Slim disease: a new disease in Uganda and its association with HTLV-III infection

Pre-exposure prophylaxis (PrEP) awareness, use, and discontinuation among Lake Victoria fisherfolk in Uganda: A cross-sectional population-based study

There is limited population-level data on the pre-exposure prophylaxis (PrEP) care continuum in eastern Africa. Here, we assessed the PrEP care continuum following PrEP rollout in a Ugandan community with ~40% HIV seroprevalence. We used cross-sectional population-based data collected between September 3 and December 19, 2018 from a Lake Victoria fishing community in southern Uganda to measure levels of self-reported PrEP awareness, ever-use, and discontinuation following 2017 PrEP rollout via a U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported phased implementation program. Our analysis included HIV-seronegative persons reporting having ever received an HIV test result. We examined associations between demographic, behavioral, and health utilization factors with each outcome using age-adjusted modified Poisson regression. There were 1,401 HIV-seronegative participants, of whom 1,363 (97.3%) reported ever receiving an HIV test result. Median age was 29 years (IQR: 23-36), and 42.3% (n = 577) were women. Most (85.5%; n = 1,166/1363) participants reported PrEP awareness, but few (14.5%; n = 197/1363) reported ever using PrEP. Among 47.7% (375/786) of men and 29.3% (169/577) of women PrEP-eligible at time of survey, 18.9% (n = 71/375) and 27.8% (n = 47/169) reported ever using PrEP, respectively. Over half (52.3%, n = 103/197) of those who had ever used PrEP, self-reported current use. In this Lake Victoria fishing community, there were low levels of PrEP use despite high levels of PrEP awareness and eligibility, particularly among men. Efforts that enhance awareness of HIV risk and increase PrEP accessibility may help increase PrEP use among HIV-seronegative persons in African settings with high HIV burden.

Insights into gastrointestinal manifestation of human immunodeficiency virus: A narrative review

Human immunodeficiency virus (HIV) modifies CD4-positive cells, resulting in immunodeficiency and a wide range of gastrointestinal (GI) manifestations. The burden of HIV-related GI illnesses has significantly evolved with the widespread use of antiretroviral therapy (ART). While ART has effectively reduced the occurrence of opportunistic infections, it has led to an increase in therapy-related GI illnesses. Common esophageal conditions in HIV patients include gastroesophageal reflux disease, idiopathic esophageal ulcers, herpes simplex virus, cytomegalovirus (CMV), and candidal esophagitis. Kaposi's sarcoma, a hallmark of acquired immunodeficiency syndrome, may affect the entire GI system. Gastritis and peptic ulcer disease are also frequently seen in patients with HIV. Diarrhea, often linked to both opportunistic infections and ART, requires careful evaluation. Bloody diarrhea, often a sign of colitis caused by bacterial infections such as Shigella or Clostridium difficile, is prevalent. Small bowel lymphoma, although rare, is increasing in prevalence. Anorectal disorders, including proctitis, fissures, and anal squamous cell carcinoma, are particularly relevant in homosexual men, underlining the importance of timely diagnosis. This review comprehensively explores the epidemiology, pathogenesis, and treatment considerations for the various GI disorders associated with HIV, highlighting the importance of accurate diagnosis and effective treatment to improve outcomes for HIV-infected patients.

Prevalence and factors associated with the Minimum Dietary Diversity among HIV-positive women receiving Antiretroviral Therapy in Kabale district, Uganda

BACKGROUND

Malnutrition and HIV form a vicious cycle and women are at an increased risk of malnutrition from HIV. The Food and Agriculture Organization (FAO) recommends a minimum dietary diversity for women (MDD-W) of five food groups; however, paucity of information exists about the diet quality of this population in Uganda. The present study aimed to determine the prevalence and factors associated with the MDD among HIV positive women of reproductive age (15-49 years) receiving antiretroviral therapy in Kabale district, Uganda.

METHODS

This was a cross-sectional study. Probability proportional to size sampling was applied to select the number of participants per clinic and respondents were sampled systematically on a particular day in each clinic. A structured questionnaire was used to collect data on the respondent characteristics and the FAO's Individual Dietary Diversity questionnaire was used to collect the 24-hour dietary intake. Data were analysed using appropriate software. Descriptive statistics were applied for univariate analysis. Modified Poisson was used to determine the factors associated with MDD. The study was approved by the Makerere University School of Public Health Institutional Review Board and informed consent was obtained from the respondents.

RESULTS

Some 90.9% of the respondents were Bakiga, mean age was 34.8 ± 8.1 years, 47.6% were married and 98.0% came from nuclear families with 4.4 ± 1.9 members. The mean number of food groups consumed was 4.7 ± 1.7 with roots and tubers, pulses, and dark leafy and vitamin A vegetables, whereas milk and eggs were mostly consumed and fruits were least consumed. The prevalence of the MDD-W was 48.2%. Factors associated with MDD score at multivariate level included; age, type of employment, having nausea, viral load status and HIV clinical stage.

CONCLUSIONS

Almost one half of the HIV positive women on antiretroviral therapy in the district achieve the MDD-W, attributed to being middle aged, being casual employment and having an unsuppressed viral load.

TAT38 and TAT38 mimics potently inhibit adipogenesis by repressing C/EBPα, PPARγ, Pi-PPARγ, and SREBP1 expression

Antiretroviral therapy-naive people living with HIV possess less fat than people without HIV. Previously, we found that HIV-1 transactivator of transcription (TAT) decreases fat in ob/ob mice. The TAT38 (a.a. 20-57) is important in the inhibition of adipogenesis and contains three functional domains: Cys-ZF domain (a.a. 20-35 TACTNCYCAKCCFQVC), core-domain (a.a. 36-46, FITKALGISYG), and protein transduction domain (PTD)(a.a. 47-57, RAKRRQRRR). Interestingly, the TAT38 region interacts with the Cyclin T1 of the P-TEFb complex, of which expression increases during adipogenesis. The X-ray crystallographic structure of the complex showed that the Cys-ZF and the core domain bind to the Cyclin T1 via hydrophobic interactions. To prepare TAT38 mimics with structural and functional similarities to TAT38, we replaced the core domain with a hydrophobic aliphatic amino acid (from carbon numbers 5 to 8). The TAT38 mimics with 6-hexanoic amino acid (TAT38 Ahx (C6)) and 7-heptanoic amino acid (TAT38 Ahp (C7)) inhibited adipogenesis of 3T3-L1 potently, reduced cellular triglyceride content, and decreased body weight of diet-induced obese (DIO) mice by 10.4-11 % in two weeks. The TAT38 and the TAT38 mimics potently repressed the adipogenic transcription factors genes, C/EBPα, PPARγ, and SREBP1. Also, they inhibit the phosphorylation of PPARγ. The TAT peptides may be promising candidates for development into a drug against obesity or diabetes.

Between a Rock and a Hard Place: "I Decided to Keep Quiet": A Qualitative Inquiry Into the Coping Experiences of Young People (15-24) Working at High-Risk Venues for HIV in Uganda

Employment linked with social venues has long been described as permissive environments for excessive drinking, disruptive/aggressive behaviors, and overt sexual behaviors, which are known risk factors for HIV. Yet, our understanding of the extent to which workers in such high-risk work settings cope with the various risks therein is still limited. This study explored the coping strategies employed by workers at social venues. We interviewed 47 workers at 22 social venues through small group discussions (15) and in-depth interviews (10) in 2021 in Rakai district, Uganda. All discussions were audiorecorded and transcribed verbatim before analysis. Data were analyzed using thematic content analysis. We found two main categories of coping strategies used by workers: acceptance of sexual risks and keeping safe. Acceptance of risks such as transactional sex was the most used strategy, hence highlighting negative coping. This calls for interventions for improving workers' coping efficiency and adjustment as well as interventions ameliorating the conditions underpinning increased risk of HIV at the venues.

Correlates of intention to screen for cervical cancer among adult women in Kyotera District, Central Uganda: a community based cross-sectional study

INTRODUCTION

Cervical cancer continues to pose a major public health challenge in low-income countries. Cervical cancer screening programs enable early detection and effectively reduce the incidence of cervical cancer as well as late-stage diagnosis and mortality. However, screening uptake remains suboptimal in Uganda. This study assessed correlates of intention to screen for cervical cancer among women in the Kyotera district of Central Uganda.

