computed using one way ANOVA for independent samples. Associations between outcome and categorical variables were examined at bivariate and multivariate levels.

RESULTS

All the symptom scales had a percentage reduction of more than 20% at three and six months follow up. The differences between the mean scores of the scales at baseline and 3 months, baseline and 6 months, and 3 and 6 months were all significant (P < 0.0001). The post test for pair wise comparisons, the Tukey HSD (Honestly Significant Difference) test was also all significant at P < 0.01 except for MADRS where there was no significant difference between 3 and 6 months for depression severity. Over 80% of the participants used biomedical services for the same symptoms in the study period. At 3 months follow up, patients who combined treatment were less likely to be cases (P = 0.002; OR 0.26 [0.15-0.58]), but more likely to be cases at 6 months follow up (P = 0.020; OR 2.05 [1.10-3.189]). Being in debt was associated with caseness both at 3 and 6 months.

CONCLUSION

This study suggests that there may be some positive effects for patients with psychosis who combine both biomedical services and traditional healing. Further research in the area of naturalistic outcome of traditional healing is necessary.

Plasma drug level validates self-reported adherence but predicts limited specificity for nonadherence to antiretroviral therapy

Introduction. Adherence to antiretroviral therapy (ART) in low-income countries is mainly assessed by self-reported adherence (S-RA) without drug level determination. Nonadherence is an important factor in the emergence of resistance to ART, presenting a need for drug level determination. Objective. We set out to establish the relationship between plasma stavudine levels and S-RA and validate S-RA against the actual plasma drug concentrations. Methods. A cross-sectional investigation involving 234 patients in Uganda. Stavudine plasma levels were determined using high-performance liquid chromatography. We compared categories of plasma levels of stavudine with S-RA using multivariable logistic regression models. Results. Overall, 194/234 patients had S-RA ≥ 95% (good adherence) and 166/234 had stavudine plasma concentrations ≥ 36 nmol/L (therapeuticconcentration). Patients with good S-RA were eight times more likely to have stavudine levels within therapeutic concentration (Adjusted Odds Ratio: 7.7, 95% Confidence Interval: 3.5–7.0). However, of the 194 patients with good S-RA, 21.7% had below therapeutic concentrations. S-RA had high sensitivity for adherence (91.6%), but limited specificity for intrinsic poor adherence (38.2%). Conclusions. S-RA is a good tool for assessing adherence, but has low specificity in detecting nonadherence, which has implications for emergence of resistance.

The efficacy of the crude root bark extracts of Erythrina abyssinica on rifampicin resistant Mycobacterium tuberculosis

INTRODUCTION

Tuberculosis (TB) is one of the leading causes of morbidity and mortality with a global mortality rate at two million deaths per year while one third of the world's population is infected with the TB bacillus.

OBJECTIVE

To determine the efficacy of the crude extracts of Erythrina abyssinica root bark on rifampicin-resistant TB.

METHODS

Crude extracts of root bark of Erythrina abyssinica, were screened against three strains of Mycobacterium tuberculosis including rifampicin-resistant TMC-331. Susceptibility tests used the disc diffusion method and were done on solid Middle brook 7H10, while the Minimum Inhibitory concentration (MICs) and minimum bactericidal concentration (MBCs) were determined by the Microtitre plate method using Middle brook 7H9 broth.

RESULTS

The total crude methanol extract showed activity against all the three strains of mycobacterium used, at 50mg/ml and diameters of zones of inhibition of up to 26 mm. Erythrina abyssinica total crude methanol extract showed the highest activity on the pan sensitive strain H37Rv (0.39±0.0 mg/ml) and the rifampicin resistant strain (TMC-331) (2.35±1.11 mg/ ml) and was also active on Mycobacterium avium (0.39±0.mg/ml. The values for isoniazid were 0.25µg/ml and 9.38µg/ml for H37Rv and TMC-331 respectively, while for rifampicin the MIC value was 0.25µg/ml for H37Rv but it was not active on TMC-331. Acute toxicity test gave an LD50 of 776.2mg/kg body weight while the phytochemical analysis showed the presence of alkaloids, tannins and flavones.

CONCLUSION

The conclusion from the study was that Erythrina abbyssinica has antimycobacterial activity and reasonable safety that merits further research.

