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The Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners launched the 90–90–90 targets. The three targets provide that by 2020, 90% of all people living with HIV (PLWH) will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART), and 90% of all people receiving ART will have viral load (VL) suppression (Abuogi et al., 2018; Granich et al., 2017; Levi et al., 2016). We use Tanzania HIV Impact Survey (THIS) data to study the barriers to achieve these targets. THIS 2017 was a population-based with a stratified multistage stage survey sampling design. We used weighted logistic regression to associate three targets with socio-demographics, HIV-related discrimination, fear and shame. We defined HIV awareness by combination of self-reported of HIV status positive and antiretrovirals (ARVs) detected in blood among PLWH. On ART was defined as those who self-reported among awareness. VL suppression was defined as 400 copies/ml or less in the blood sample. The three targets were estimated at 61–90-85 in Tanzania from the weighted analysis. The first target was far from being achieved. The weighted regression showed that being female, having attained higher education, married, having insurance, and living in urban areas were associated with a high likelihood of having ever tested for HIV. Yet, we found HIV related discrimination and fear were the barrier of HIV awareness and hence lower rates of being on ART and VL suppression. The second and third targets are derivatives of the first one. The results indicated that intervention programs in Tanzania should focus on the first target. To achieve the first target, population-based massive screen program is necessary. Intervention programs should be designed for each target separately. Integrated strategies in context of low and middle income countries are needed to achieve these targets.

Background We describe the decentralisation of antiretroviral therapy (ART) alongside Option B+ roll-out in public healthcare facilities in the Lablite project in Uganda. Lessons learned will inform programmes now implementing universal test and treat (UTT). Methods Routine data were retrospectively extracted from ART registers between October 2012 and March 2015 for all adults and children initiating ART at two primary care facilities (spokes) and their corresponding district hospitals (hubs) in northern and central Uganda. We describe ART initiation over time and retention and use of Cox models to explore risk factors for attrition due to mortality and loss to follow-up. Results from tracing of patients lost to follow-up were used to correct retention estimates. Results Of 2100 ART initiations, 1125 were in the north, including 944 (84%) at the hub and 181 (16%) at the spokes; children comprised 95 (10%) initiations at the hubs and 14 (8%) at the spokes. Corresponding numbers were 642 (66%) at the hub and 333 (34%) at the spokes in the central region (77 [12%] and 22 [7%], respectively, in children). Children Conclusions After ART decentralisation, people living with human immunodeficiency virus (HIV) were willing to initiate ART in rural primary care facilities. Retention on ART was variable across facilities and attrition was higher among some groups, including younger adults and women initiating ART during pregnancy/breastfeeding. Interventions to support these groups are required to optimise benefits of expanded access to HIV services under UTT.

BACKGROUND: Heart rate-corrected QT (QTc) interval is associated with increased risk for cardiovascular events and mortality among individuals with diabetes mellitus (DM). Little is known about the epidemiology of prolonged QTc among people with DM in resource-limited settings. METHODS: We conducted a cross-sectional study among adults with diabetes in ambulatory care at the Mbarara Regional Referral Hospital, from November 2018 to April 2019. Twelve-lead ECG recordings were performed on all participants. We collected clinical and laboratory data related to diabetes disease status and treatment control. We estimated QTc using Bazett’s formula and categorized it according to standardized sex-adjusted thresholds. Linear regression analysis was performed to identify correlates of QTc. RESULTS: We recruited 299 participants with a mean age of 50.1 years (SD±9.8) and mean HbA1c of 9.7 % (SD±2.6), and 69.6% were female. We detected prolonged and borderline QTc in 6.4% (19/299, 95% CI: 3.9–9.7%) and 23.4% (70/299, 95% CI: 18.7–28.6%) of participants, respectively. In multivariate models, factors associated with increasing QTc interval were mean arterial pressure (β=0.34; 95% CI: 0.07–0.63, p=0.019) and female sex (β=15.26; 95% CI: 7.58–22.94, p0.001). CONCLUSIONS: The prevalence of abnormal QTc among individuals in routine diabetes care in southwestern Uganda was high. Female sex and mean arterial pressure were correlated with QTc interval. Given these findings, future studies should explore the clinical impact of abnormal QTc in this patient population.

Incidence and persistence of major depressive disorder (MDD) in children and adolescents with HIV (CA-HIV) in Uganda is described. 1339 CA-HIV attending care were enrolled and followed up for 12 months. MDD was assessed using the DSM-5 referenced Child and Adolescent Symptom Inventory-5 (CASI-5), with a prevalence for MDD at baseline of 5% (95% CI 3.3-7.3). Kaplan-Meir method was used to estimate incidence of MDD and Cox models were fitted to investigate predictors of incident MDD. Cumulative incidence of MDD over 12 months was 7.6 per 100 person-years 95% CI (6.2-9.4) and a rate of persistent MDD of 10/105 (9.5% CI 3.9-15.1). Significant independent predictors of incident MDD were: highest educational level of CA-HIV (protective), increasing depressive scores and decreasing CD4 Nadir. These finding have implications for what should constitute components of a mental health integration model in HIV youth services and for the future development of individualised mental health care.