METHODS

We analyzed cross-sectional data collected to determine the effectiveness of community audio towers (CATs) as a modality of health communication to support cervical cancer prevention. Women (n = 430) aged 21-60 years without a prior history of cervical cancer screening were surveyed about demographics, sources of health information and cervical cancer screening intentions in 2020. We used generalized linear modelling with modified Poisson regression and backwards variable elimination to identify adjusted prevalence ratios and 95% confidence intervals (CI) to determine factors associated with intention to screen for cervical cancer.

RESULTS

Half (50.2%) of the participants had intentions to screen for cervical cancer within twelve months and 26.5% had moderate knowledge about cervical cancer. Nearly half (46.0%) considered themselves at risk of cervical cancer. Compared to residents who primarily received their health information from social media and radio, participants who received health information primarily from CATs (aPR:0.64, 95% CI:0.52-0.80, p < 0.001) and TV (aPR:0.52, 95% CI:0.34-0.82, p = 0.005) had a lower prevalence of intention to screen for cervical cancer. The prevalence of intentions to screen for cervical cancer in twelve months was higher among those resided in town councils (aPR:1.44, 95% CI:1.12-1.86, p = 0.004) compared to rural areas, and higher among those who considered themselves to be at risk of cervical cancer (aPR:1.74, 95% CI:1.28-2.36, p < 0.001) compared to those who did not.

CONCLUSIONS

We found suboptimal prevalence of intentions to screen for cervical cancer among women in central Uganda. Additional research and implementation projects are needed to increase cervical cancer screening. Targeting risk perceptions and behavioral approaches to increase intentions could be effective in future intervention work. Based on urban-rural differences, additional work is needed to support equitable sharing of information to support cancer prevention messaging; CATs and TV may best help reach those with lower intentions to screen based on our research.

Pre-exposure prophylaxis (PrEP) knowledge, use, and discontinuation among Lake Victoria fisherfolk in Uganda: a cross-sectional population-based study

Background

There are limited population-level data on the pre-exposure prophylaxis (PrEP) care continuum in eastern Africa. Here, we assessed the PrEP care continuum following PrEP rollout in a Ugandan community with ~40% HIV seroprevalence.

Methods

We used cross-sectional population-based data collected between September 3 and December 19, 2018 from a Lake Victoria fishing community in southern Uganda to measure levels of self-reported PrEP knowledge, ever use, and discontinuation following 2017 PrEP rollout via a U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported phased implementation program. Our analysis included HIV-seronegative persons reporting having ever received an HIV test result. We examined associations between demographic, behavioral, and health utilization factors with each outcome using age-adjusted modified Poisson regression.

Results

There were 1,401 HIV-seronegative participants, of whom 1,363 (97.3%) reported ever receiving an HIV test result. Median age was 29 years (IQR: 23-36), and 42.3% (n=577) were women. Most (85.5%; n=1,166) participants reported PrEP knowledge, but few (14.5%; n=197) reported ever using PrEP. Among 375 (47.7%) men and 169 (29.3%) women PrEP-eligible at time of survey, 18.9% (n=71) and 27.8% (n=47) reported ever using PrEP, respectively. Over half (52.3%, n=103) of those who had ever used PrEP, self-reported current use.

Conclusion

In this Lake Victoria fishing community, there were low levels of PrEP use despite high levels of PrEP awareness and eligibility, particularly among men. Efforts that enhance awareness of HIV risk and increase PrEP accessibility may help increase PrEP use among HIV-seronegative persons in African settings with high HIV burden.

HIV enteropathy and 'Slim disease': Historical and current perspectives

OBJECTIVES

Chronic diarrhoea and severe wasting associated with HIV infection were first described in East African patients as slim disease (SD) in 1985. The main histological features are flattening of the villi (villous atrophy) and crypt hyperplasia (elongated crypts), i.e., HIV enteropathy (HIVE). Selective loss of mucosal clusters of differentiation 4 (CD4)+ T helper (Th)17+ lymphocytes is the immunological hallmark of HIVE. This review explores (i) the historical background of HIVE and SD, (ii) the relationship between gut mucosal CD4+ Th17+ and intestinal-resident intra-epithelial gamma delta (IRIE) T lymphocytes in pathogenesis of HIVE, (iii) the role of cytokines in regulation of intestinal epithelial proliferation, and (iv) the role of antiretroviral therapy in HIVE.

METHODS

Recent studies have highlighted the role of IRIE T lymphocytes, mostly CD8+, in regulating gut epithelial regeneration. CD4+Th17+ and IRIE T cells are necessary to maintain intestinal barrier integrity and mucosal antimicrobial immune defence. However, the immunological cross-talk between such lymphocyte sub-sets culminating in HIVE is uncertain. We undertook a narrative literature review under the headings 'HIVE', 'SD', and 'Highly active antiretroviral therapy (HAART). Relevant studies were located using the electronic search engines Google Scholar and PubMed from 1984 to 2022.

RESULTS

Depletion of Th17+ cells in the lamina propria, attributed to low-level viraemia, is accompanied by concomitant increase in the density of gut mucosal IRIE T lymphocytes in AIDS. The latter express a broad range of cytokines (interferon-gamma, tumor necrosis factor-alpha, interleukin-17) and chemokines e.g., keratinocyte growth factor, post exposure to HIV-infected cells. Keratinocyte growth factor induces epithelial proliferation mainly in the crypts, leading to functional immaturity of enterocytes, reduced gut absorptive surface area and malabsorption in animal experiments. Of note, the absence of IRIE T cells is associated with a reduction in epithelial cell turnover. Patients with HIVE receiving early HAART show enhanced expression of mucosal repair genes and improvement of gut symptoms.

CONCLUSION

Multiple lines of enquiry suggest HIVE is directly related to HIV infection and is a consequence of perturbations in mucosal CD4+Th17+ and IRIE T lymphocytes. The pathological result is enterocyte immaturity and dysfunction. SD whose main features are malabsorption, diarrhoea and weight loss, is a severe clinical expression of HIVE. A better understanding of immuno-pathogenesis of HIVE opens a window of opportunity for the potential use of immunotherapy in HIV disease and other T cell-mediated enteropathies.

Longitudinal population-level HIV epidemiologic and genomic surveillance highlights growing gender disparity of HIV transmission in Uganda

HIV incidence in eastern and southern Africa has historically been concentrated among girls and women aged 15-24 years. As new cases decline with HIV interventions, population-level infection dynamics may shift by age and gender. Here, we integrated population-based surveillance of 38,749 participants in the Rakai Community Cohort Study and longitudinal deep sequence viral phylogenetics to assess how HIV incidence and population groups driving transmission have changed from 2003 to 2018 in Uganda. We observed 1,117 individuals in the incidence cohort and 1,978 individuals in the transmission cohort. HIV viral suppression increased more rapidly in women than men, however incidence declined more slowly in women than men. We found that age-specific transmission flows shifted, while HIV transmission to girls and women (aged 15-24 years) from older men declined by about one third, transmission to women (aged 25-34 years) from men that were 0-6 years older increased by half in 2003 to 2018. Based on changes in transmission flows, we estimated that closing the gender gap in viral suppression could have reduced HIV incidence in women by half in 2018. This study suggests that HIV programs to increase HIV suppression in men are critical to reduce incidence in women, close gender gaps in infection burden and improve men's health in Africa.

Age Patterns of HSV-2 Incidence and Prevalence in Two Ugandan Communities: A Catalytic Incidence Model Applied to Population-Based Seroprevalence Data

BACKGROUND

Herpes simplex virus type 2 (HSV-2) is an incurable sexually transmitted infection associated with increased risk of acquiring and transmitting human immunodeficiency virus (HIV). HSV-2 is highly prevalent in sub-Saharan Africa, but population-level estimates of incidence are sparse.

METHODS

We measured HSV-2 prevalence from cross-sectional serological data among adults aged 18-49 years in 2 south-central Uganda communities (fishing, inland). We identified risk factors for seropositivity, then inferred age patterns of HSV-2 with a Bayesian catalytic model.