Pharmacokinetics of the nonnucleoside reverse transcriptase inhibitor efavirenz among HIV-infected Ugandans

BACKGROUND

Pharmacokinetic variability of the nonnucleoside reverse transcriptase inhibitor efavirenz has been documented, and high variation in trough concentrations or clearance has been found to be a risk for virological failure. Africans population exhibits greater variability in efavirenz concentrations than other ethnic groups, and so a better understanding of the pharmacokinetics of the drug is needed in this population. This study characterized efavirenz pharmacokinetics in HIV-infected Ugandans.

METHODS

Efavirenz plasma concentrations were obtained for 66 HIV-infected Ugandans initiating efavirenz- based regimens, with blood samples collected at eight time-points over 24 h on day 1 of treatment, and at a further eight time-points on day 14. Noncompartmental analysis was used to describe the pharmacokinetics of efavirenz.

RESULTS

The mean steady-state minimum plasma concentration (C(min) ) of efavirenz was 2.9 µg/mL, the mean area under the curve (AUC) was 278.5 h µg/mL, and mean efavirenz clearance was 7.4 L/h. Although overall mean clearance did not change over the 2 weeks, 41.9% of participants showed an average 95.8% increase in clearance. On day 14, the maximum concentration (C(max) ) of efavirenz was >4 µg/mL in 96.6% of participants, while C(min) was <1 µg/mL in only 4.5%. Overall, 69% of participants experienced adverse central nervous system (CNS) symptoms attributable to efavirenz during the 2-week period, and 95% of these participants were found to have efavirenz plasma concentrations >4 µg/mL, although only half maintained a high concentration until at least 8 h after dosing.

CONCLUSION

The findings of this study show that HIV-infected patients on efavirenz may exhibit autoinduction to various extents, and this needs to be taken into consideration in the clinical management of individual patients. Efavirenz CNS toxicity during the initial phase of treatment may be related to C(max) , regardless of the sampling time.

Prevalence and factors associated with traditional herbal medicine use among patients on highly active antiretroviral therapy in Uganda

Background

In Africa, herbal medicines are often used as primary treatment for Human immunodeficiency virus (HIV) related problems. Concurrent use of traditional herbal medicines (THM) with antiretroviral drugs (ARVs) is widespread among HIV infected patients. However, the extent of THM use is not known in most settings in Sub-Saharan Africa. This study aimed at determining the prevalence and factors associated with THM use among HIV infected patients on highly active antiretroviral therapy (HAART) attending The AIDS Support Organization (TASO) in Uganda. TASO is a non-governmental organization devoted to offering HIV/AIDS care and treatment services in the population.

Methods

This was a cross-sectional study carried out in two TASO treatment centres in Uganda among 401 randomly selected eligible participants. We included participants who were 18 years and above, were enrolled on HAART, and consented to participate in the study. Data was collected using an interviewer-administered semi-structured questionnaire. THM use referred to someone who had ever used or was currently using herbal medicine while on highly active antiretroviral therapy (HAART) by the time of the study. Data was captured in Epi-data version 3.1 and exported to STATA version 9.0 for analysis.

Results

The prevalence of THM use was 33.7%. Patients on HAART for < 4 years were more likely to use THM (OR = 5.98, 95% CI 1.13 - 31.73) as well as those who experienced HAART side effects (OR = 3.66, 95% CI: 1.15 - 11.68). Older patients (≥39 years) were less likely to use THM (OR = 0.26 95% CI: 0.08 - 0.83). Participants with HAART adherence levels > 95% were less likely to use THM (OR = 0.09, 95% CI 0.01 - 0.65).

Conclusion

The prevalence of THM use among participants on HAART was high. This raises clinical and pharmacological concerns that need attention by the health care service providers.