ObjectiveTo determine the maternal and newborn characteristics associated with high umbilical artery lactate levels at Mulago National Referral Hospital.DesignCross-sectional observational study.SettingDepartment of Obstetrics and Gynecology at a national referral hospital located in the capital of Uganda, Kampala.ParticipantsWe randomly selected 720 pregnant mothers at term who presented in labour and their newborn babies.Primary outcomeUmbilical artery lactate level.ResultsDuring the study, there were 579 vaginal deliveries (18 instrumental) and 141 caesarean sections which met the inclusion criteria. One hundred and eighty-seven neonates (187) had high arterial lactate levels. The following factors were associated with an increased likelihood of high lactate concentration: male sex (adjusted OR (aOR)=1.71; 95% CI 1.16 to 2.54; p<0.05), primigravidity (aOR=2.78; 95% CI 1.89 to 4.08; p<0.05).ConclusionAbout a fifth of the babies born in Mulago National Referral Hospital during the study period had high umbilical artery lactate. The maternal-fetal factors significantly associated with high umbilical artery lactate levels included: baby’s sex, mother’s gravidity, meconium-stained amniotic fluid and oxytocin administration during labour.

BackgroundOrthostatic hypotension (OH) and orthostatic hypertension (OHT) are often unrecognized in clinical care for diabetic individuals, yet they are associated with increased risk for adverse cardiovascular outcomes. We aimed to determine the prevalence of the abnormal orthostatic blood pressure (BP) responses, and associated factors among diabetic individuals in ambulatory care for diabetes in southwestern Uganda.MethodsWe conducted a cross-sectional study among diabetic individuals aged 18–65 years at Mbarara Regional Referral Hospital, southwestern Uganda from November 2018 to April 2019. We obtained demographic and clinical data including a detailed medical history, and glycemic profile. BP measurements were taken in supine position and within 3 min of standing. We defined OH in participants with either ≥ 20 mmHg drop in systolic BP (SBP) or ≥ 10 mmHg drop in diastolic BP (DBP) after assuming an upright position. OHT was defined in participants with either a ≥ 20 mmHg rise in SBP, or ≥ 10 mmHg rise in DBP after assuming an upright position. Multivariate logistic regression was used to identify factors associated with OH and OHT.ResultsWe enrolled 299 participants, with a mean age of 50 years (SD ± 9.8), and mean HbA1c of 9.7% (SD ± 2.6); 70% were female. Of the 299 participants, 52 (17.4%; 95% CI 13.3–22.2%) met the definition of OH and 43 (14.4%; 95% CI 10.6–18.9%) were classified as having OHT. In multivariable models, factors associated with diabetic OH were older age (OR = 2.40 for 51–65 years vs 18–50 years, 95% CI 1.02–5.67,P = 0.046), diabetic retinopathy (OR = 2.51; 95% CI 1.14–5.53,P = 0.022), higher resting SBP ≥ 140 mmHg (OR = 3.14; 95% CI 1.31–8.7.56,P = 0.011), and history of palpitations (OR = 2.31; 95% CI 1.08–4.92,P = 0.031). Self-report of palpitations (OR = 3.14; 95% CI 1.42–6.95,P = 0.005), and higher resting SBP ≥ 140 mmHg (OR = 22.01; 95% CI 1.10–4.42,P = 0.043) were associated with OHT.ConclusionOH and OHT are common among diabetic individuals in ambulatory diabetes care in southwestern Uganda. Orthostatic BP measurements should be considered as part of routine physical examination to improve detection of OH and OHT, especially among older diabetics with complications of the disease. Future studies to assess the health and prognostic implications of OH and OHT among diabetics in the region are warranted.

In sub-Saharan Africa, adult mortality estimates mainly obtained from nationally representative surveys such as Demographic and Health Surveys show discrepancies in all-cause mortality between men and women. It is important to understand factors that explain these differences. Using data for adults aged ≥15 years from the Nairobi Urban Demographic Health Surveillance System (NUHDSS), this study assesses whether gender differences in all-cause mortality are mediated through household poverty. We used the generalised structural equation model, a unified framework that allows to calculate both direct and indirect effects of exposure on outcome. Results show that overall mortality rates in 151,865 individuals were 32.9 and 28.4 per 100 person years among men and women, respectively during median(IQR) follow-up of 7.3 (3.7, 10.6) years. The effects of gender on mortality decreased with age. We observed a male versus female aOR 1.39 [95% CI (1.25, 1.53)] which represents a higher odds of dying among men compared to women in the 15–35 age group, but lower odds of dying in the age group 35–60 years and >60 years, aOR 0.90 [95% CI (0.81, 0.99)], aOR 0.91 [95% CI (0.73, 1.12)], respectively. We estimated the direct effect of gender on mortality mediated through household poverty but the mediated effects were marginal. All estimates are adjusted for age, slum area, education level and ethnicity. In summary, differences in mortality between men and women decrease with age, and partly are mediated by household poverty. Given that differences in mortality between men and women who share the same household decreases with age, it is essential for future interventions aimed at reducing the gap in gender mortality particularly in older age groups, to consider other factors that interact with poverty.

Background and Purpose Stroke outcome data in Uganda is lacking. The objective of this study was to capture 30-day mortality outcomes in patients presenting with acute and subacute stroke to Mbarara Regional Referral Hospital (MRRH) in Uganda. Methods A prospective study enrolling consecutive adults presenting to MRRH with abrupt onset of focal neurologic deficits suspicious for stroke, from August 2014 to March 2015. All patients had head computed tomography (CT) confirmation of ischemic or hemorrhagic stroke. Data was collected on mortality, morbidity, risk factors, and imaging characteristics. Results Investigators screened 134 potential subjects and enrolled 108 patients. Sixty-two percent had ischemic and 38% hemorrhagic stroke. The mean age of all patients was 62.5 (SD 17.4), and 52% were female. More patients had hypertension in the hemorrhagic stroke group than in the ischemic stroke group (53% vs. 32%, p = 0.0376). Thirty-day mortality was 38.1% (p = 0.0472), and significant risk factors were National Institutes of Health Stroke Scale (NIHSS) score, female sex, anemia, and HIV infection. A one unit increase of the NIHSS on admission increased the risk of death at 30 days by 6%. Patients with hemorrhagic stroke had statistically higher NIHSS scores (p = 0.0408) on admission compared to patients with ischemic stroke, and also had statistically higher Modified Rankin Scale (mRS) scores at discharge (p = 0.0063), and mRS score change from baseline (p = 0.04). Conclusions Our study highlights an overall 30-day stroke mortality of 38.1% in southwestern Uganda, and identifies NIHSS at admission, female sex, anemia, and HIV infection as predictors of mortality.