RESULTS

HSV-2 prevalence was 53.6% (n = 975/1819; 95% confidence interval, 51.3%-55.9%). Prevalence increased with age, was higher in the fishing community, and among women, reaching 93.6% (95% credible interval, 90.2%-96.6%) by age 49 years. Factors associated with HSV-2 seropositivity included more lifetime sexual partners, HIV positive status, and lower education. HSV-2 incidence peakied at age 18 years for women and 19-20 years for men. HIV prevalence was up to 10-fold higher in HSV-2-positive individuals.

CONCLUSIONS

HSV-2 prevalence and incidence were extremely high, with most infections occurring in late adolescence. Interventions against HSV-2, such as future vaccines or therapeutics, must target young populations. Remarkably higher HIV prevalence among HSV-2-positive individuals underscores this population as a priority for HIV prevention.

'Mummy told me that I have HIV, that is the only thing she told me': Experiences of HIV status disclosure to children in Masaka Region, Uganda

BACKGROUND

In sub-Saharan Africa (SSA), disclosure of HIV status to children remains low. Few studies have examined how children navigate and come to terms with their HIV status. The aim of this study was to explore experiences of children about disclosure of their HIV status.

METHODS

Between October 2020 and July 2021, 18 purposively selected children aged between 12-17 whose HIV status had been disclosed to them by their caregivers or healthcare providers (HCPs) were recruited for this study. We conducted 18 in-depth interviews (IDIs) to collect data for this study. Data were analyzed using the semantic thematic analysis approach.

RESULTS

Primary data obtained through IDIs revealed that disclosure of HIV status to children occurred as a one-time event without pre-disclosure preparatory planning or focused post disclosure follow-up counseling irrespective of the discloser. Post disclosure psycho-social experiences elicited mixed responses. Some children experienced insults and belittlement and stigma and discrimination in the family and community for out-of-school children and at school for school-going children. Positive disclosure experiences involved receiving support to improve ART adherence through constantly being reminded to take their medications timely at the workplace, by supervisors, for working children and by teachers, at school for school-going children.

CONCLUSIONS

This research contributes to knowledge about children' s experiences of being HIV infected and can specifically be used to improve disclosure strategies.

Scale-Up of HIV Antiretroviral Therapy and Estimation of Averted Infections and HIV-Related Deaths - Uganda, 2004-2022

On January 28, 2003, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to address a single disease in history, was announced.* In April 2004, the first person in the world to receive PEPFAR-supported antiretroviral therapy (ART) was a man aged 34 years in Uganda. Effective ART reduces morbidity and mortality among persons with HIV infection (1) and prevents both mother-to-child transmission (MTCT) (2) and sexual transmission once viral load is suppressed to undetectable levels (<200 viral copies/mL) (3). By September 2022, more than 1.3 million persons with HIV infection in Uganda were receiving PEPFAR-supported ART, an increase of approximately 5,000% from September 2004. As indicators of the ART program's effectiveness, a proxy MTCT rate decreased 77%, from 6.4% in 2010 to 1.5% in 2022, and the viral load suppression rate (<1,000 viral copies/mL) increased 3%, from 91% in 2016 to 94% in September 2022. During 2004-2022, ART scale-up helped avert nearly 500,000 HIV infections, including more than 230,000 infections among HIV-exposed infants, and approximately 600,000 HIV-related deaths. Going forward, efforts will focus on identifying all persons with HIV infection and rapidly linking them to effective ART. PEPFAR remains committed to continued strong partnership with the Government of Uganda, civil society, and other development partners toward sustainable solutions aligned with the Joint United Nations Programme on HIV/AIDS (UNAIDS) fast-track strategy to ending the global AIDS epidemic by 2030^† and safeguarding impact achieved in the long term.

Socio-Cultural Influencers of Disclosure of HIV Status to Children on Antiretroviral Therapy in the Masaka Region, Uganda: A Qualitative Study

This study explored sociocultural influencers of disclosure of HIV status to children taking daily antiretroviral therapy (ART) in the Masaka region, Uganda using data collected from 26 key informant interviews with caregivers between October 2020 and July 2021. The findings revealed both positive and negative sociocultural influencers of disclosure. Beliefs that disclosure cultivates responsibility in the child to improve ART adherence and the culture of routine sexual health education conversations with children were positive socio-cultural influencers. Beliefs that disclosure increases children's loss of hope in life and breaks confidentiality with children inadvertently disclosing their HIV status to others leading to discrimination and social rejection, were key negative sociocultural influencers. These findings suggest a need for socio-culturally informed interventions that target caregiver negative socio-cultural disclosure influencers in this setting through contextualized sensitization and training to prepare children taking daily ART to receive disclosure progressively.

Rethinking our Rigor Mortis: Creating space for more adaptive and inclusive truth-seeking in community-based global health research in Kenya

As global health researchers, we have long embraced the conviction that the answers to complex problems of poverty and disease will reveal themselves if only we apply enough scientific rigor. Yet, at the community level, our group of American and Kenyan investigators has begun to question whether our veneration of rigor is itself contributing to the intractability of certain types of global health problems. Here, we illustrate examples from our experience among the remote island communities of Lake Victoria, Kenya, and join a chorus of emerging voices, to examine how our culture of control as global health scientists may marginalise truth-seekers and change-makers within communities we seek to serve. More broadly, we seek to acknowledge the limitations of control over truth that rigorous academic research affords. We suggest that by relinquishing this pervasive illusion of control, we can more fully appreciate complementary modes of answering important questions that rely upon the intrinsic resourcefulness and creativity of community-based enterprises taking place across sub-Saharan Africa. While such inquiries may never solve all problems facing the diverse populations of the continent, we advocate for a deeper appreciation of the inherent capacity of adaptive, locally contextualised investigations to identify meaningful and enduring solutions.

HIV status disclosure and antiretroviral therapy adherence among children in Masaka region, Uganda

HIV-infected children are now living into adolescence and early adulthood in large numbers due to the availability and increased use of antiretroviral therapy (ART). However, receipt of HIV status disclosure among children remains low. We assessed the association between disclosure of HIV status and adherence to ART among children in the Masaka region of Uganda using multivariable logistic regression with generalised linear models with Poisson log-link function and robust variance in Stata software version 15.1. Data were collected from 524 assenting children aged 12-17 years between March and December 2020. Results show that, although not statistically significant, children who received disclosure of their HIV status reported improved ART adherence compared to children with no disclosure. Out-of-school children with post-primary education and children on first-line ART regimens were significantly more likely to report improved ART in both crude and adjusted analyses. Innovative interventions to promote progressive disclosure of HIV status to children on ART, in school, are needed to improve their ART adherence. There is also a need to evaluate the suitability of current counselling interventions provided to children being switched to second-line ART regimens to delay the need for third-line ART regimens.

Prevalence of overweight and obesity and associated factors among people living with HIV attending a tertiary care clinic in Uganda

Background:

Overweight and obesity are significantly increasing among people living with HIV (PLWH), contributing to the risk of major adverse cardio-metabolic events. However, little is known on its prevalence among PLWH in sub-Saharan Africa. In this study, we report the prevalence and factors associated with overweight and obesity among PLWH in a large tertiary HIV clinic in Kampala, Uganda.

Methods:

A cross-sectional, retrospective review of electronic database of all PLWH that attended the Adult Infectious Diseases Institute clinic between November 2018 and April 2019 was conducted. Demographic, body mass index (BMI) [kg/m²] and clinical variables were extracted. Based on BMI, nutritional status was classified as undernutrition (< 18.5kg/m²), normal (≥ 18.5 < 25kg/m²), overweight (≥ 25 < 30kg/m²) and obesity (≥ 30kg/m²). Poisson regression analysis was performed to determine factors associated with overweight and obesity.