Chewing-stick practices using plants with anti-streptococcal activity in a ugandan rural community

Background: The high dental disease burden in developing countries has created a need to explore and develop cheap and accessible methods of dental disease prevention. Traditional toothbrushes (chewing-sticks) prepared from specific plants have been used for dental hygiene for generations. When properly used, chewing-sticks may be as effective as synthetic toothbrushes. This study set out to describe traditional chewing-stick practices in a Ugandan rural community, and evaluate the antibacterial activity of two most commonly used plants. Methods: Interviews were done to identify chewing-stick plants and obtain socio-cultural information relating to the practice in two villages in rural Uganda. Field walks were done to pick and voucher the plants, for taxonomical identification and storage. For the two most reported plants, aqueous extracts were prepared and tested for antibacterial activity against Streptococcus mutans using the agar-well diffusion method. Results: Of the 21 key informants interviewed, all were using or had used chewing-sticks in the past. A total of eight plants were identified as sources of chewing-sticks, with Rhus vulgaris and Lantana trifolia most commonly mentioned. Chewing-sticks were preferred over synthetic tooth brushes because they were less likely to traumatize the gums. Their use has been limited of recent due to scarcity of some plants. R. vulgaris and L. trifolia aqueous extracts showed antibacterial activity against S. mutans with mean diameters of inhibition of 24.33 ± 0.58 and 14.17 ± 0.29 mm on Blood agar respectively, compared to benzyl penicillin control 30.67 ± 0.29 mm. Conclusion: R. vulgaris and L. trifolia are the most common sources of chewing-sticks for cleaning teeth in this community. The plants contain compounds that are active against S. mutans. These plants merit further studies as they are possible sources of cheap dental health care for the rural poor.

Multiple ART Programs Create a Dilemma for Providers to Monitor ARV Adherence in Uganda

BACKGROUND

Increased availability and accessibility of antiretroviral therapy (ART) has improved the length and quality of life amongst people living with HIV/AIDS. This has changed the landscape for care from episodic to long-term care that requires more monitoring of adherence. This has led to increased demand on human resources, a major problem for most ART programs. This paper presents experiences and perspectives of providers in ART facilities, exploring the organizational factors affecting their capacity to monitor adherence to ARVs.

METHODS

From an earlier survey to test adherence indicators and rank facilities as good, medium or poor adherence performances, six facilities were randomly selected, two from each rank. Observations on facility set-up, provider-patient interactions and key informant interviews were carried out. The strengths, weaknesses, opportunities and threats identified by health workers as facilitators or barriers to their capacity to monitor adherence to ARVs were explored during group discussions.

RESULTS

Findings show that the performance levels of the facilities were characterized by four different organizational ART programs operating in Uganda, with apparent lack of integration and coordination at the facilities. Of the six facilities studied, the two high adherence performing facilities were Non-Governmental Organization (NGO) programs, while facilities with dual organizational programs (Governmental/NGO) performed poorly. Working conditions, record keeping and the duality of programs underscored the providers' capacity to monitor adherence. Overall 70% of the observed provider-patient interactions were conducted in environments that ensured privacy of the patient. The mean performance for record keeping was 79% and 50% in the high and low performing facilities respectively. Providers often found it difficult to monitor adherence due to the conflicting demands from the different organizational ART programs.

CONCLUSION

Organizational duality at facilities is a major factor in poor adherence monitoring. The different ART programs in Uganda need to be coordinated and integrated into a single well resourced program to improve ART services and adherence monitoring. The focus on long-term care of patients on ART requires that the limitations to providers' capacity for monitoring adherence become central during the planning and implementation of ART programs.

A novel polymorphism in ABCB1 gene, CYP2B6*6 and sex predict single-dose efavirenz population pharmacokinetics in Ugandans

AIMS

Efavirenz exhibits pharmacokinetic variability causing varied clinical response. The aim was to develop an integrated population pharmacokinetic/pharmacogenetic model and investigate the impact of genetic variations, sex, demographic and biochemical variables on single-dose efavirenz pharmacokinetics among Ugandan subjects, using NONMEM.

METHODS

Efavirenz plasma concentrations (n = 402) from 121 healthy subjects were quantified by high-performance liquid chromatography. Subjects were genotyped for 30 single nucleotide polymorphisms (SNPs), of which six were novel SNPs in CYP2B6, CYP3A5 and ABCB1. The efavirenz pharmacokinetics was described by a two-compartment model with zero- followed by first-order absorption.