In this article, we examine the opportunities and challenges digital connectedness creates in the fight against epidemics, in particular the coronavirus (COVID‐19). We deduce that digital connectedness of individuals and organizations eased sharing of information on the causes and measures aimed at controlling and avoid the rapid spread of the epidemic in developing economies of Africa. We conclude that digital connectedness enabled African countries to access; share and implement globally suggested mechanisms aimed at controlling the spread of the COVID‐19 epidemic. Future, studies should examine how African economies use digital connectedness to increase individual and organizational participation in curbing epidemics and also boost health management.

Access to improved water, sanitation, and hygiene (WASH) services at the household level remains a good strategy to improve the health and well-being of individuals. Informal settlements, such as urban slums, are at risk of the spread of diseases due to the relative lack of access to safe, clean drinking water and basic sanitation, as well as poor hygiene. Global initiatives, such as the Sustainable Development Goals (SDGs) adopted by the United Nations, are aimed at transitioning households and communities from unimproved to sustained improved states of WASH services. To deepen understanding of the time dynamics between states of WASH services in the Nairobi Urban and Demographic Surveillance System (NUHDSS), this study employs the multi-state transition model to assess the influence of potential risk factors on these transitions. Results indicated that study sites, wealth tertile, age of household head, poverty status, the ethnicity of household head, household ownership, and food security were associated with household transitions of WASH services. There was a lower probability for households to transition from unimproved to improved toilet services than the reverse transition, but a higher chance for households to transition from unimproved to improved water and garbage services. The estimated average time that households spent in the unimproved and improved states before transitioning were, respectively, 35 months and 9 months for toilet services, 7 months and 66 months for water services, and 16 months and 19 months for garbage services. Thus, households tend to remain longer in the unimproved state of toilet and garbage services, and when in the improved states, they transition back relatively faster compared to water services. In conclusion, sanitation services in Nairobi informal settings remain largely unsatisfactory as transitions to improved services are not sustained. It is therefore important for governments, policy-makers, and stakeholders to put in place policies and interventions targeting vulnerable households for improved and sustained WASH services.

Principal-agency problems due to hidden incentives might be amplified, for example, under circumstances when unjustified trust in an inspector is associated with higher perception of building quality. This paper sets out to determine whether a significant difference exists in the owner’s perception of the building quality based on the perception of the inspector and the inspection process within multi-dwelling housing. A principal-agent theoretical perspective and the question of trust is applied on data from a survey sent to 1563 housing cooperatives in Sweden and analysed using a one-sided ANOVA as well as Kruskal-Wallis and post-hoc Dunn’s test. The major finding is that differences in perception associated with the company size of the developer, the timing of the inspection as well as the complexity of the process for the owners affects reported defect. The main implication is that efforts to address shortcomings related to the gap between the developer and the owner, in the context of building quality and perceived severity of defects, need to be customised to different owner groups. A better understanding of the inspection process by the owner improves active participation, which leads to efficient quality improvement. Society benefits from improved comprehension and utilisation of the results.

With countries moving towards reaching the UNAIDS 90-90-90 goal to achieve HIV epidemic control, there are going to be an unprecedented number of persons tested, treated, and regularly monitored for viral suppression. However, most of the countries with the greatest burden of HIV/AIDS experience regular stock outages which could be detrimental to reaching these targets. Antiretroviral therapy and other commodities such as HIV test kits and laboratory supplies need to be readily and consistently available in order to achieve these targets. Medical Access Uganda Limited implemented several interventions as part of a procurement and supply chain strengthening project with the ultimate goal of supply chain improvement for access to HIV medicines. These interventions were evaluated using performance-monitoring-indicators from 2011-2016. We tested for the significance in the change in scores of performance-monitoring-indicators using the test for difference in proportions. Health facilities were scored on six categories and accredited as bronze, silver, or gold based on their total scores. Kaplan Meier estimates were computed for time to silver and gold ranking and Cox proportional hazards models were computed for time to gold ranking. The 13 sites with a baseline score 10 aHR:5.78,p= 0.003) were associated with better stock management ranking scores. Improvements in supply chain management in countries committed to achieving the 90-90-90 goals are crucial to achieving HIV epidemic control. Health system strengthening and mentorship investments in Uganda were feasible and are essential for sustainable disease control efforts.

Decision-making power and access to and control over resources are key elements of women's bargaining power within a household, and plays an important role in improving healthcare seeking behaviours for women and their children, which in turn augment maternal and child health outcomes. We examined the relationship between intra-household bargaining power and utilization of postnatal and child healthcare services within 6 months after delivery, based on cross-sectional survey data from Kyenjojo district, Tooro sub-region of Western Uganda. We assessed independent associations between women's intra-household bargaining autonomy and postnatal care attendance using a modified Poisson approach for common outcomes. We found that women who contributed to the decision-making processes on child healthcare, personal healthcare, and how to raise money for healthcare of family members were about 20% more likely to attend postnatal and child healthcare within 6 months of delivery, compared with women who were unable to make such decisions. Therefore, contributing to efforts that empower women to have greater control over child and personal healthcare through gender transformative approaches and policy engagements in important.