Results:

Overall, 7,818 participants were included in the analysis, 64% (n = 4,976) were female, with a median age of 44 years (interquartile range (IQR): 36–51) and a median BMI of 24.2 (IQR: 21.2–28.1). The prevalence of overweight and obesity combined was 46% (55% female versus 30% male), obesity 18.2% (24.6% female versus 7.1% male) and overweight 27.8% (30.4% female versus 22.9% male). Factors associated with overweight and obesity were: Females (adjusted prevalence ratio [aPR]: 1. 8, 95%CI:1.69–1.87), age category 25—59 years (aPR: 1.9, 95%CI: 1.63–2.24) and ≥ 60 years (aPR: 1.8, 95%CI:1.49–2.12); duration on antiretroviral therapy (ART) for 6—10 years (aPR: 1.1, 95%CI:1.08–1.18), CD4 count 200–500 (aPR:0.08, 95%CI:0.01–0.15) and > 500 (aPR:0.46, 95%CI:0.39–0.54) and having at least one noncommunicable disease (NCD) (aPR: 1.1, 95%CI:1.07–1.18).

Conclusion

There is a high burden of overweight and obesity among PLWH in Uganda. Nutrition and weight management programs particularly targeting high risk groups such as females and persons with underlying NCDs should be integrated into HIV care.

Predictors of mortality among people living with HIV in the test and treat era within rural Uganda: a retrospective cohort study

Background: Uganda adopted the test and treat strategy in 2016 where all people living with HIV are initiated on antiretroviral drugs irrespective of CD4 count and WHO clinical stage, as one of the major strategies to end the HIV epidemic by 2030. Despite these measures, there are still more than 2 000 HIV-related death annually. The study aim was to determine the mortality rate and factors predictive of mortality in the test and treat era among people living with HIV in rural Uganda.Methods: We conducted a retrospective cohort study among people living with HIV enrolled into care between January 2016 and December 2020 at Kabwohe Clinical Research Centre in south-western Uganda. Kaplan-Meier curves were used for survival analysis and Cox regression analysis at bivariate and multivariable levels was used to determine the adjusted hazard ratios (AHR) and identify predictors of death during the study period.Results: Of the 976 participants included in the study, 57.1% (557) were females while 42.9% (419) were males. The median age of the participants was 35 years. The average follow-up period was 2.9 years with an overall mortality rate of 0.99 per 100 person-years at risk. In multivariate analysis, the independent predictors for mortality were: CD4 < 200cells/mm³ (AHR 3.68; 95% CI 1.7-8.1), viral load ≥ 1 000 copies/ml (AHR 5.22; 95% CI 2.4-11.4) and a non-optimised antiretroviral regimen (AHR 4.08; 95% CI 1.5-0.8).Conclusion: There was a low mortality rate observed in this study with a higher risk of death associated with advanced HIV disease and unsuppressed initial viral load. The findings of the study therefore support efforts in early antiretroviral therapy initiation as it increases the likelihood of people living with HIV surviving and can accelerate efforts in ending the HIV epidemic by 2030.

Debating Sex and Sovereignty: Uganda's New National Sexuality Education Policy

Introduction

This article examines recent moral panics over sex education in Uganda from historical perspectives. Public outcry over comprehensive sexuality education erupted in 2016 over claims that children were being taught "homosexuality" by international NGOs. Subsequent debates over sex education revolved around defending what public figures claimed were national, religious, and cultural values from foreign infiltration.

Methods

This paper is grounded in a survey of Uganda's two English-print national newspapers (2016-2018), archival research of newspapers held at Uganda's Vision Group media company (1985-2005), analyses of public rhetoric as reported in nationally circulating media, textual analysis of Uganda's National Sexuality Education Framework (2018), formal interviews with Ugandan NGO officers (3), and semi-structured interviews with Ugandan educators (3).

Results

Uganda's current panic over sex education reignited longstanding anxieties over foreign interventions into the sexual health and rights of Ugandans. We argue that in the wake of a 35-year battle with HIV/AIDS and more recent controversies over LGBT rights, both of which brought international donor resources and governance, the issue of where and how to teach young people about sex became a new battleground over the state's authority to govern the health and economic prosperity of its citizens.

Conclusions

Ethno- and religio-nationalist rhetoric used to oppose the state's new sexuality education policy was also used to justify sex education as a tool for economic development.

Policy Implications

Analyzing rhetoric mobilized by both supporters and detractors of sex education reveals the contested political terrain policy advocates must navigate in Uganda and other postcolonial contexts.

HIV / AIDS as a model for emerging infectious disease: origin, dating and circumstances of an emblematic epidemiological success

In June 1981, the Centers for Disease Control (CDC) "Morbidity and Mortality Weekly Report" described the first cases of what was to be known as the Acquired Immunodeficiency Syndrome (AIDS). Two years later, the agent responsible for the disease, the human immunodeficiency virus (HIV), was identified. Since then, according to the World Health Organization an estimated 40 million people have died from the disease. Where does this virus come from, and why such an emergence in the late 20^th century? These are the questions that it is now possible to answer in large part thanks to the numerous studies published over a little more than three decades. As with other emerging infectious diseases, initial cross-species transmission from an animal reservoir and subsequent favorable sociological factors associated with the evolution of human societies have led to the spread of a dramatic disease, for which no vaccine is presently available.

When Coffee Collapsed: An Economic History of HIV in Uganda

In some Ugandan fishing communities, almost half the population lives with HIV. Researchers designate these communities "HIV hotspots" and attribute disproportionate disease burdens to "sex-for-fish" relationships endemic to the lakeshores. In this article, we trace the emergence of Uganda's HIV hotspots to structural adjustment. We show how global economic policies negotiated in the 1990s precipitated the collapse of Uganda's coffee sector, causing mass economic dislocation among women workers, who migrated to the lake. There, they entered overt forms of sex work or marriages they may have otherwise avoided, intimate economic arrangements that helped to "engineer the spread of HIV," as one respondent recounted.

Bioinformatics mentorship in a resource limited setting

BACKGROUND

The two recent simultaneous developments of high-throughput sequencing and increased computational power have brought bioinformatics to the forefront as an important tool for effective and efficient biomedical research. Consequently, there have been multiple approaches to developing bioinformatics skills. In resource rich environments, it has been possible to develop and implement formal fully accredited graduate degree training programs in bioinformatics. In resource limited settings with a paucity of expert bioinformaticians, infrastructure and financial resources, the task has been approached by delivering short courses on bioinformatics-lasting only a few days to a couple of weeks. Alternatively, courses are offered online, usually over a period of a few months. These approaches are limited by both the lack of sustained in-person trainer-trainee interactions, which is a key part of quality mentorships and short durations which constrain the amount of learning that can be achieved.

METHODS

Here, we pioneered and tested a bioinformatics training/mentorship model that effectively uses the available expertise and computational infrastructure to deliver an in-person hands-on skills training experience. This is done through a few physical lecture hours each week, guided personal coursework over the rest of the week, group discussions and continuous close mentorship and assessment of trainees over a period of 1 year.

RESULTS

This model has now completed its third iteration at Makerere University and has successfully mentored trainees, who have progressed to a variety of viable career paths.

CONCLUSIONS

One-year (intermediate) skills based in-person bioinformatics training and mentorships are viable, effective and particularly appropriate for resource limited settings.

Development and external validation of a risk calculator to predict internalising symptoms among Ugandan youths affected by HIV

The aim of the study was to develop and externally validate a model to predict individualized risk of internalizing symptoms among AIDS-affected youths in low-resource settings in sub-Saharan Africa. Longitudinal data from 558 Ugandan adolescents orphaned by AIDS was used to develop our predictive model. Least Absolute Shrinkage and Selection Operator logistic regression was used to select the best subset of predictors using 10-fold cross-validation. External validation of the final model was conducted in a sample of 372 adolescents living with HIV in Uganda. Best predictors for internalizing symptoms were gender, family cohesion, social support, asset ownership, recent sexually transmitted infection (STI) diagnosis, physical health self-rating, and previous poor mental health; area under the curve (AUC)  = 72.2; 95% CI  = 67.9-76.5. For adolescents without history of internalizing symptoms, the AUC = 69.0, 95% CI = 63.4-74.6, and was best predicted by gender, drug use, social support, asset ownership, recent STI diagnosis, and physical health self-rating. Both models were well calibrated. External validation in adolescents living with HIV sample was similar, AUC = 69.7; 95% CI = 64.1-75.2. The model predicted internalizing symptoms among African AIDS-affected youth reasonably well and showed good generalizability. The model offers opportunities for the design of public health interventions addressing poor mental health among youth affected by HIV/AIDS.