RESULTS

Apparent oral clearance (95% confidence interval) was 4 l h l(-1) (3.5, 4.5) in extensive metabolizers. In the final model, incorporating multiple covariates, statistical significance was found only for CYP2B6*6 and CYP2B6*11 on apparent oral clearance as well as ABCB1 (rs3842) on the relative bioavailability. Subjects homozygous for CYP2B6*6 (G516T, A785G) and *11 displayed 21 and 20% lower apparent oral clearance, respectively. Efavirenz relative bioavailability was 26% higher in subjects homozygous for ABCB1 (rs3842). The apparent peripheral volume of distribution was twofold higher in women compared with men.

CONCLUSIONS

The model identified the four factors CYP2B6*6, CYP2B6*11, a novel variant allele in ABCB1 (rs3842) and sex as major predictors of efavirenz plasma exposure in a healthy Ugandan population after single-dose administration. Use of mixed-effects modelling allowed the analysis and integration of multiple pharmacogenetic and demographic covariates in a pharmacokinetic population model.

The prevalence and severity of mental illnesses handled by traditional healers in two districts in Uganda

BACKGROUND

Little is known about the prevalence and severity of DSM-IV mental disorders treated by traditional healers in Uganda.

OBJECTIVE

To describe the prevalence and severity of DSM-IV disorders handled by traditional healers in Jinja and Iganga districts, Eastern Uganda.

METHOD

Between January and March 2008, Face-to-Face Interviews were conducted with 400 patients attending traditional healers' shrines for mental health problems, using Self Rating Questionnaire 25 (SRQ-25) for screening, the Mini International Neuropsychiatric Interview (MINI-Plus) for specific DSM-IV diagnosis and the Global Assessment of Functioning (GAF) for severity of illness. Descriptive data analysis and frequency estimates were performed using SPSS version 15.0 for Windows. Pearson's chi-square tests and odds ratios were used to explore the relationship between severity and combined use of biomedical services and traditional healing.

RESULTS

Of 387 respondents, 60.2% had diagnosable current mental illness and 16.3% had had one disorder in their lifetime. Of the diagnosable current mental illnesses, 29.7% were Psychosis; 5.4% Major depressive episode; 5.6% Anxiety disorders; 3.6% mixed Anxiety-Depression; and 3.9% Suicidality. In terms of severity, 37.7% of the current mental illnesses were severe, 35.1% moderate and 13.2% mild. Patients with moderate to severe symptoms were more likely to use both biomedical services and traditional healers.

CONCLUSION

These findings suggest that a considerable number of patients with DSM-IV diagnosable mental disorders attend traditional healing shrines; the majority had moderate to severe symptoms. Mental health professionals therefore need to come up with ways to co-operate with traditional healers, e.g. as officially designated Traditional Mental Attendants (TMA), for the benefit of their patients.

The anti-mycobacterial activity of Lantana camara a plant traditionally used to treat symptoms of tuberculosis in South-western Uganda

INTRODUCTION

Tuberculosis continues to be a devastating public health problem. Many communities in Uganda use medicinal plants to treat various infections, including respiratory tract infections. There are claims that some can treat tuberculosis. Verifying some of these claims could lead to discovery of lead compounds for development of a TB drug.

METHODS

Chloroform and methanol extracts of L. camara collected from South-western Uganda were screened against three strains of Mycobacterium tuberculosis using the agar-well diffusion method. H37Rv, the rifampicin-resistant TMC-331 and a non-resistant wild strain (28-25271). The MIC and MBC were determined using the Agar dilution method on Middle brook 7H11.

RESULTS

The methanol extract showed the highest activity against all the three strains used, with zones of inhibition of 18.0-22.5 mm and MIC values of 20 µg/ml for H37Rv and 15 µg/ml for both TMC-331 and wild stain. The values for rifampicin were 1.0 µg/ml for both H37Rv and wild strain but rifampicin hardly showed any activity on TMC-331. The MBC value for the methanol extract of L. camara was 30µg/ml for the H37Rv, and 20µg/ml for both the TMC-331 and wild strains of M. tuberculosis. The MBC for rifampicin was 2.0µg/ml for both H37Rv and the wild strain.

CONCLUSION

We conclude that L. camara contains principles active against M. tuberculosis, which merit further research.