Complications often arise during pregnancy leading to unfavorable pregnancy outcomes such as stillbirths, abortions/miscarriages, and neonatal losses placing a substantial burden on families, communities, and the health care system. In this study, we estimate pregnancy loss and identify associated factors that drive pregnancy loss among women in two urban slums in Nairobi. In order to estimate the population-level effects of risk factors on pregnancy loss, we use the generalized estimation equation (GEE), which also allows us to account for the clustering of deliveries within pregnant women. From 2003 to 2016, the rate of pregnancy loss was 16 per 1000 deliveries (7 per 1000 and 9 per 1000 for stillbirth and miscarriages, respectively). Pregnancy loss was 6% less likely among pregnant women in Viwandani as compared to Korogocho, for a unit increase in years while holding other factors constant [i.e adjusted odds ratio (AOR) of 0.9429, 95% confidence interval (CI) of (0.9006, 0.9872)]. In addition, the study found that for a unit change in gravidity, the odds of experiencing pregnancy loss was 16% less among women in the lowest wealth tertile compared to women in the highest wealth tertile. Also, the odds of pregnancy loss was 6% more for a unit increase in women's age [AOR: 0.8425; 95% CI: (0.7134, 0.9949)]. Currently married and previously married pregnant women were, respectively, thrice and twice more likely to lose pregnancy compared to never-married women [AOR: 3.0180; 95% CI: (1.6930, 5.3798)]. In conclusion, advanced maternal age and being married were found to be strongly associated with the risk of pregnancy loss. The association between pregnancy loss and wealth tertile depends on the level of gravidity of the women. Identification of risk factors associated with pregnancy loss in slum settings can aid in public health programming and designing interventions to ensure safer pregnancy for women. Further research is required to investigate possible hidden factors affecting pregnancy loss for women with higher gravidity in the highest household wealth tertiles.

Background The burden of type 2 diabetes in Sub-Saharan Africa is projected to double by 2040, partly attributable to rapidly changing diets. In this paper, we analysed how community members in rural Uganda understood the concept of a healthy or unhealthy diet, food preparation and serving practices to inform the process of facilitating knowledge and skill necessary for self-management and care for type 2 diabetes. This was a qualitative study involving 20 focus group discussions and eight in-depth interviews among those at risk, patients with type 2 diabetes and the general community members without diabetes mellitus. Data was coded and entered into Atlas ti version 7.5.12 and interpreted using thematic analysis. We identified three main themes, which revealed, the perceptions on food and diet concerning health; the social dimensions of food and influence on diet practices; and food as a gendered activity. Participants noted that eating and cooking practices resulted in unhealthy diets. Their practices were affected by beliefs, poverty and food insecurity. Women determined which foods to prepare, but men prepared only some of the foods such as delicacies like a rice dish “pilau.” New commercial and processed foods were increasingly available and consumed even in rural areas. Participants linked signs and symptoms of illness to diet as they narrated changes from past to current food preparation behaviours. Their view of overweight and obesity was also gendered and linked to social status. Participants’ perception of disease influenced by diet was similar among those with and without type 2 diabetes, and those at risk. People described what is a healthy diet was as recommended by the health workers, but stated that their practices differed greatly from their knowledge. There was high awareness about healthy and balanced diets, but food is entrenched within social and gendered paradigms, which are slowly changing. Social and gender dimensions of food will need to be addressed through interventions in communities to promote change on a society level.

Background: Cardiovascular autonomic neuropathy (CAN) is a common complication in individuals with diabetes mellitus (DM) but often overlooked in clinical practice. The burden and correlates of CAN have not been extensively studied in low-income countries, particularly in sub-Saharan Africa. Objectives: To determine the prevalence and correlates of CAN among adults in ambulatory diabetes care in southwestern Uganda. Method: We conducted a cross-sectional study among adults with diabetes from November 2018 to April 2019. CAN was assessed using the five autonomic function tests: deep breathing, Valsalva maneuver, postural index on standing, change in blood pressure during standing and diastolic blood pressure response to isometric exercise. We estimated the prevalence of CAN and fit regression models to identify its demographic and clinical correlates. Results: We enrolled 299 individuals. The mean age was 50.1 years (SD ± 9.8), mean HbA1c was 9.7 (SD ± 2.6) and 69.6% were female. CAN was detected in 156/299 (52.2%) of the participants on the basis of one or more abnormal cardiovascular autonomic reflex tests. Out of 299 participants, 88 (29.4%) were classified as early CAN while 61/299 (20.4%) and 7/299 (2.3%) were classified as definite and severe (advanced) CAN respectively. In multivariable regression models, age over 50 years (aOR 3.48, 95%CI 1.35 –8.99, p = 0.010), duration of diabetes over 10 years (aOR 4.09, 95%CI 1.78 –9.38, p = 0.001), and presence of diabetic retinopathy (aOR 2.25, 95%CI 1.16 –4.34, p = 0.016) were correlated with CAN. Conclusions: Our findings reveal a high prevalence of CAN among individuals in routine outpatient care for diabetes mellitus in Uganda. Older age, longer duration of diabetes and coexistence of retinopathy are associated with CAN. Future work should explore the clinical significance and long term outcomes associated with CAN in this region.