HIV epidemic in fishing communities in Uganda: A scoping review

BACKGROUND

Fishing communities in many Sub-Saharan African countries are a high-risk population group disproportionately affected by the HIV epidemic. In Uganda, literature on HIV in fishing communities has grown extensively since the first country's documented case of HIV in a fishing community in 1985. The current study describes the status of the HIV burden, prevention, and treatment in Ugandan fishing communities.

METHOD

This scoping review was conducted based on the York Framework outlined by Arksey and O'Malley. We searched the PubMed, Embase, and Web of Science databases to identify relevant quantitative and qualitative studies on HIV incidence, HIV prevalence, HIV-related risk factors, HIV testing, antiretroviral therapy coverage and adherence, and interventions to improve treatment outcomes and reduce HIV risk factors.

RESULTS & CONCLUSION

We identified 52 papers and 2 reports. Thirty-four were quantitative, 17 qualitative, and 3 had a mixed-methods design. Eleven studies reported on the prevalence of HIV and 8 on HIV incidence; 9 studies documented factors associated with HIV incidence or HIV positive status; 10 studies reported on HIV testing coverage and/or associated factors; 7 reported on antiretroviral therapy coverage/adherence/outcomes; and 1 study reported on the impact of combination HIV interventions in fishing communities. This scoping review revealed a significant lack of evidence in terms of what works in HIV prevention and for improving adherence to ART, in contrast to the relatively large amount of evidence from observational quantitative and qualitative studies on HIV prevalence, incidence and related risk factors in Ugandan fishing communities. Intervention studies are urgently needed to fill the current evidence gaps in HIV prevention and ART adherence.

Alcohol use, intimate partner violence, and HIV sexual risk behavior among young people in fishing communities of Lake Victoria, Uganda

BACKGROUND

Few studies have investigated the association between alcohol use, intimate partner violence, and HIV sexual risk behavior among young people in fishing communities from eastern and central Uganda. Therefore, we aimed to determine the association between alcohol use, intimate partner violence, and HIV sexual risk behavior among young people in the fishing communities on the shores of Lake Victoria, in Uganda.

METHODS

We conducted multivariable logistic regression analyses of HIV risk behavior using cross-sectional data from 501 young people from Mukono (Katosi landing site) and Namayingo districts (Lugala landing site).

RESULTS

Almost all (97%) respondents reported at least one HIV risk behavior; more than half (54%) reported engagement in three or more HIV risk behaviors. Results from the adjusted model indicate that alcohol use, working for cash or kind, being married, and having multiple sexual partners increased the odds of HIV risk behavior. IPV was not associated with HIV risk behavior.

CONCLUSION

Interventions to promote consistent condom use and fewer sexual partnerships are critical for young people in the fishing communities in Uganda.

Feasibility and acceptability of a pilot, peer-led HIV self-testing intervention in a hyperendemic fishing community in rural Uganda

Background

Novel interventions are needed to reach young people and adult men with HIV services given the low HIV testing rates in these population sub-groups. We assessed the feasibility and acceptability of a peer-led oral HIV self-testing (HIVST) intervention in Kasensero, a hyperendemic fishing community (HIV prevalence: 37–41%) in Rakai, Uganda.

Methods

This study was conducted among young people (15–24 years) and adult men (25+ years) between May and August 2019. The study entailed distribution of HIVST kits by trained “peer-leaders,” who were selected from existing social networks and trained in HIVST distribution processes. Peer-leaders received up to 10 kits to distribute to eligible social network members (i.e. aged 15–24 years if young people or 25+ years if adult man, not tested in the past 3 months, and HIV-negative or of unknown HIV status at enrolment). The intervention was evaluated against the feasibility benchmark of 70% of peer-leaders distributing up to 70% of the kits that they received; and the acceptability benchmark of >80% of the respondents self-testing for HIV.

Results

Of 298 enrolled into the study at baseline, 56.4% (n = 168) were young people (15–24 years) and 43.6% (n = 130) were adult males (25+ years). Peer-leaders received 298 kits and distributed 296 (99.3%) kits to their social network members. Of the 282 interviewed at follow-up, 98.2% (n = 277) reported that they used the HIVST kits. HIV prevalence was 7.4% (n = 21). Of the 57.1% (n = 12) first-time HIV-positives, 100% sought confirmatory HIV testing and nine of the ten (90%) respondents who were confirmed as HIV-positive were linked to HIV care within 1 week of HIV diagnosis.

Conclusion

Our findings show that a social network-based, peer-led HIVST intervention in a hyperendemic fishing community is highly feasible and acceptable, and achieves high linkage to HIV care among newly diagnosed HIV-positive individuals.

Recombination Analysis of Near Full-Length HIV-1 Sequences and the Identification of a Potential New Circulating Recombinant Form from Rakai, Uganda

The Phylogenetics And Networks for Generalized HIV Epidemics in Africa (PANGEA-HIV) consortium has been vital in the generation and examination of near full-length HIV-1 sequences generated from Sub-Saharan Africa. In this study, we examined a subset (n = 275) of sequences from Rakai, Uganda, collected between August 2011 and January 2015. Sequences were initially screened with COMET for subtyping and then evaluated using bootscanning and phylogenetic inference. Among 275 sequences, 38.6% were subtype D, 19.3% were subtype A, 2.9% were subtype C, and 39.3% were recombinant. The recombinants were structurally diverse in the number of breakpoints observed, the location of recombinant segments, and represented subtypes, with AD recombinants accounting for the majority of all recombinants (29.8%). Within the AD subpopulation, we identified a potential new circulating recombinant form in five individuals where the polymerase gene was subtype D and most of env was subtype A (D-A junctures at HXB2 6760 and 8709). While the breakpoints were identical for the viruses from these individuals, the viral fragments did not cluster together. These results suggest selection for a viral strain where properties of the subtype A and subtype D portions of the virus confer a survival advantage. The continued study of recombinants will increase our breadth of knowledge for the genetic diversity and evolution of HIV-1, which can further contribute to our understanding toward a universal HIV-1 vaccine.

HIV infection, and overweight and hypertension: a cross-sectional study of HIV-infected adults in Western Kenya

Background

Non-communicable diseases (NCDs) are increasing in Kenya, where HIV/AIDS remains a leading cause of death; however, few studies have investigated obesity and hypertension among adults with HIV infection. We conducted a cross-sectional study in Homa Bay, Western Kenya, during 2015 to determine the prevalence of overweight/obesity and hypertension among HIV-infected adults and to identify their risk factors.

Results

Anthropometric measurements and a structured questionnaire were administered to adults with HIV infection receiving care at Mbita Sub-county Hospital. A total of 251 HIV-positive individuals were enrolled. More women were overweight (17.2%) and obese (3.6%) than underweight (8.3%). The prevalence of abdominal obesity was high in women (62.7%), especially those aged 30–39 years. The prevalence of hypertension was 9.8% and 11.8% in men and women, respectively. Male participants tended to develop hypertension at an early age. Multivariate analysis showed that female sex was significantly associated with abdominal obesity. Regarding clinical factors, we identified an association between overweight and a history of opportunistic infections, as well as between hypertension and World Health Organization clinical stage. Sixty percent of HIV-infected participants assumed that a very thin body size indicated HIV infection.

Conclusions

The main findings of this study include a greater prevalence of overweight than underweight as well as a high prevalence of abdominal obesity among women. Social perception toward body size among people with HIV infection might remain problematic. Individuals living with HIV in Kenya should receive preventive intervention for overweight and abdominal obesity, with consideration of relevant social and cultural aspects.

Prevention of cardiovascular disease among people living with HIV in sub-Saharan Africa

As longevity has increased for people living with HIV (PLWH) in the United States and Europe, there has been a concomitant increase in the prevalence of cardiovascular disease (CVD) risk factors and morbidity in this population. Whereas the availability of HIV antiretroviral therapy has resulted in dramatic increases in life expectancy in sub-Saharan Africa (SSA), where over two thirds of PLWH reside, if and how these trends impact the epidemiology of CVD is less clear. In this review, we describe the current state of the science on how both HIV and its treatment impact CVD risk factors and outcomes among PLWH in sub-Saharan Africa, including regional factors (unique to SSA) likely to differentiate these relationships from the global North. We then outline how current regional guidelines address CVD prevention among PLWH and which clinical and structural interventions are best poised to confront the co-epidemics of HIV and CVD in the region. We conclude with a discussion of key research gaps that need to be addressed to optimally develop an actionable public health response.