A strategy to improve skills in pharmaceutical supply management in East Africa: the regional technical resource collaboration for pharmaceutical management

BACKGROUND

International initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative have significantly increased availability and access to medicines in some parts of the developing world. Despite this, however, skills remain limited on quantifying needs for medications and ordering, receiving and storing medications appropriately; recording medications inventories accurately; distributing medications for use appropriately; and advising patients on how to use medications appropriately. The Regional Technical Resource Collaboration for Pharmaceutical Management (RTRC) has been established to help address the problem of skills shortage in pharmaceutical management in East Africa.

METHODS

The initiative brings together academic institutions from four East African countries to participate in skills-building activities in pharmaceutical supply management. The initiative targeted the institutions' ability to conduct assessments of pharmaceutical supply management systems and to develop and implement effective skills-building programmes for pharmaceutical supply chain management.

RESULTS

Over a two-year period, the RTRC succeeded in conducting assessments of pharmaceutical supply management systems and practices in Kenya, Rwanda, Tanzania and Uganda. In 2006, the RTRC participated in a materials-development workshop in Kampala, Uganda, and contributed to the development of comprehensive HIV/AIDS pharmaceutical management training materials; these materials are now widely available in all four countries. In Tanzania and Uganda the RTRC has been involved with the training of health care workers in HIV/AIDS pharmaceutical management. In Kenya, Tanzania and Uganda the RTRC has been conducting operations research to find solutions to their countries' skills-shortage problems. Some of the interventions tested include applying and evaluating the effectiveness of a novel skills-building approach for pharmaceutical supply management.

CONCLUSION

Nurturing collaboration between regional institutions in resource-limited countries to build in-country skills in pharmaceutical supply management appears to be an effective intervention. Support from local programmes and technical assistance from organizations and institutions with the necessary expertise is critical for success, particularly at inception. The skills acquired by local institutions can be incorporated into both pre-service and in-service teaching curricula. This ensures long-term availability of skills in-country. The ability of trained institutions to mobilize their own resources for skills-building activities is crucial for the success and sustainability of these programmes.

Psychological distress and associated factors among the attendees of traditional healing practices in Jinja and Iganga districts, Eastern Uganda: a cross-sectional study

BACKGROUND

Mental health problems are a major public health concern worldwide. Evidence shows that African communities, including Uganda, use both modern and traditional healing systems. There is limited literature about the magnitude of psychological distress and associated factors among attendees of traditional healing practices. This study aimed to determine the prevalence and associated factors of psychological distress among attendees of traditional healing practices in two districts in Uganda.

METHODS

Face-to-face interviews with the Lusoga version of the Self Reporting Questionnaire (SRQ-20) were carried out with 400 patients over the age of 18 years attending traditional healing in Iganga and Jinja districts in Eastern Uganda. Patients were recruited consecutively in all the traditional healers' shrines that could be visited in the area. Persons with 6 or more positive responses to the SRQ were identified as having psychological distress. Prevalence was estimated and odds ratios of having psychological distress were obtained with multiple logistic regression analysis.

RESULTS

387 questionnaire responses were analyzed. The prevalence of psychological distress in connection with attendance at the traditional healers' shrines was 65.1%. Having a co-wife and having more than four children were significantly associated with psyclogical distress. Among the socioeconomic indicators, lack of food and having debts were significantly associated with psychological distress. The distressed group was more likely to need explanations for ill health. Those who visited both the healer and a health unit were less likely to be distressed.

CONCLUSION

This study provides evidence that a substantial proportion of attendees of traditional healing practices suffer from psychological distress. Associated factors include poverty, number of children, polygamy, reason for visiting the healer and use of both traditional healing and biomedical health units. These findings may be useful for policy makers and biomedical health workers for the engagement with traditional healers.

Monitoring adherence and defaulting for antiretroviral therapy in 5 East african countries: an urgent need for standards

OBJECTIVES

A cross-sectional survey was performed in 24 systems of care providing antiretroviral medications in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda to examine current practices in monitoring rates of treatment adherence and defaulting.

RESULTS

Only 20 of 48 facilities reported routinely measuring individual patient adherence levels; only 12 measured rates of adherence for the clinic population. The rules for determining which patients were included in the calculation of rates were unclear. Fourteen different definitions of treatment defaulting were in use. Facilities routinely gather potentially useful data, but the frequency of doing so varied widely.

CONCLUSIONS

Individual and program treatment adherence and defaulting are not routinely monitored; when done, the operational definitions and methods varied widely, making comparisons across programs unreliable. There is a pressing need to determine which measures are the most feasible and reliable to collect, the most useful for clinical counseling, and most informative for program management.