Background The aim of this study was to determine the prevalence of neurological disorders and their associated correlates and relations with clinical and behavioural problems among children and adolescents with HIV/AIDS (CA-HIV). Methods This study involved a sample of 1070 CA-HIV/caregiver dyads who were evaluated at their 6-month follow-up visit as part of their participation in the longitudinal study, ‘Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)’. Participants completed an extensive battery of measures that included a standardized DSM-5- referenced rating scale, the parent version (5–18 years) of the Child and Adolescent Symptom Inventory-5 (CASI-5). Using logistic regression, we estimated the prevalence of neurological disorders and characterised their associations with negative clinical and behavioural factors. Results The overall prevalence of at least one neurological disorders was 18.5% (n = 198; 95% CI, 16.2–20.8). Enuresis / encopresis was the most common (10%), followed by motor/vocal tics (5.3%); probable epilepsy was the least prevalent (4%). Correlates associated with neurological disorders were in two domains: socio-demographic factors (age, ethnicity and staying in rural areas) and HIV-related factors (baseline viral load suppression). Enuresis/encopresis was associated with psychiatric comorbidity. Neurological disorders were associated with earlier onset of sexual intercourse (adjusted OR 4.06, 95% CI 1.26–13.1, P = 0.02). Conclusions Neurological disorders impact lives of many children and adolescents with HIV/AIDS. There is an urgent need to integrate the delivery of mental and neurological health services into routine clinical care for children and adolescents with HIV/AIDS in sub-Saharan Africa. Electronic supplementary material The online version of this article (10.1186/s12888-019-2023-9) contains supplementary material, which is available to authorized users.

This study grounded in the user centered media theory of uses and gratification; it investigated on the usage and gratification of social media among international students pursuing higher education in Turkey, through a survey conducted on a sample of international students in Istanbul City, Turkey. The study was quantitative in nature in which structured questionnaires were used to get data on a randomly selected sample. Findings indicate that 68.2% of the respondents used social media for more than twice a week to interact with peers for studying outside classroom. Likewise, social media platform commonly used included YouTube, Facebook, WhatsApp, Google group and Twitter. As a gratification, the respondents used You Tube to watch educational video clips on lectures delivered from other universities, watched Turkish videos to improve on their Turkish language skills. Facebook and Whatsapp were used for instant messaging, sharing academic information with classmates and professors. Findings indicate that using Social Media positively influenced their lifestyles and helped them to excel academically as reflected in the responses. The study therefore concludes that Social Media is an essential communication tool among international students in Turkey in supporting their higher education.

Background: We conducted unlinked cross-sectional population-based surveys in Northern Uganda before and after antiretroviral therapy (ART) provision (including Option B+ [lifelong ART for pregnant/breast-feeding women]) at a local primary care facility (Lira Kato Health Centre [HC]). Prior to decentralisation, people travelled 56-76 km round-trip for ART; we aimed to evaluate changes in uptake of HIV-testing, ART coverage and access to ART following decentralisation. Methods: A total of 2124 adults in 1351 households in two parishes closest to Lira Kato HC were interviewed using questionnaires between March and April 2013 and 2123 adults in 1229 households between January and March 2015. Results: Adults reporting HIV-testing in the last year increased from 1077/2124 (50.7%) to 1298/2123 (61.1%) between surveys (p

We investigated the prevalence, incidence and predictors of new peripheral neuropathy episodes in previously untreated, symptomatic HIV-infected Ugandan/Zimbabwean adults initiating zidovudine-based antiretroviral therapy (ART).An open-label, multicentre, randomized trial.Peripheral neuropathy was self-reported at 12-weekly clinic visits. Cox regression models (excluding participants reporting preexisting peripheral neuropathy at ART initiation), considered sex; pre-ART WHO stage, age and CD4(+) cell count; CD4(+) cell count versus no CD4(+) cell count monitoring; and time-updated CD4(+) cell count, weight and use of stavudine, isoniazid and didanosine.Four hundred and twenty-one out of 3316(13%) patients reported preexisting peripheral neuropathy at ART initiation. Median (interquartile range, IQR) follow-up in 2895 participants without preexisting peripheral neuropathy was 4.9 (4.7-5.4) years. Three hundred and fifty-four (12%) took stavudine as first-line substitution and 518 (18%) took isoniazid during follow-up. Two hundred and ninety (11%) participants developed a new peripheral neuropathy episode, an incidence of 2.12 per 100 person-years. Eighteen (0.1%) had a grade 3/4 episode. Independent predictors of peripheral neuropathy were current stavudine use [adjusted hazard ratio (a)HR 4.16 (95% confidence interval, 95% CI 3.06-5.66], current isoniazid use [aHR 1.59 (95% CI 1.02-2.47)] and current didanosine use [aHR 1.60 (95% CI 1.19-2.14)]. Higher risks were independently associated with higher pre-ART weight [aHR (per+5 kg) 1.07 (95% CI 1.01-1.13)] and older age aHR (per 10 years older) 1.29 (95% CI 1.12-1.49), but there was no significant effect of sex (P = 0.13), pre-ART CD4(+) cell count (P = 0.91) or CD4(+) cell count monitoring (P = 0.73).Current stavudine, didanosine or isoniazid use continue to increase peripheral neuropathy risks, as does older age and weight at ART initiation; however, we found no evidence of increased risk in women in contrast to previous studies. The incidence of peripheral neuropathy may now be lower in ART programmes, as stavudine and didanosine are no longer recommended. All patients receiving isoniazid, either as part of antituberculosis (TB) chemotherapy or TB-preventive therapy, should receive pyridoxine as recommended in national guidelines.