Population-level adult mortality following the expansion of antiretroviral therapy in Rakai, Uganda

There are limited data on the impact of antiretroviral therapy (ART) on population-level adult mortality in sub-Saharan Africa. We analysed data for 2000-14 from the Rakai Community Cohort Study (RCCS) in Uganda, where free ART was scaled up after 2004. Using non-parametric and parametric (Weibull) survival analysis, we estimated trends in average person-years lived between exact ages 15 and 50, per capita life-years lost to HIV, and the mortality hazards of people living with HIV (PLHIV). Between 2000 and 2014, average adult life-years lived before age 50 increased significantly, from 26.4 to 33.5 years for all women and from 28.6 to 33.8 years for all men. As of 2014, life-years lost to HIV had declined significantly, to 1.3 years among women and 0.4 years among men. Following the roll-out of ART, mortality reductions among PLHIV were initially larger in women than men, but this is no longer the case.

Migration, hotspots, and dispersal of HIV infection in Rakai, Uganda

HIV prevalence varies markedly throughout Africa, and it is often presumed areas of higher HIV prevalence (i.e., hotspots) serve as sources of infection to neighboring areas of lower prevalence. However, the small-scale geography of migration networks and movement of HIV-positive individuals between communities is poorly understood. Here, we use population-based data from ~22,000 persons of known HIV status to characterize migratory patterns and their relationship to HIV among 38 communities in Rakai, Uganda with HIV prevalence ranging from 9 to 43%. We find that migrants moving into hotspots had significantly higher HIV prevalence than migrants moving elsewhere, but out-migration from hotspots was geographically dispersed, contributing minimally to HIV burden in destination locations. Our results challenge the assumption that high prevalence hotspots are drivers of transmission in regional epidemics, instead suggesting that migrants with high HIV prevalence, particularly women, selectively migrate to these areas.

Pervasive and non-random recombination in near full-length HIV genomes from Uganda

Recombination is an important feature of HIV evolution, occurring both within and between the major branches of diversity (subtypes). The Ugandan epidemic is primarily composed of two subtypes, A1 and D, that have been co-circulating for 50 years, frequently recombining in dually infected patients. Here, we investigate the frequency of recombinants in this population and the location of breakpoints along the genome. As part of the PANGEA-HIV consortium, 1,472 consensus genome sequences over 5 kb have been obtained from 1,857 samples collected by the MRC/UVRI & LSHTM Research unit in Uganda, 465 (31.6 per cent) of which were near full-length sequences (>8 kb). Using the subtyping tool SCUEAL, we find that of the near full-length dataset, 233 (50.1 per cent) genomes contained only one subtype, 30.8 per cent A1 (n = 143), 17.6 per cent D (n = 82), and 1.7 per cent C (n = 8), while 49.9 per cent (n = 232) contained more than one subtype (including A1/D (n = 164), A1/C (n = 13), C/D (n = 9); A1/C/D (n = 13), and 33 complex types). K-means clustering of the recombinant A1/D genomes revealed a section of envelope (C2gp120-TMgp41) is often inherited intact, whilst a generalized linear model was used to demonstrate significantly fewer breakpoints in the gag-pol and envelope C2-TM regions compared with accessory gene regions. Despite similar recombination patterns in many recombinants, no clearly supported circulating recombinant form (CRF) was found, there was limited evidence of the transmission of breakpoints, and the vast majority (153/164; 93 per cent) of the A1/D recombinants appear to be unique recombinant forms. Thus, recombination is pervasive with clear biases in breakpoint location, but CRFs are not a significant feature, characteristic of a complex, and diverse epidemic.

Progress and history of the 10th Federation of African Immunological Societies Congress

The 10th Federation of African Immunological Societies (FAIS) Congress, held in Tunisia in November 2017, marked a significant scientific milestone. It enabled scientists from across the continent to promote immunology research and to showcase major achievements made by immunologists throughout Africa. This issue of the Journal of Leukocyte Biology (JLB) features manuscripts from the FAIS Congress. As noted in these papers, research in infectious diseases remains the focus of the African immunology community; however, increasingly noncommunicable diseases-such as autoimmunity, allergy, primary immunodeficiency, cancer and transplantation immunology-are also an emerging priority. This overview gives a brief history of the FAIS meeting, which also commemorated the 25th anniversary of the FAIS. It describes the current activities of the organization, as well as its history and the future opportunities for this Federation.

Spatial analysis of HIV-TB co-clustering in Uganda

BACKGROUND

Tuberculosis (TB) is the leading cause of death for individuals infected with Human immunodeficiency virus (HIV). Conversely, HIV is the most important risk factor in the progression of TB from the latent to the active status. In order to manage this double epidemic situation, an integrated approach that includes HIV management in TB patients was proposed by the World Health Organization and was implemented in Uganda (one of the countries endemic with both diseases). To enable targeted intervention using the integrated approach, areas with high disease prevalence rates for TB and HIV need to be identified first. However, there is no such study in Uganda, addressing the joint spatial patterns of these two diseases.

METHODS

This study uses global Moran's index, spatial scan statistics and bivariate global and local Moran's indices to investigate the geographical clustering patterns of both diseases, as individuals and as combined. The data used are TB and HIV case data for 2015, 2016 and 2017 obtained from the District Health Information Software 2 system, housed and maintained by the Ministry of Health, Uganda.

RESULTS

Results from this analysis show that while TB and HIV diseases are highly correlated (55-76%), they exhibit relatively different spatial clustering patterns across Uganda. The joint TB/HIV prevalence shows consistent hotspot clusters around districts surrounding Lake Victoria as well as northern Uganda. These two clusters could be linked to the presence of high HIV prevalence among the fishing communities of Lake Victoria and the presence of refugees and internally displaced people camps, respectively. The consistent cold spot observed in eastern Uganda and around Kasese could be explained by low HIV prevalence in communities with circumcision tradition.

CONCLUSIONS

This study makes a significant contribution to TB/HIV public health bodies around Uganda by identifying areas with high joint disease burden, in the light of TB/HIV co-infection. It, thus, provides a valuable starting point for an informed and targeted intervention, as a positive step towards a TB and HIV-AIDS free community.

Field Performance of PIMA Point-of-Care Machine for CD4 Enumeration Under a Mobile HIV Counseling and Testing Program in Remote Fishing Communities of Lake Victoria, Uganda

Uganda is among the most HIV/AIDS-afflicted countries, and many HIV-infected persons live in remote areas with poor access to health care. The success of HIV care programs relies in part on patient monitoring using CD4 T cell counts. We conducted an evaluation of the point-of-care PIMA test using BD FACSCount as a gold standard. One hundred fifty-one participants were enrolled, provided venous blood and samples tested at the point of care with the Alere PIMA™ CD4 Analyzer and the BD FACSCount in the UVRI-IAVI main laboratory. Correlation between the methods was assessed, as was the ability of the Pima Analyzer to predict values <200, <350, and ≥500 CD4 cells/mm³ when compared with BD FACSCount as the gold standard. A near-perfect positive Pearson correlation coefficient (r = 0.948; p < .0001) between the two methods was observed. The Alere PIMA Analyzer had a mean bias of -32.5 cells/mm³. The sensitivity and specificity, for PIMA to predict CD4 lymphocyte count less than 200 cells/mm³, were 71.4% and 100%, respectively; less than 350 cells/mm³ were 84.6% and 94.6%, respectively; and at CD4 count less than 500 cells/mm³ were 94.4% and 100%. The Alere Pima Analyzer provides reliable CD4 cell count measurement and is suitable for monitoring and screening eligible HIV patients in hard-to-reach settings.

Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogenetic analysis

To prevent new infections with human immunodeficiency virus type 1 (HIV-1) in sub-Saharan Africa, UNAIDS recommends targeting interventions to populations that are at high risk of acquiring and passing on the virus. Yet it is often unclear who and where these 'source' populations are. Here we demonstrate how viral deep-sequencing can be used to reconstruct HIV-1 transmission networks and to infer the direction of transmission in these networks. We are able to deep-sequence virus from a large population-based sample of infected individuals in Rakai District, Uganda, reconstruct partial transmission networks, and infer the direction of transmission within them at an estimated error rate of 16.3% [8.8-28.3%]. With this error rate, deep-sequence phylogenetics cannot be used against individuals in legal contexts, but is sufficiently low for population-level inferences into the sources of epidemic spread. The technique presents new opportunities for characterizing source populations and for targeting of HIV-1 prevention interventions in Africa.

Phylogeography of HIV-1 suggests that Ugandan fishing communities are a sink for, not a source of, virus from general populations

Although fishing communities (FCs) in Uganda are disproportionately affected by HIV-1 relative to the general population (GP), the transmission dynamics are not completely understood. We earlier found most HIV-1 transmissions to occur within FCs of Lake Victoria. Here, we test the hypothesis that HIV-1 transmission in FCs is isolated from networks in the GP. We used phylogeography to reconstruct the geospatial viral migration patterns in 8 FCs and 2 GP cohorts and a Bayesian phylogenetic inference in BEAST v1.8.4 to analyse the temporal dynamics of HIV-1 transmission. Subtype A1 (pol region) was most prevalent in the FCs (115, 45.1%) and GP (177, 50.4%). More recent HIV transmission pairs from FCs were found at a genetic distance (GD) <1.5% than in the GP (Fisher’s exact test, p = 0.001). The mean time depth for pairs was shorter in FCs (5 months) than in the GP (4 years). Phylogeographic analysis showed strong support for viral migration from the GP to FCs without evidence of substantial viral dissemination to the GP. This suggests that FCs are a sink for, not a source of, virus strains from the GP. Targeted interventions in FCs should be extended to include the neighbouring GP for effective epidemic control.

Increased hepatitis C virus co-infection and injection drug use in HIV-infected fishermen in Myanmar

Background

In Southeast Asia, though fishermen are known to be a key population at high risk of HIV, little is known about their co-infection rates with Hepatitis C virus (HCV), or how illness and risk behaviors vary by occupation or type of fishermen. In Myanmar, this lack of knowledge is particularly acute, despite the fact that much of the country’s border is coastline.

Methods

We conducted a retrospective analysis to assess clinical, demographic, and risk characteristics of HIV-infected, ≥15-year-old males under HIV care from 2004 to 2014. Subgroups of fishermen were categorized according to the location of fishing activities, boat ownership, and length of time at sea. Generalized linear models assessed odds of high risk behaviors, including MSM (men who have sex with men), transactional sex, injection drug use (IDU), and HCV co-infection among international, local subsistence, and national migrant fishermen.

Results

Of 2798 adult males who enrolled in HIV care between 2004 and 2014, 41.9% (n = 1172) were fishermen. Among these, migrants had the highest odds of engaging in risk behaviors such as sex work (Myanmar national migrants: OR 3.26 95% CI: 2.20 to 4.83), and injecting drugs (international migrants: OR 2.93, 95% CI: 1.22 to 3.87) when compared to the general male HIV clinic population. 15.9% of all fishermen reported past or current IDU (23.0% of international migrants). 22.8% of all fishermen were also co-infected with HCV, and though predictably injectors had the highest odds (OR 20.1, 95% CI: 13.7 to 29.5), even after controlling for other risk factors, fishermen retained higher odds (OR 2.37 95% CI: 1.70 to 3.32).

Conclusions

HIV positive fishermen in Myanmar had higher odds of HCV co-infection. They also disproportionally injected drugs and engaged in transactional sex more than other patients. This is especially pronounced among international migrant fishermen. HIV-infected fishermen should be counseled on high risk activities, screened for HCV, and targeted by harm reduction programs.

HIV Epidemiology in Uganda: survey based on age, gender, number of sexual partners and frequency of testing

Background

Human Immunodeficiency Virus (HIV) is a major cause of morbidity and mortality in the world. When compared to the developed countries where HIV prevalence is on the decline, sub-Saharan Africa has experienced either a rise or stagnation in rates.

Objectives

The aim of this study was to test and educate the community in the villages of Masajja and Kibiri of Wakiso district in Uganda for HIV and safe sex practices.

Methods

A sociodemographic survey was also performed to obtain data for gender, age, number of sexual partners during the previous year, frequency of testing and if ever tested positive for other sexually transmitted diseases (STDs).

Results

While 7 of the tested individuals were positive for HIV, 77 reported that they had once tested positive for other STDs. Of the 7 HIV positive individuals, 4 were females and 3 males. Over half of the tested individuals reported only one sexual partner in past 12 months and more than a quarter were sexually active with more than one partner. Majority of our population also reported getting HIV tested every 6 months or less.

Conclusion

Robust implementation of methods such as education and frequent testing can lower Uganda's prevalence of HIV even further.

Evaluation of oral serum-derived bovine immunoglobulins in HIV-infected patients with chronic idiopathic diarrhea

Objectives To evaluate serum-derived bovine immunoglobulin/protein isolate (SBI) for safety and impact on gastrointestinal (GI) symptoms in HIV patients with chronic idiopathic diarrhea. Methods A multi-center trial comprised of a double-blind, placebo (PBO)-controlled lead-in phase, (participants received PBO or SBI at 2.5 or 5.0 g BID for 4 weeks) followed by a 20-week, PBO-free phase (SBI at either 2.5 or 5.0 g BID). Participants included HIV-infected patients who were virologically suppressed with a history of chronic idiopathic diarrhea, defined as > 3 loose stools per day for ≥ 3 months without an identifiable cause. Safety was evaluated by monitoring adverse events (AEs) and clinical laboratory testing. Health status and changes in GI symptoms were assessed using validated questionnaires. Results SBI was well tolerated by the 103 participants with only 2 withdrawals due to AEs potentially associated with SBI. Mean number of daily unformed stools decreased from about 4 at baseline to less than 2 by week 4 for all study groups. Improvements in several other GI symptoms were also reported. Comparison of the PBO group to SBI groups showed no significant differences, although both SBI cohorts reported significantly improved health status scores. GI symptom improvements were maintained throughout the 20-week PBO-free phase. Conclusions Oral SBI is safe and well tolerated at the doses studied in HIV patients with chronic diarrhea. No conclusions could be drawn regarding impact on GI symptoms. Additional studies are ongoing to examine the biological and immunologic effects of SBI in virologically suppressed HIV-infected patients.

Inferring population dynamics of HIV-1 subtype C epidemics in Eastern Africa and Southern Brazil applying different Bayesian phylodynamics approaches

The subtype C Eastern Africa clade (C_EA), a particularly successful HIV-1 subtype C lineage, has seeded several sub-epidemics in Eastern African countries and Southern Brazil during the 1960s and 1970s. Here, we characterized the past population dynamics of the major C_EA sub-epidemics in Eastern Africa and Brazil by using Bayesian phylodynamic approaches based on coalescent and birth-death models. All phylodynamic models support similar epidemic dynamics and exponential growth rates until roughly the mid-1980s for all the C_EA sub-epidemics. Divergent growth patterns, however, were supported afterwards. The Bayesian skygrid coalescent model (BSKG) and the birth-death skyline model (BDSKY) supported longer exponential growth phases than the Bayesian skyline coalescent model (BSKL). The BDSKY model uncovers patterns of a recent decline for the C_EA sub-epidemics in Burundi/Rwanda and Tanzania (R_e < 1) and a recent growth for Southern Brazil (R_e > 1); whereas coalescent models infer an epidemic stabilization. To the contrary, the BSKG model captured a decline of Ethiopian C_EA sub-epidemic between the mid-1990s and mid-2000s that was not uncovered by the BDSKY model. These results underscore that the joint use of different phylodynamic approaches may yield complementary insights into the past HIV population dynamics.

HIV prevalence by ethnic group covaries with prevalence of herpes simplex virus-2 and high-risk sex in Uganda: An ecological study

Background

HIV prevalence varies from 1.7% to 14.8% between ethnic groups in Uganda. Understanding the factors responsible for this heterogeneity in HIV spread may guide prevention efforts.