Impact of an educational intervention to improve prescribing by private physicians in Uganda

INTRODUCTION

Private physicians in urban Uganda treat a large percentage of common adult illnesses. Improving their prescribing would not only encourage more rational drug use, but also reduce costs to patients. Interventions to improve drug use are generally more successful when face-to-face educational methods are included.

OBJECTIVES

To determine the effectiveness of a face-to-face educational intervention on the treatment of acute respiratory infections (ARI), malaria, and non-dysenteric diarrhoea by private physicians in three urban areas of Uganda.

METHODS

The study used an intervention with comparison group design to evaluate the impact of the educational intervention. A total of 108 private physicians was divided into intervention (n = 30) and control (n = 78) groups. Surrogate patients, trained to simulate presenting symptoms and signs of the target conditions, were used to collect data on the medical practices and prescribing behaviours of the physicians. Intervention physicians were invited to a one-day interactive educational seminar facilitated by local opinion leaders that covered principles of rational drug use and the National Standard Treatment Guidelines for treating the target conditions. Physicians were also provided with data about baseline practices.

RESULTS

Baseline data indicated high rates of inappropriate treatment practices by both intervention and control groups. There was nearly universal antibiotic use for ARI (over 90%), high rates of injections recommended for malaria (over 30%), and high rates of polypharmacy (over thee drugs per patient). After the intervention, some significant improvements in key practices were observed in the intervention group. Compared to control physicians, antibiotic prescribing for ARI decreased by 23% in the intervention group, use of combination products for malaria declined by 28%, there were trends towards better adherence to guidelines for ARI and malaria, and marginal decreases in drug costs. However, the overall impacts of the intervention were limited, especially on quality indicators concerning history taking, adequate examination, and advice to patients.

CONCLUSION

The face-to-face educational intervention resulted in some small improvements in key prescribing practices of private physicians. However, an intervention that involved repeated contacts with prescribers and which addressed economic considerations would be needed to obtain larger improvements. Private physicians need to be sensitized to and encouraged to use the National Standard Treatment Guidelines, and attempts to improve their prescribing should be supported by community education.

A comparison of prescribing practices between public and private sector physicians in Uganda

INTRODUCTION

Previous studies in the public sector in Uganda have demonstrated major prescribing problems due to polypharmacy and irrational use of antibiotics and injections. Little is known about prescribing in the private sector although there is little government regulation influencing practice in this sector. The introduction of policies such as the Uganda National Standard Treatment Guidelines (UNSTG) was expected to improve prescribing practices in the public and private sectors. This paper measures appropriateness of prescribing practices in the public and private sectors in Uganda for the treatment of Acute Respiratory Infections (ARI) and malaria in adult patients. DESIGN AND SAMPLING: We combined a prospective survey of treatment for simulated patients presenting with symptoms of malaria and ARI in 119 randomly selected private clinics and a retrospective survey of 600 prescription records for malaria and ARI (300 for each condition) randomly selected from 10 public health units in the Kampala, Masaka, and Jinja urban areas.

OUTCOME MEASURES

Percentage of drug appropriately prescribed in each condition, % injection prescription, percentage antibiotic prescription, average number of drugs per case, average standardized cost per prescription, distribution of types of drugs prescribed.

RESULTS

The overall appropriateness of prescribing for ARI and malaria was poor in both public and private sectors. Treatment of malaria was significantly less appropriate in the public sector compared to the private sector (14% vs. 27%, p = 0.002), with injectable chloroquine much more commonly prescribed. Prescribing of antibiotics for ARI was nearly universal in both sectors, with some prescriptions containing up to three antibiotics; newer, more expensive antibiotics were more commonly prescribed in the private sector. Polypharmacy and unnecessary prescribing of vitamins were common in both conditions and both sectors.

CONCLUSIONS

Prescribing for adult malaria and ARI by both private and public practitioners did not conform to the UNSTGs. Although practitioners were largely the same in both sectors, prescribing practices often differed dramatically. The extent of inappropriate prescribing in both sectors calls for in-depth investigation of the system factors and motivations that underlie problem practices, and the development of interventions that target these causative factors.