PurposeThe purpose of this article is to critically evaluate maintenance strategies and determine to what extent models from other sectors can be applied to building maintenance.Design/methodology/approachThe paper is a theoretical paper based on a number of Swedish studies, both case studies and questionnaires. From these a number of stylized facts have been identified and the purpose is to explain and draw conclusions from these.FindingsThe main finding is that there are a number of specific uncertainties that affect building maintenance planning making more detailed long‐term plans less meaningful. A new structure for maintenance is proposed focusing on long‐term strategies goals for various buildings/components and then short run adjustments when new information comes up.Research limitations/implicationsThe case for the new model needs to be strengthened by further studies, including studies from other countries.Practical implicationsMaintenance activities will be more important as the large building stock from the 1950s and 1960s needs to be renovated or demolished. A rational structure and realistic expectations concerning maintenance planning is then important.Originality/valueThe most important contribution of the article is to underline the importance of different types of uncertainty for the structure of maintenance planning for building.

In patients with sickle cell anaemia (SCA), recurrent episodes of sequestration, micro-infarction, ischaemia and necrosis within the renal cortex cause nephron damage. Micro-albuminuria results from compensatory mechanisms aimed at preserving the glomerular filtration rate.To establish the prevalence of micro-albuminuria among children with SCA and to describe associated factors.A cross-sectional study of patients aged 2-18 years with SCA was undertaken at the sickle cell clinic, Mulago Hospital, Kampala between November 2007 and April 2008. Haemoglobin was measured and urine dipstick was used to determine protein, glucose, red blood cells and nitrites, serum creatinine and albumin and urine creatinine and albumin. Binary logistic regression was performed to determine factors associated with micro-albuminuria.Of 305 children studied, 48·2% were male. The mean (SD) age of the study participants was 9·7 (4·9) years. The prevalence of micro-albuminuria (30-300 μg/mg) was 28·2% (86/305, 95% CI 23·1-33·3). Use of diclofenac (p = 0·01) and ibuprofen (p = 0·001) were found to increase the risk of micro-albuminuria only by bivariate analysis. By multivariate analysis, increasing age (p = 0·001), a higher number of blood transfusions (p = 0·001) and presence of urine nitrites (p = 0·031) were associated with a risk of micro-albuminuria, whereas high levels of haemoglobin (p = 0·018) were protective. There was no association between estimated glomerular filtration rate and micro-albuminuria.The prevalence of micro-albuminuria among children with SCA is relatively high. SCA patients over 5 years of age should be screened for micro-albuminuria. Those with lower haemoglobin levels should be monitored closely because of its association with micro-albuminuria.

The objectives of this study were to determine the epidemiology and correlates of cardiovascular disease (CVD) risk among Ugandans on first-line antiretroviral therapy (ART). We conducted a cross-sectional study at an HIV clinic in southwestern Uganda. We enrolled adult patients on non-nucleoside-based ART regimens for a minimum of 2 years. We collected anthropometric and clinical measurements, smoking history, and blood for fasting lipid profile and blood sugar (FBS). Outcomes of interest were (1) presence of metabolic syndrome (at least two of the following: FBS >100 mg/dL, blood pressure of ≥130/85 mmHg, triglycerides ≥150 mg/dL, HDL 5% 10-year CVD risk. Of the 250 participants enrolled, metabolic syndrome was detected in 145/250 (58%) of participants (62% in females and 50% in males). Forty-three participants (17%) had a Framingham risk correlating to a 5% or greater risk for CVD within 10 years (26% in males and 13% in females). In multivariate analyses, being female (AOR 3.13; 95% CI: 1.0–9.70; p = 0.04) and over 40 years of age (AOR 1.78; 95% CI: 1.00–3.17; p = 0.05) was independently associated with having metabolic syndrome. We found no independent risk factors for a Framingham risk score 10-year risk exceeding 5%, or associations between ART regimen and CVD risk profiles. We conclude that metabolic abnormalities are common among patients on first-line ART in rural Uganda, and appear to be more common in women than men.

Background Childbirth is one of the most painful experiences of a woman’s life. Authorities in the fields of obstetrics and anaesthesia encourage use of labour analgesia. Unlike in high-income countries, pain relief in labour in Africa is not a well established service, especially in the low-income countries like Uganda. Little is known about whether parturients would be amenable to labour analgesia. We sought to determine knowledge, attitudes and use of labour analgesia among women attending the antenatal clinic at Mulago National Referral Hospital. Methods Upon obtaining institutional approval, we conducted a cross-sectional descriptive study. Women were requested to complete the researcher-administered survey following informed consent. The study was conducted in the general antenatal clinic at the Mulago National Referral Hospital. Results Of 1293 participants interviewed, only 7 % of the participants had knowledge of labour analgesia. Of the multiparous mothers 87.9 % did not have labour analgesia in their previous deliveries, although 79.2 % of them had delivered in a national referral hospital. The commonest reason for refusal of labour analgesia was to experience natural childbirth. 87.7 % of the participants wanted labour analgesia for their next delivery. Conclusion There is a wide gap between the desire for labour analgesia and its availability. Obstetricians and anaesthesiologists have a role to educate the women, and to provide this much desired service.