Methods

We evaluated the relationship between HIV prevalence by ethnic group and a range of risk factors as well as the prevalence of herpes simplex virus-2 (HSV-2), syphilis and symptomatic STIs in the 2004/2005 Uganda HIV/AIDS Sero-Behavioural Survey—a two stage, nationally representative, population based survey of 15–59-year-olds. Spearman’s correlation was used to assess the relationship between HIV prevalence and each variable.

Results

There was a positive association between HIV prevalence and HSV-2, symptomatic STIs and high-risk sex (sex with a non-cohabiting, non-marital partner) for women. Non-significant positive associations were present between HIV and high-risk sex for men and lifetime number of partners for men and women.

Conclusion

Variation in sexual behavior may contribute to the variations in HIV, HSV-2 and other STI prevalence by ethnic group in Uganda. Further work is necessary to delineate which combinations of risk factors determine differential STI spread in Uganda.

HIV viral suppression and geospatial patterns of HIV antiretroviral therapy treatment facility use in Rakai, Uganda

OBJECTIVE

To assess geospatial patterns of HIV antiretroviral therapy (ART) treatment facility use and whether they were impacted by viral load suppression.

METHODS

We extracted data on the location and type of care services utilized by HIV-positive persons accessing ART between February 2015 and September 2016 from the Rakai Community Cohort Study in Uganda. The distance from Rakai Community Cohort Study households to facilities offering ART was calculated using the open street map road network. Modified Poisson regression was used to identify predictors of distance traveled and, for those traveling beyond their nearest facility, the probability of accessing services from a tertiary care facility.

RESULTS

In total, 1554 HIV-positive participants were identified, of whom 68% had initiated ART. The median distance from households to the nearest ART facility was 3.10 km (interquartile range, 1.65-5.05), but the median distance traveled was 5.26 km (interquartile range, 3.00-10.03, P < 0.001) and 57% of individuals travelled further than their nearest facility for ART. Those with higher education and wealth were more likely to travel further. In total, 93% of persons on ART were virally suppressed, and there was no difference in the distance traveled to an ART facility between those with suppressed and unsuppressed viral loads (5.26 vs. 5.27 km, P = 0.650).

CONCLUSION

Distance traveled to HIV clinics was increased with higher socioeconomic status, suggesting that wealthier individuals exercise greater choice. However, distance traveled did not vary by those who were or were not virally suppressed.

Incidence of Postsuppression Virologic Rebound in Perinatally HIV-Infected Asian Adolescents on Stable Combination Antiretroviral Therapy

PURPOSE

To assess the incidence and predictors of postsuppression virologic rebound (VR) among adolescents on stable combination antiretroviral therapy in Asia.

METHODS

Perinatally HIV-infected Asian adolescents (10-19 years) with documented virologic suppression (two consecutive viral loads [VLs] <400 copies/mL ≥6 months apart) were included. Baseline was the date of the first VL <400 copies/mL at age ≥10 years or the 10th birthday for those with prior suppression. Cox proportional hazards models were used to identify predictors of postsuppression VR (VL >1,000 copies/mL).

RESULTS

Of 1,379 eligible adolescents, 47% were males. At baseline, 22% were receiving protease inhibitor-containing regimens; median CD4 cell count (interquartile range [IQR]) was 685 (448-937) cells/mm³; 2% had preadolescent virologic failure (VF) before subsequent suppression. During adolescence, 180 individuals (13%) experienced postsuppression VR at a rate of 3.4 (95% confidence interval: 2.9-3.9) per 100 person-years, which was consistent over time. Median time to VR during adolescence (IQR) was 3.3 (2.1-4.8) years. Wasting (weight-for-age z-score <-2.5), being raised by grandparents, receiving second-line protease inhibitor-based regimens, starting combination antiretroviral therapy after 2005, and having preadolescent VF were independent predictors of adolescent VR. At VR, median age, CD4 cell count, and VL (IQR) were 14.8 (13.2-16.4) years, 507 (325-723) cells/mm³, and 4.1 (3.5-4.7) log₁₀ copies/mL, respectively.

CONCLUSIONS

A modest and consistent incidence of postsuppression VR was documented during adolescence in our cohort. Having poor weight, receiving second-line regimens, and prior VF were associated with an increased VR rate. Adolescents at higher risk of VR may benefit from more intensive VL monitoring to enhance adherence management.

HIV prevalence and uptake of HIV/AIDS services among youths (15-24 Years) in fishing and neighboring communities of Kasensero, Rakai District, South Western Uganda

BACKGROUND

Although fishing communities have a significantly higher HIV prevalence than the general population, there is paucity of data on the burden of HIV and service utilization, particularly among the youth. We assessed the HIV prevalence and utilization of HIV prevention and treatment services among youth in Kasensero fishing community and the neighboring communities.

METHOD

Data were derived from the Rakai Community Cohort Study (RCCS) surveys conducted between 2013 and 2014. The RCCS is a population-based household survey that collects data annually from individuals aged 15-49 years, resident in 48 communities in Rakai and neighboring districts in Uganda. For this analysis, socio-demographic, behavioral and HIV-related data were obtained for 792 individuals aged 15-24 years. We used logistic regression to conduct bivariate and multivariable analysis to determine the factors that are independently associated with HIV-positive status and their corresponding 95% confidence intervals. Data were analyzed using STATA version 13.

RESULTS

Overall HIV prevalence was 19.7% (n = 155); higher in Kasensero (n = 141; 25.1%) and Gwanda (n = 8; 11%) than in Kyebe (n = 6; 3.9%), p < 0.001 and among females (n = 112; 26.0%) than males (n = 43; 12.0%), p < 0.001. Uptake of HIV testing was high in both HIV-positive (n = 136; 89.5%) and HIV-negative youth (n = 435; 92%). Consistent condom use was virtually non-existent in HIV-positive youth (n = 1; 0.6%) compared to HIV-negative youth (n = 20; 4.2%). Only 22.4% (n = 34) of the HIV-positive youth were receiving antiretroviral therapy (ART) in 2013-2014; higher in the HIV-positive females (n = 31; 28.4%) than HIV-positive males (n = 03; 6.7%). Slightly more than half of males (n = 134; 53.8%) reported that they were circumcised; the proportion of circumcised youth was higher among HIV-negative males (n = 122; 58%) than HIV-positive males (n = 12; 27.9%). Factors significantly associated with HIV-positive status included living in Kasensero landing site (adjusted Odds Ratio [aOR] = 5.0; 95%CI: 2.22-13.01) and reporting one (aOR = 5.0; 95%CI: 1.33-15.80) or 2+ sexual partners in the past 12 months (aOR = 11.0; 95% CI; 3.04-36.72).

CONCLUSION

The prevalence of HIV is high especially among young females and in landing site communities than in the peripheral communities. Uptake of HIV prevention and treatment services is very low. There is an urgent need for youth-friendly services in these communities.

Introduction: The Complexity and Challenge of Preventing, Treating, and Managing Blood Diseases in the Developing Countries

Managing hematologic disorders in developing countries poses problems not encountered in Western societies. The clinical features of hematologic conditions may be modified by malnutrition, chronic bacterial infection, or parasitic illness. Iron deficiency is the major factor in anemia worldwide. Anemia is more common in the wet season when malaria transmission peaks. After anemia, eosinophilia is the next most common hematologic abnormality in children in the tropics. Infection with the human immunodeficiency virus can cause hematologic abnormalities. The pattern of distribution of primary disorders of the blood varies among populations and some disorders are unique to certain parts of the world.

AIDS in the African Press

Newspapers have the potential to take a leading role in AIDS education in Africa. With their relatively small circulations, they mainly reach educated urban citizens, a population particularly hard hit by the epidemic. This study reports findings of a content analysis of AIDS coverage of government owned newspapers in Senegal, Togo, Nigeria, Uganda and Kenya. Although most papers have printed educational articles, they have undertaken only a very minor role in any national effort. Coverage has tended to reflect government reaction, usually moving through stages of denial, scapegoating and blame before responding constructively to the epidemic. African countries surveyed are still largely engaged in epidemiological response to the epidemic; widespread education has not yet occurred. Newspapers have not yet fulfilled their potential as educational media.