Background Decentralization of ART services scaled up significantly with the country wide roll out of option B plus in Uganda. Little work has been undertaken to examine population level access to HIV care particularly in hard to reach areas in rural Africa. Most work on ART scale up has been done at health facility level which omits people not accessing healthcare in the community. This study describes health service usage, particularly HIV testing and care in 2/6 parishes of Lapono sub-county of northern Uganda, prior to introduction of ART services in Lira Kato Health Centre (a local lower-level health centre III), as part of ART decentralization. Methods Household and individual questionnaires were administered to household members (aged 15–59 years). Logit random effects models were used to test for differences in proportions (allowing for clustering within villages). Results 2124 adults from 1351 households were interviewed (755 [36 %] males, 1369 [64 %] females). 2051 (97 %) participants reported seeking care locally for fever, most on foot and over half at Lira Kato Health Centre. 574 (76 %) men and 1156 (84 %) women reported ever-testing for HIV (P

Background: Adherence is one of the most important determinants of viral suppression and drug resistance in HIV-infected people receiving antiretroviral therapy (ART).Methods: We examined the association between long-term mortality and poor adherence to ART in DART trial participants in Uganda and Zimbabwe randomly assigned to receive laboratory and clinical monitoring (LCM), or clinically driven monitoring (CDM). Since over 50% of all deaths in the DART trial occurred during the first year on ART, we focussed on participants continuing ART for 12 months to investigate the implications of longer-term adherence to treatment on mortality. Participants' ART adherence was assessed by pill counts and structured questionnaires at 4-weekly clinic visits. We studied the effect of recent adherence history on the risk of death at the individual level (odds ratios from dynamic logistic regression model), and on mortality at the population level (population attributable fraction based on this model). Analyses were conducted separately for both randomization groups, adjusted for relevant confounding factors. Adherence behaviour was also confounded by a partial factorial randomization comparing structured treatment interruptions (STI) with continuous ART (CT).Results: In the CDM arm a significant association was found between poor adherence to ART in the previous 3-9 months with increased mortality risk. In the LCM arm the association was not significant. The odds ratios for mortality in participants with poor adherence against those with optimal adherence was 1.30 (95% CI 0.78,2.10) in the LCM arm and 2.18 (1.47,3.22) in the CDM arm. The estimated proportions of deaths that could have been avoided with optimal adherence (population attributable fraction) in the LCM and CDM groups during the 5 years follow-up period were 16.0% (95% CI 0.7%,31.6%) and 33.1% (20.5%,44.8%), correspondingly.Conclusions: Recurrent poor adherence determined even through simple measures is associated with high mortality both at individual level as well as at the ART programme level. The number of lives saved through effective interventions to improve adherence could be considerable particularly for individuals monitored without using CD4 cell counts. The findings have important implications for clinical practice and for developing interventions to enhance adherence. © 2013 Kiwuwa-Muyingo et al. licensee BioMed Central Ltd., 0, SCOPUS: ar.j, info:eu-repo/semantics/published

Objective To study the feasibility and acceptability of using video Internet communication to teach and evaluate surgical skills in a low-resource setting. Methods This case-controlled study used video Internet communication for surgical skills teaching and evaluation. We randomized intern physicians rotating in the Obstetrics and Gynecology Department at Mulago Hospital at Makerere University in Kampala, Uganda, to the control arm (usual practice) or intervention arm (three video teaching sessions with University of California, San Francisco faculty). We made preintervention and postintervention videos of all interns tying knots using a small video camera and uploaded the files to a file hosting service that offers cloud storage. A blinded faculty member graded all of the videos. Both groups completed a survey at the end of the study. Results We randomized 18 interns with complete data for eight in the intervention group and seven in the control group. We found score improvement of 50% or more in six of eight (75%) interns in the intervention group compared with one of seven (14%) in the control group (P=.04). Scores declined in five of the seven (71%) controls but in none in the intervention group. Both intervention and control groups used attendings, colleagues, and the Internet as sources for learning about knot-tying. The control group was less likely to practice knot-tying than the intervention group. The trainees and the instructors felt this method of training was enjoyable and helpful. Conclusion Remote teaching in low-resource settings, where faculty time is limited and access to visiting faculty is sporadic, is feasible, effective, and well-accepted by both learner and teacher. Level of evidence II.

BackgroundThe Morisky Medication Adherence scale (MMAS-8) is a widely used self-reported measure of adherence to antihypertensive medications that has not been validated in hypertensive patients in sub-Saharan Africa.MethodsWe carried out a cross-sectional study to examine psychometric properties of a translated MMAS-8 (MMAS-U) in a tertiary care hypertension clinic in Uganda. We administered the MMAS-U to consecutively selected hypertensive adults and used principal factor analysis and Cronbach's alpha to determine its validity and internal consistency respectively. Then we randomly selected one-sixth of participants for a 2-week test-retest telephone interview. Lastly, we used ordinal logistic regression modeling to explore factors associated with levels of medication adherence.ResultsOf the 329 participants, 228 (69%) were females, median age of 55 years [Interquartile range (IQR) (46-66)], and median duration of hypertension of 4 years [IQR (2-8)]. The adherence levels were low (MMAS-U score ≤ 5) in 85%, moderate (MMAS-U score 6-7) in 12% and high (MMAS-U score ≥8) in 3%. The factor analysis of construct validity was good (overall Kaiser's measure of sampling adequacy for residuals of 0.72) and identified unidimensionality of MMAS-U. The internal consistency of MMAS-U was moderate (Cronbach α = 0.65), and test-retest reliability was low (weighted kappa = 0.36; 95% CI -0.01, 0.73). Age of 40 years or greater was associated with low medication adherence (p = 0.02) whereas a family member buying medication for participants (p = 0.02) and purchasing medication from a private clinic (p = 0.02) were associated with high adherence.ConclusionThe Ugandan version of the MMAS-8 (MMAS-U) is a valid and reliable measure of adherence to antihypertensive medication among Ugandan outpatients receiving care at a public tertiary facility. Though the limited supply of medication affected adherence, this easy to use tool can be adapted to assess medication adherence among adults with hypertension in Uganda.

Corporate responsibility is business’ way of adhering to the concept of sustainable development as expressed in the 1987 Brundtland Report “Our common future” (World Commission on Environment and Development [WCED], 1987). It refers to re-thinking the corporate role in society in terms of stakeholders (who businesses have a responsibility towards) and models for creating value. The traditional corporate short term objective of maximizing profit (value) is replaced by a long term perspective of creating value in a “triple bottom line” framework. The principle of the triple bottom line, as stipulated by Elkington (1998), emphasises that the economic bottom line has to be complemented with social and environmental values and challenges. Major environmental challenges that society requires businesses to address include biodiversity loss, climate change, land use, freshwater consumption, chemical pollution and ocean acidification (Rockstrom et al., 2009). The social challenges include issues related to air pollution, poverty, health and safety, equal opportunities and diversity, and skills and competence building (Visser & Tolhurst, 2010).

Background Economic theory and limited empirical data suggest that costs per unit of HIV prevention program output (unit costs) will initially decrease as small programs expand. Unit costs may then reach a nadir and start to increase if expansion continues beyond the economically optimal size. Information on the relationship between scale and unit costs is critical to project the cost of global HIV prevention efforts and to allocate prevention resources efficiently. Methods The "Prevent AIDS: Network for Cost-Effectiveness Analysis" (PANCEA) project collected 2003 and 2004 cost and output data from 206 HIV prevention programs of six types in five countries. The association between scale and efficiency for each intervention type was examined for each country. Our team characterized the direction, shape, and strength of this association by fitting bivariate regression lines to scatter plots of output levels and unit costs. We chose the regression forms with the highest explanatory power (R2). Results Efficiency increased with scale, across all countries and interventions. This association varied within intervention and within country, in terms of the range in scale and efficiency, the best fitting regression form, and the slope of the regression. The fraction of variation in efficiency explained by scale ranged from 26% – 96%. Doubling in scale resulted in reductions in unit costs averaging 34.2% (ranging from 2.4% to 58.0%). Two regression trends, in India, suggested an inflection point beyond which unit costs increased. Conclusion Unit costs decrease with scale across a wide range of service types and volumes. These country and intervention-specific findings can inform projections of the global cost of scaling up HIV prevention efforts.

The objective of this study was to determine the financial incentives that companies have to treat HIV-infected employees, in a health care services company in Kampala, Uganda.Cost-benefit analysis from the company's perspective of three interventions to treat HIV-infected employees.The costs and benefits of each intervention were compared with no intervention and with each other: cotrimoxazole prophylaxis (CTX) starting at WHO stage 2; highly active antiretroviral therapy (HAART) plus CTX starting at WHO stage 2; and a 'hybrid' strategy that begins with CTX at WHO stage 2 and later includes HAART. The 5-year health and economic outcomes were calculated using a Markov model. Inputs for disease progression rates and effects of HIV on company costs were derived from published and unpublished data and a survey administered to company officers.The analysis showed that the 'hybrid' intervention is the most cost-effective. For 100 skilled employees it would save the company 38,939 US dollars and 73 disability adjusted life-years (DALYs). For unskilled workers 'CTX' is the most cost effective and would save 16,417 US dollars and 60 DALYs. 'Hybrid' has an incremental cost-effectiveness ratio of 45 US dollars per DALY for unskilled workers whereas HAART is far less economical at an incremental cost per DALY of 4118 US dollars. For 'CTX', net savings are preserved across the full range of input values.A 'hybrid' intervention combining CTX prophylaxis followed by HAART would generate savings to a Ugandan company. Governments and other donors may find opportunities to share costs with the private sector as part of their phase-in strategy for antiretroviral therapy.

Results (Scientific Abstract)/Collaborative Partners (Programmatic Abstract): Seventy-eight percent of the sample was female with a mean age of 38 years old. Seventy-eight percent of the participants were on antiretroviral therapy (ART) at the time of the interviews. The perceived role of the FBOs was described by the following themes: 1) rare disclosure due to HIV-related stigma within the FBOs. Higher stigma was attributable to HIV-related preaching focused on abstinence and vigilance of promiscuity. PLWHA were less inclined to disclose HIV status and sought help within the organizations. 2) Insufficient support from the organizations. Regardless of HIV disclosure status, PLWHA felt the support was limited and impractical. 3) Higher social capital led to better HIV health outcomes. PLWHA engaging community-based organizations (CBO) or HIV support groups beyond the FBOs have a higher rate of disclosure and self-efficacy, as well as perceived lower stigma. Summary/Conclusion: FBOs can contribute to care of HIV by providing HIV-specific support such as stigma reduction, promoting HIV testing and ART, bridging people to HIV support groups or CBOs. Instead of providing direct HIV-related services, organizing and linking people to available community services and resources can expand its role as a valuable social capital in HIV care and treatment in resource-limited settings.

BACKGROUND: HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa. METHODS: In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per microL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second-line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per microL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1.18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779. FINDINGS: Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85-88) in the CDM group and 90% (88-91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4.9 years' follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6.94 [95% CI 6.33-7.60] vs 5.24 [4.72-5.81] per 100 person-years; absolute difference 1.70 per 100 person-years [0.87-2.54]; HR 1.31 [1.14-1.51]; p=0.0001). Differences in disease progression occurred from the third year on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1.12 [0.94-1.32]; p=0.19), with anaemia the most common (76 vs 61 cases). INTERPRETATION: ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment. FUNDING: UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories.