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Footer K, Lake CM, Porter JR, Ha GK, Ahmed T, Glogowski A, Ndyanabo A, Grabowski MK, Chang LW, Ssekasanvu J, Kagaayi J, Serwadda DM, Mckina J, Whalen C, Ssentongo L, Nsimbi I, Kakeeto B, Kigozi G, Ssekubugu R, Lutalo T, Wawer MJ, Gray RH, Reynolds SJ, Rosenthal A, Quinn TC, Tartakovsky M. Using publicly available, interactive epidemiological dashboards: an innovative approach to sharing data from the Rakai Community Cohort Study. JAMIA Open 2024; 7:ooae069. [PMID: 39044942 PMCID: PMC11265297 DOI: 10.1093/jamiaopen/ooae069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 04/17/2024] [Accepted: 07/15/2024] [Indexed: 07/25/2024] Open
Abstract
Objectives Public sharing of de-identified biomedical data promotes collaboration between researchers and accelerates the development of disease prevention and treatment strategies. However, open-access data sharing presents challenges to researchers who need to protect the privacy of study participants, ensure that data are used appropriately, and acknowledge the inputs of all involved researchers. This article presents an approach to data sharing which addresses the above challenges by using a publicly available dashboard with de-identified, aggregated participant data from a large HIV surveillance cohort. Materials and Methods Data in this study originated from the Rakai Community Cohort Study (RCCS), which was integrated into a centralized data mart as part of a larger data management strategy for the Rakai Health Sciences Program in Uganda. These data were used to build a publicly available, protected health information (PHI)-secured visualization dashboard for general research use. Results Using two unique case studies, we demonstrate the capability of the dashboard to generate the following hypotheses: firstly, that HIV prevention strategies ART and circumcision have differing levels of impact depending on the marital status of investigated communities; secondly, that ART is very successful in comparison to circumcision as an interventional strategy in certain communities. Discussion The democratization of large-scale anonymized epidemiological data using public-facing dashboards has multiple benefits, including facilitated exploration of research data and increased reproducibility of research findings. Conclusion By allowing the public to explore data in depth and form new hypotheses, public-facing dashboard platforms have significant potential to generate new relationships and collaborations and further scientific discovery and reproducibility.
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Affiliation(s)
- Kevin Footer
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Camille M Lake
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Joshua R Porter
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Grace K Ha
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Tanvir Ahmed
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Alex Glogowski
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | | | - M Kate Grabowski
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD 21287, United States
| | - Larry W Chang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
- Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
| | - Joseph Ssekasanvu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | | | | | | | - Christopher Whalen
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Lloyd Ssentongo
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Ivan Nsimbi
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Benedicto Kakeeto
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | | | | | - Tom Lutalo
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - Maria J Wawer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Ronald H Gray
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Steven J Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Alex Rosenthal
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Thomas C Quinn
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
| | - Michael Tartakovsky
- Office of Cyber Infrastructure & Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20892, United States
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Rosen JG, Ndyanabo A, Nakawooya H, Galiwango RM, Ssekubugu R, Ssekasanvu J, Kim S, Rucinski KB, Nakigozi G, Nalugoda F, Kigozi G, Quinn TC, Chang LW, Kennedy CE, Reynolds SJ, Kagaayi J, Grabowski MK. Incidence of Health Facility Switching and Associations With HIV Viral Rebound Among Persons on Antiretroviral Therapy in Uganda: A Population-based Study. Clin Infect Dis 2024; 78:1591-1600. [PMID: 38114162 PMCID: PMC11175689 DOI: 10.1093/cid/ciad773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/02/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND A substantial proportion of persons on antiretroviral therapy (ART) considered lost to follow-up have actually transferred their human immunodeficiency virus (HIV) care to other facilities. However, the relationship between facility switching and virologic outcomes, including viral rebound, is poorly understood. METHODS We used data from 40 communities (2015-2020) in the Rakai Community Cohort Study to estimate incidence of facility switching and viral rebound. Persons aged 15-49 years with serologically confirmed HIV who self-reported ART use and contributed ≥1 follow-up visit were included. Facility switching and virologic outcomes were assessed between 2 consecutive study visits (ie, index and follow-up visits, interval of approximately 18 months). Those who reported different HIV treatment facilities between index and follow-up study visits were classified as having switched facilities. Virologic outcomes included viral rebound among individuals initially suppressed (<200 copies/mL). Multivariable Poisson regression was used to estimate associations between facility switching and viral rebound. RESULTS Overall, 2257 persons who self-reported ART use (median age, 35 years; 65% female, 92% initially suppressed) contributed 3335 visit-pairs and 5959 person-years to the analysis. Facility switching was common (4.8 per 100 person-years; 95% confidence interval [CI], 4.2-5.5) and most pronounced in persons aged <30 years and fishing community residents. Among persons suppressed at their index visit (n = 2076), incidence of viral rebound was more than twice as high in persons who switched facilities (adjusted incidence rate ratio = 2.27; 95% CI, 1.16-4.45). CONCLUSIONS Facility switching was common and associated with viral rebound among persons initially suppressed. Investments in more agile, person-centered models for mobile clients are needed to address system inefficiencies and bottlenecks that can disrupt HIV care continuity.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | - Seungwon Kim
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Katherine B Rucinski
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | - Thomas C Quinn
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Larry W Chang
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Nishimura H, Kaptchuk RP, Mbabali I, Mulamba J, Nakyanjo N, Anok A, Wawer MJ, Kennedy CE, Nakigozi G, Chang LW, Amico KR, Hutton H. Motivational interviewing experiences from a community health worker-led HIV prevention and care intervention in rural Uganda: a qualitative study. AIDS Care 2024; 36:491-499. [PMID: 37713732 DOI: 10.1080/09540121.2023.2253504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/25/2023] [Indexed: 09/17/2023]
Abstract
Motivational Interviewing (MI) and Community Health Workers (CHWs) are increasingly utilized in global settings to improve HIV outcomes, yet research exploring implementation strategies using MI and CHWs is lacking. We examined the experiences of CHWs and their clients in a counseling intervention which used MI-informed counseling to increase engagement in HIV prevention and treatment. This study was nested within the mLAKE cluster-randomized trial in a high HIV prevalence fishing community in rural Rakai District, Uganda. We conducted in-depth interviews with purposively-sampled CHWs (n = 8) and clients (n = 51). Transcripts were analyzed thematically to characterize CHWs' implementation of the intervention. Main themes identified included use of specific MI strategies (including evocation, guidance towards positive behavior change, active listening, and open-ended questions), and MI spirit (including collaboration, power-sharing, trust, and non-judgmental relationship building). Through these specific MI mechanisms, CHWs supported client behavior change to facilitate engagement with HIV services. This study provides evidence from a low-resource setting that CHWs with no previous experience in MI can successfully implement MI-informed counseling that is well-received by clients. CHW-led MI-informed counseling appears to be a feasible and effective approach to increase uptake of HIV prevention and care services in low-resource, HIV endemic regions.
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Affiliation(s)
- Holly Nishimura
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rose Pollard Kaptchuk
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ismail Mbabali
- Social and Behavioral Sciences Department, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Jeremiah Mulamba
- Social and Behavioral Sciences Department, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Neema Nakyanjo
- Social and Behavioral Sciences Department, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Aggrey Anok
- Social and Behavioral Sciences Department, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Maria J Wawer
- Social and Behavioral Sciences Department, Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gertrude Nakigozi
- Social and Behavioral Sciences Department, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Larry W Chang
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Social and Behavioral Sciences Department, Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - K Rivet Amico
- Department of Health Behavior Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Heidi Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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4
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Kim S, Kigozi G, Martin MA, Galiwango RM, Quinn TC, Redd AD, Ssekubugu R, Bonsall D, Ssemwanga D, Rambaut A, Herbeck JT, Reynolds SJ, Foley B, Abeler-Dörner L, Fraser C, Ratmann O, Kagaayi J, Laeyendecker O, Grabowski MK. Increasing intra- and inter-subtype HIV diversity despite declining HIV incidence in Uganda. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.14.24303990. [PMID: 38558994 PMCID: PMC10980117 DOI: 10.1101/2024.03.14.24303990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
HIV incidence has been declining in Africa with scale-up of HIV interventions. However, there is limited data on HIV evolutionary trends in African populations with waning epidemics. We evaluated changes in HIV viral diversity and genetic divergence in southern Uganda over a twenty-five-year period spanning the introduction and scale-up of HIV prevention and treatment programs using HIV sequence and survey data from the Rakai Community Cohort Study, an open longitudinal population-based HIV surveillance cohort. Gag (p24) and env (gp41) HIV data were generated from persons living with HIV (PLHIV) in 31 inland semi-urban trading and agrarian communities (1994 to 2018) and four hyperendemic Lake Victoria fishing communities (2011 to 2018) under continuous surveillance. HIV subtype was assigned using the Recombination Identification Program with phylogenetic confirmation. Inter-subtype diversity was estimated using the Shannon diversity index and intra-subtype diversity with the nucleotide diversity and pairwise TN93 genetic distance. Genetic divergence was measured using root-to-tip distance and pairwise TN93 genetic distance analyses. Evolutionary dynamics were assessed among demographic and behavioral sub-groups, including by migration status. 9,931 HIV sequences were available from 4,999 PLHIV, including 3,060 and 1,939 persons residing in inland and fishing communities, respectively. In inland communities, subtype A1 viruses proportionately increased from 14.3% in 1995 to 25.9% in 2017 (p<0.001), while those of subtype D declined from 73.2% in 1995 to 28.2% in 2017 (p<0.001). The proportion of viruses classified as recombinants significantly increased by more than four-fold. Inter-subtype HIV diversity has generally increased. While p24 intra-subtype genetic diversity and divergence leveled off after 2014, diversity and divergence of gp41 increased through 2017. Inter- and intra-subtype viral diversity increased across all population sub-groups, including among individuals with no recent migration history or extra-community sexual partners. This study provides insights into population-level HIV evolutionary dynamics in declining African HIV epidemics following the scale-up of HIV prevention and treatment programs. Continued molecular surveillance may provide a better understanding of the dynamics driving population HIV evolution and yield important insights for epidemic control and vaccine development.
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Affiliation(s)
- Seungwon Kim
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Michael A. Martin
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Thomas C. Quinn
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - David Bonsall
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Deogratius Ssemwanga
- Medical Research Council (MRC)/Uganda Virus Research Institute (UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- Uganda Virus Research Institute, Entebbe, Uganda
| | - Andrew Rambaut
- Institute of Evolutionary Biology, University of Edinburgh, Edinburgh, UK
| | - Joshua T. Herbeck
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Brian Foley
- Theoretical Biology and Biophysics, Los Alamos National Laboratory, Los Alamos, New Mexico, USA
| | - Lucie Abeler-Dörner
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Christophe Fraser
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Oliver Ratmann
- Department of Mathematics, Imperial College London, London, England, United Kingdom
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Oliver Laeyendecker
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M. Kate Grabowski
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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5
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Popoola VO, Kagaayi J, Ssekasanvu J, Ssekubugu R, Kigozi G, Ndyanabo A, Nalugoda F, Chang LW, Lutalo T, Tobian AAR, Kabatesi D, Alamo S, Mills LA, Kigozi G, Wawer MJ, Santelli J, Gray RH, Reynolds SJ, Serwadda D, Lessler J, Grabowski MK. HIV epidemiologic trends among occupational groups in Rakai, Uganda: A population-based longitudinal study, 1999-2016. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002891. [PMID: 38377078 PMCID: PMC10878534 DOI: 10.1371/journal.pgph.0002891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/12/2024] [Indexed: 02/22/2024]
Abstract
Certain occupations have been associated with heightened risk of HIV acquisition and spread in sub-Saharan Africa, including female bar and restaurant work and male transportation work. However, data on changes in population prevalence of HIV infection and HIV incidence within occupations following mass scale-up of African HIV treatment and prevention programs is very limited. We evaluated prospective data collected between 1999 and 2016 from the Rakai Community Cohort Study, a longitudinal population-based study of 15- to 49-year-old persons in Uganda. Adjusted prevalence risk ratios for overall, treated, and untreated, prevalent HIV infection, and incidence rate ratios for HIV incidence with 95% confidence intervals were estimated using Poisson regression to assess changes in HIV outcomes by occupation. Analyses were stratified by gender. There were 33,866 participants, including 19,113 (56%) women. Overall, HIV seroprevalence declined in most occupational subgroups among men, but increased or remained mostly stable among women. In contrast, prevalence of untreated HIV substantially declined between 1999 and 2016 in most occupations, irrespective of gender, including by 70% among men (12.3 to 4.2%; adjPRR = 0.30; 95%CI:0.23-0.41) and by 78% among women (14.7 to 4.0%; adjPRR = 0.22; 95%CI:0.18-0.27) working in agriculture, the most common self-reported primary occupation. Exceptions included men working in transportation. HIV incidence similarly declined in most occupations, but there were no reductions in incidence among female bar and restaurant workers, women working in local crafts, or men working in transportation. In summary, untreated HIV infection and HIV incidence have declined within most occupational groups in Uganda. However, women working in bars/restaurants and local crafts and men working in transportation continue to have a relatively high burden of untreated HIV and HIV incidence, and as such, should be considered priority populations for HIV programming.
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Affiliation(s)
- Victor O. Popoola
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Entebbe, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Joseph Ssekasanvu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | | | - Larry W. Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Tom Lutalo
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Aaron A. R. Tobian
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Donna Kabatesi
- Division of Global HIV and TB, Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Stella Alamo
- Division of Global HIV and TB, Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Lisa A. Mills
- Division of Global HIV and TB, Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Maria J. Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Entebbe, Uganda
| | - John Santelli
- Department of Population and Family Health and Pediatrics, Columbia University, New York, New York, United States of America
| | - Ronald H. Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J. Reynolds
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
| | - M. Kate Grabowski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
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6
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Rosen JG, Ssekubugu R, Chang LW, Ssempijja V, Galiwango RM, Ssekasanvu J, Ndyanabo A, Kisakye A, Nakigozi G, Rucinski KB, Patel EU, Kennedy CE, Nalugoda F, Kigozi G, Ratmann O, Nelson LJ, Mills LA, Kabatesi D, Tobian AAR, Quinn TC, Kagaayi J, Reynolds SJ, Grabowski MK. Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viraemia during Universal Test and Treat scale-up in Uganda: a population-based study. J Int AIDS Soc 2024; 27:e26200. [PMID: 38332519 PMCID: PMC10853573 DOI: 10.1002/jia2.26200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/04/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION Population-level data on durable HIV viral load suppression (VLS) following the implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viraemia among persons living with HIV in 40 Ugandan communities during the UTT scale-up. METHODS In 2015-2020, we measured VLS (<200 RNA copies/ml) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/ml) or high-level (≥1000 copies/ml) viraemia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e. visit-pairs; ∼18-month visit intervals) and classified as durable VLS (<200 copies/ml at both visits), new/renewed VLS (<200 copies/ml at follow-up only), viral rebound (<200 copies/ml at initial visit only) or persistent viraemia (≥200 copies/ml at both visits). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viraemia were also assessed using multivariable Poisson regression with generalized estimating equations. RESULTS Overall, 3080 participants contributed 4604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with any viraemia at the initial visit (23.5%, n = 1083), 46.9% remained viraemic through follow-up, 91.3% of which was high-level viraemia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viraemia self-reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high-level viraemia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (vs. 40- to 49-year-olds; adjusted risk ratio [adjRR] = 2.96; 95% confidence interval [95% CI]: 2.21-3.96), males (vs. females; adjRR = 2.40, 95% CI: 1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (vs. persons with marital/permanent partners only; adjRR = 1.38, 95% CI: 1.10-1.74) and persons reporting hazardous alcohol use (adjRR = 1.09, 95% CI: 1.03-1.16). The prevalence of persistent high-level viraemia was highest among males <30 years (32.0%). CONCLUSIONS Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting any viraemia, nearly half exhibited high-level viraemia for ≥12 months and reported higher-risk behaviours associated with onward HIV transmission. Intensified efforts linking individuals to HIV treatment services could accelerate momentum towards HIV epidemic control.
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Affiliation(s)
- Joseph Gregory Rosen
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | - Larry W. Chang
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Victor Ssempijja
- Rakai Health Sciences ProgramEntebbeUganda
- Clinical Monitoring Research Program DirectorateFrederick National Laboratory for Cancer ResearchFrederickMarylandUSA
| | | | - Joseph Ssekasanvu
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
| | | | | | | | - Katherine B. Rucinski
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Eshan U. Patel
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Caitlin E. Kennedy
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
| | | | | | | | - Lisa J. Nelson
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Lisa A. Mills
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Donna Kabatesi
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Aaron A. R. Tobian
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Thomas C. Quinn
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Division of Intramural ResearchNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | | | - Steven J. Reynolds
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Division of Intramural ResearchNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Mary Kathryn Grabowski
- Rakai Health Sciences ProgramEntebbeUganda
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMarylandUSA
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7
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Rosen JG, Nakyanjo N, Ddaaki WG, Zhao T, Van Vo A, Nakubulwa R, Ssekyewa C, Isabirye D, Katono RL, Nabakka P, Ssemwanga RJ, Kigozi G, Odiya S, Nakigozi G, Nalugoda F, Kigozi G, Kagaayi J, Grabowski MK, Kennedy CE. Identifying longitudinal patterns of HIV treatment (dis)engagement and re-engagement from oral histories of virologically unsuppressed persons in Uganda: A thematic trajectory analysis. Soc Sci Med 2023; 339:116386. [PMID: 37984182 PMCID: PMC10841599 DOI: 10.1016/j.socscimed.2023.116386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/01/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND There is limited study of persons deemed "harder to reach" by HIV treatment services, including those discontinuing or never initiating antiretroviral therapy (ART). We conducted narrative research in southern Uganda with virologically unsuppressed persons identified through population-based sampling to discern longitudinal patterns in HIV service engagement and identify factors shaping treatment persistence. METHODS In mid-2022, we sampled adult participants with high-level HIV viremia (≥1000 RNA copies/mL) from the prospective, population-based Rakai Community Cohort Study. Using life history calendars, we conducted initial and follow-up in-depth interviews to elicit oral histories of participants' journeys in HIV care, from diagnosis to the present. We then used thematic trajectory analysis to identify discrete archetypes of HIV treatment engagement by "re-storying" participant narratives and visualizing HIV treatment timelines derived from interviews and abstracted clinical data. RESULTS Thirty-eight participants (median age: 34 years, 68% men) completed 75 interviews. We identified six HIV care engagement archetypes from narrative timelines: (1) delayed ART initiation, (2) early treatment discontinuation, (3) treatment cycling, (4) prolonged treatment interruption, (5) transfer-related care disruption, and (6) episodic viremia. Patterns of service (dis)engagement were highly gendered, occurred in the presence and absence of optimal ART adherence, and were shaped by various factors emerging at different time points, including: denial of HIV serostatus and disclosure concerns; worsening HIV-related symptoms; psychological distress and depression; social support; intimate partner violence; ART side effects; accessibility constraints during periods of mobility; incarceration; and inflexible ART dispensing regulations. CONCLUSIONS Identified trajectories uncovered heterogeneities in both the timing and drivers of ART (re-)initiation and (dis)continuity, demonstrating the distinct characteristics and needs of people with different patterns of HIV treatment engagement throughout the life course. Enhanced mental health service provision, expanded eligibility for differentiated service delivery models, and streamlined facility switching processes may facilitate timely (re-)engagement in HIV services.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | | | | | - Tongying Zhao
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Anh Van Vo
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | | | | | - Silas Odiya
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda; Division of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda
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8
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Senteza I, Castelnuovo B, Mukunya D, Makumbi F. Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda. PLoS One 2023; 18:e0293057. [PMID: 37856568 PMCID: PMC10586650 DOI: 10.1371/journal.pone.0293057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/04/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Virological non-suppression is a critical factor in driving HIV transmission rates, yet there is limited data available on the determinants of this phenomenon, particularly in fishing communities where the incidence of HIV is disproportionately high. We aimed to determine the prevalence and determinants of virological non-suppression among adult males (≥15 years) attending HIV care services in the fishing communities of Bulisa district. METHODS We conducted a cross-sectional study among all adult males (≥15 years) living with HIV who were resident within the fishing communities, and in care for atleast 6 months at the six health facilities offering HIV services in the fishing communities in Bulisa district. To obtain data on patient and health facility characteristics, we reviewed patients' records and conducted face-to-face interviews with the participants. We conducted descriptive and regression analyses using modified Poisson regression, accounting for data correlation of observation at the facility level to obtain prevalence ratios (PR) with 95% confidence intervals in Stata version 14.0. RESULTS 413 participants were studied and 379 (91.8%) were interviewed. The participant's average age (SD) was 40 (10.7) years and 70.5% (267/379) were engaged in the fishing business. The prevalence of virological non-suppression was 88/413-21.3% (95% CI: 18%-26%). Factors associated with higher odds of virological non-suppression included: Age 26-50 years (adj.PR = 1.53, 95%CI: 1.11-2.08) and 15-25 years (adj.PR = 2.99, 95%CI: 1.27-7.05) compared to age above 50 years; unemployment (adj.PR = 1.28, 95%CI: 1.10-1.49); hazardous use of alcohol (adj.PR = 1.34, 95%CI: 1.10-1.62); non-mobility between fish landing sites (adj.PR = 1.37, 95%CI: 1.003-1.87); distant HIV treatment services (adj.PR = 1.37, 95%CI: 1.11-1.69) and TB diagnosis (adj.PR = 1.87, 95%CI: 1.33-2.64). CONCLUSION Virological non-suppression among people living with HIV in fishing communities along the shores of Lake Albert is alarmingly high, exceeding the UNAIDS threshold of 10% by two-fold. Several key determinants were identified, including hazardous alcohol use, unemployment, and access barriers to HIV treatment services.
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Affiliation(s)
- Ignatius Senteza
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Barbara Castelnuovo
- Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David Mukunya
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Busitema, Uganda
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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9
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Chang LW, Pollard R, Mbabali I, Anok A, Hutton H, Amico KR, Kong X, Mulamba J, Ssekasanvu J, Long A, Thomas AG, Thomas K, Bugos E, van Wickle K, Kennedy CE, Nalugoda F, Beres LK, Bollinger RC, Quinn TC, Serwadda D, Gray RH, Wawer MJ, Reynolds SJ, Nakigozi G. Mixed Methods, Implementation Science Evaluation of a Community Health Worker Strategy for HIV Service Engagement in Uganda. J Acquir Immune Defic Syndr 2023; 94:28-36. [PMID: 37195924 PMCID: PMC10524323 DOI: 10.1097/qai.0000000000003220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 03/16/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND A trial found that a community health worker (CHW) strategy using "Health Scouts" improved HIV care uptake and ART coverage. To better understand outcomes and areas for improvement, we conducted an implementation science evaluation. METHODS Using the RE-AIM framework, quantitative methods included analyses of a community-wide survey (n = 1903), CHW log books, and phone application data. Qualitative methods included in-depth interviews (n = 72) with CHWs, clients, staff, and community leaders. RESULTS Thirteen Health Scouts logged 11,221 counseling sessions; 2532 unique clients were counseled. 95.7% (1789 of 1891) of residents reported awareness of the Health Scouts. Overall, reach (self-reported receipt of counseling) was 30.7% (580 of 1891). Unreached residents were more likely to be male and HIV seronegative ( P < 0.05). Qualitative themes included the following: (1) reach was promoted by perceived usefulness but deterred by busy client lifestyles and stigma, (2) effectiveness was enabled through good acceptability and consistency with the conceptual framework, (3) adoption was facilitated by positive impacts on HIV service engagement, and (4) implementation fidelity was initially promoted by the CHW phone application but deterred by mobility. Maintenance showed consistent counseling sessions over time. The findings suggested the strategy was fundamentally sound but had suboptimal reach. Future iterations could consider adaptations to improve reach to priority populations, testing the need for mobile health support, and additional community sensitization to reduce stigma. CONCLUSIONS A CHW strategy to promote HIV services was implemented with moderate success in an HIV hyperendemic setting and should be considered for adoption and scale-up in other communities as part of comprehensive HIV epidemic control efforts. TRIAL REGISTRATION ClinicalTrials.gov Trial Number NCT02556957.
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Affiliation(s)
- Larry W Chang
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Departments of Epidemiology
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Rakai, Uganda
| | - Rose Pollard
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Aggrey Anok
- Rakai Health Sciences Program, Rakai, Uganda
| | - Heidi Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | - K Rivet Amico
- Department of Health Behavior Health Education, University of Michigan, Ann Arbor, MI
| | - Xiangrong Kong
- Departments of Epidemiology
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD; and
| | | | | | - Amanda Long
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Alvin G Thomas
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin Thomas
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Eva Bugos
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kimiko van Wickle
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Caitlin E Kennedy
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Rakai, Uganda
| | | | - Laura K Beres
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Robert C Bollinger
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Thomas C Quinn
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | | | - Ronald H Gray
- Departments of Epidemiology
- Rakai Health Sciences Program, Rakai, Uganda
| | - Maria J Wawer
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Departments of Epidemiology
- Rakai Health Sciences Program, Rakai, Uganda
| | - Steven J Reynolds
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Rakai Health Sciences Program, Rakai, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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10
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Agwang W, Nangendo J, Nabikande S, Okello T, Tusabe J, Semitala FC, Kasasa S, Matovu JKB. Factors associated with willingness to take Pre-Exposure Prophylaxis (PrEP) among high-risk adolescent boys and young men in Masese fishing community, Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001191. [PMID: 37289700 DOI: 10.1371/journal.pgph.0001191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 05/15/2023] [Indexed: 06/10/2023]
Abstract
Pre-Exposure Prophylaxis (PrEP) is a known HIV prevention strategy for high-risk populations however, some high-risk communities have not yet fully embraced it. We sought to determine willingness to take PrEP and the associated factors among high-risk adolescent boys and young men (ABYM) in Masese fishing community, Jinja district, Eastern Uganda. We conducted a cross-sectional study, between October and November 2020, using a semi-structured questionnaire among ABYM aged 10-24 years in Masese fishing community, Eastern Uganda. We surveyed 479 participants, who had two or more sexual partners with inconsistent or no condom use. We carried out modified Poisson regression analysis to determine factors associated with willingness to take PrEP.Of 479 high-risk ABYM, 86.4% (n = 414) were willing to take PrEP. Confidence in PrEP safety (adj.PR = 1.56; 95%CI: 1.55, 2.24), availability of PrEP in areas easily accessible by ABYM (adj.PR = 1.40; 95%CI: 1.25, 1.57), and perceiving oneself as being at a very high risk of HIV infection (adj.PR = 1.11; 95%CI: 1.03, 1.20) were positively associated with willingness to take PrEP. On the other hand, being unmarried (adj.PR = 0.92; 95%CI: 0.87, 0.98) and earning more than USD 27 a month (adj.PR = 0.92; 95%CI: 0.87, 0.97) were negatively associated with willingness to take PrEP. There was high willingness to take PrEP among adolescent boys and young men in Masese fishing community. Confidence in PrEP safety, access to PrEP in their community and self-perception to be at high risk for HIV acquisition had a positive bearing on willingness to take PrEP while being unmarried and earning more than USD27 had a negative bearing on willingness to take PrEP. These findings suggest a need for target-specific interventions for unmarried men and those earning >USD27.
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Affiliation(s)
- Winnie Agwang
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joanita Nangendo
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sherifah Nabikande
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tom Okello
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joan Tusabe
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fred C Semitala
- Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Simon Kasasa
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph K B Matovu
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Faculty of Health Sciences, Busitema University, Mbale, Uganda
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11
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Ssempijja V, Ssekubugu R, Kigozi G, Nakigozi G, Kagaayi J, Ekstrom AM, Nalugoda F, Nantume B, Batte J, Kigozi G, Yeh PT, Nakawooya H, Serwadda D, Quinn TC, Gray RH, Wawer MJ, Grabowski KM, Chang LW, Hoog AV, Cobelens F, Reynolds SJ. Dynamics of Pre-Exposure (PrEP) Eligibility Because of Waxing and Waning of HIV Risk in Rakai, Uganda. J Acquir Immune Defic Syndr 2023; 93:143-153. [PMID: 36889304 PMCID: PMC10179981 DOI: 10.1097/qai.0000000000003182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
BACKGROUND We conducted a retrospective population-based study to describe longitudinal patterns of prevalence, incidence, discontinuation, resumption, and durability of substantial HIV risk behaviors (SHR) for pre-exposure prophylaxis (PrEP) eligibility. METHODS The study was conducted among HIV-negative study participants aged 15-49 years who participated in survey rounds of the Rakai Community Cohort Study between August 2011 and June 2018. Substantial HIV risk was defined based on the Uganda national PrEP eligibility as reporting sexual intercourse with >1 partner of unknown HIV status, nonmarital sex without a condom, having genital ulcers, or having transactional sex. Resumption of SHR meant resuming of SHR after stopping SHR, whereas persistence of SHR meant SHR on >1 consecutive visit. We used generalized estimation equations with log-binomial regression models and robust variance to estimate survey-specific prevalence ratios; Generalized estimation equations with modified Poisson regression models and robust variance to estimate incidence ratios for incidence, discontinuation, and resumption of PrEP eligibility. FINDINGS Incidence of PrEP eligibility increased from 11.4/100 person-years (pys) in the first intersurvey period to 13.9/100 pys (adjusted incidence rate ratios = 1.28; 95%CI = 1.10-1.30) and declined to 12.6/100 pys (adjusted incidence rate ratios = 1.06; 95%CI = 0.98-1.15) in the second and third intersurvey periods, respectively. Discontinuation rates of SHR for PrEP eligibility were stable (ranging 34.9/100 pys-37.3/100 pys; P = 0.207), whereas resumption reduced from 25.0/100 pys to 14.5/100 pys ( P < 0.001). PrEP eligibility episodes lasted a median time of 20 months (IQR = 10-51). INTERPRETATION Pre-exposure prophylaxis use should be tailored to the dynamic nature of PrEP eligibility. Preventive-effective adherence should be adopted for assessment of attrition in PrEP programs.
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Affiliation(s)
- Victor Ssempijja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | | | - Anna Mia Ekstrom
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases, South Central Hospital, Stockholm, Sweden
| | | | | | - James Batte
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | - Ping Teresa Yeh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Thomas C. Quinn
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Ronald H. Gray
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria J. Wawer
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kate M. Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Larry W. Chang
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anja van't Hoog
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands; and
- Health Research and Training Consultancy, Utrecht, the Netherlands
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands; and
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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12
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Ogale YP, Kennedy CE, Nalugoda F, Mpagazi J, Jackson JC, Galiwango R, Ssekubugu R, Kigozi G, Denison JA, Gaydos CA, Kagaayi J, Grabowski MK. Nearly half of adults with symptoms of sexually transmitted infections (STIs) did not seek clinical care: A population-based study of treatment-seeking behavior among adults in Rakai, Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001626. [PMID: 37126490 PMCID: PMC10150988 DOI: 10.1371/journal.pgph.0001626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/02/2023] [Indexed: 05/02/2023]
Abstract
Understanding treatment-seeking behavior is critical to the treatment and control of sexually transmitted infections (STIs), yet current data on STI treatment seeking in low-resource settings is rare. This population-based study aimed to describe STI treatment-seeking behavior and identify factors associated with seeking treatment at a clinic among adults with STI-related symptoms in rural Uganda. The STI prevalence study (STIPS) conducted a survey and STI testing among all consenting adults aged 18-49 in two communities in rural south-central Uganda. Of 1,825 participants, 962 individuals self-reported STI symptoms in the past six months; we present descriptive data on treatment seeking and STI prevalence among these individuals. We used multivariable Poisson regressions with robust variance to determine the sociodemographic and symptom-related factors independently associated with seeking STI treatment at a clinic and assessed the association with previous clinic treatment seeking and current STI diagnosis. Forty-three percent of adults who reported STI-related symptoms in the past six months said they did not seek any treatment. Among those who did, 58% sought treatment at a private clinic, 28% at a government clinic, 9% at a pharmacy/drug store, 3% at a traditional healer, 2% at a market/shop, and 5% at another location. Among both males and females, having multiple STI related symptoms was positively associated with clinic treatment seeking (males = PRR: 1.73, 95%CI: 1.36-2.21; females = PR: 1.41, 95%CI: 1.12-1.78). Approximately one-third of males and females who reported previously seeking clinic treatment for their symptoms were diagnosed with a curable STI at the time of the survey. In this setting, nearly half of adults with STI-related symptoms are not seeking clinical care and many who report having sought treatment for recent STI symptoms have curable STIs. Future studies should explore barriers to care-seeking and strategies to improve STI services.
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Affiliation(s)
- Yasmin P. Ogale
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Caitlin E. Kennedy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | | | - Jade C. Jackson
- Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | | | | | | | - Julie A. Denison
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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13
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Luseno WK, Rennie S, Gilbertson A. A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa. Int J Impot Res 2023; 35:269-278. [PMID: 34702986 PMCID: PMC8545773 DOI: 10.1038/s41443-021-00484-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022]
Abstract
Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.
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Affiliation(s)
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA
- UNC Center for Bioethics, University of North Carolina, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, NC, USA
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14
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Kremer C, Kamali A, Kuteesa M, Seeley J, Hens N, Nsubuga RN. Modelling the impact of combining HIV prevention interventions on HIV dynamics in fishing communities in Uganda. BMC Infect Dis 2023; 23:173. [PMID: 36949387 PMCID: PMC10031877 DOI: 10.1186/s12879-023-08113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/22/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND In countries with mature generalized HIV epidemics such as Uganda, there are still groups of individuals that are disproportionately affected. Among the key populations in Uganda are fishing communities, which make up about 10% of the population. Compared to the general population, HIV prevalence and incidence among individuals living in these communities is high. This high HIV burden has been attributed to several factors including limited access to prevention and treatment services as well as ongoing high-risk sexual behaviour. METHODS We investigated the impact of combined HIV prevention interventions on HIV transmission dynamics in high-risk fishing communities in Uganda using a deterministic compartmental model. The model was calibrated to seroprevalence data from a census performed in 2014. To account for remaining uncertainty in the calibrated model parameters, 50 000 simulated scenarios were modelled to investigate the impact of combined prevention interventions. RESULTS The projected HIV incidence decreased from 1.87 per 100 PY without intervention scale-up to 0.25 per 100 PY after 15 years (2014-2029) of intervention scale-up. A potential combination achieving this 87% reduction in incidence over 15 years in Ugandan FCs included condom use in about 60% of sexual acts, 23% of susceptible men circumcised, 87% of people living with HIV aware of their status, 75% of those on ART, and about 3% of susceptible individuals on oral PrEP. Uncertainty analysis revealed relative reductions in incidence ranging from 30.9 to 86.8%. Sensitivity analyses suggested that condom use and early ART were the most important interventions. CONCLUSION Reducing HIV incidence, as well as prevalence and AIDS-related mortality, in these high-risk fishing communities in Uganda is attainable over 15 years with a combination prevention package. Our projected intervention coverage levels are well within the national targets set by the Uganda government and enable coming close to reaching the UNAIDS 95-95-95 targets to end AIDS as a public health threat by 2030.
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Affiliation(s)
- Cécile Kremer
- Interuniversity Institute for Biostatistics and Bioinformatics (I-BioStat), Data Science Institute, Hasselt University, Hasselt, Belgium.
| | | | - Monica Kuteesa
- London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK
- Medical Research Council, Virus Research Unit & LSHTM Uganda Research Unit (MRC/UVRI & LSHTM), Entebbe, Uganda
| | - Niel Hens
- Interuniversity Institute for Biostatistics and Bioinformatics (I-BioStat), Data Science Institute, Hasselt University, Hasselt, Belgium
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Rebecca N Nsubuga
- Medical Research Council, Virus Research Unit & LSHTM Uganda Research Unit (MRC/UVRI & LSHTM), Entebbe, Uganda
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Bose DL, Hundal A, Singh S, Singh S, Seth K, Hadi SU, Saran A, Joseph J, Goyal K, Salve S. Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs). CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1297. [PMID: 36911864 PMCID: PMC9831290 DOI: 10.1002/cl2.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design. OBJECTIVES The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research. METHODS This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added. SELECTION CRITERIA To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes. RESULTS This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied. CONCLUSION This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.
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Nakamanya S, Nakyanjo N, Kennedy C, Ddaaki W, Ayanga C, Ssemwanga RJ, Jackson J, Grabowski MK, Seeley J. Understanding the drivers of preferential migration of people living with HIV to fishing communities of Lake Victoria in Uganda. Glob Public Health 2023; 18:2256819. [PMID: 37699746 DOI: 10.1080/17441692.2023.2256819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023]
Abstract
Fishing communities around Lake Victoria have among the highest burdens of HIV globally. Growing evidence suggests that high HIV prevalence is partially due to selective migration of people living with HIV to fishing communities. However, the reasons for this preferential migration are unclear. We recruited 60 men and women for qualitative in-depth interviews (30% living with HIV; 70% recent migrants of unknown HIV status) from seven Ugandan fishing communities. Interviews discussed mobility histories and the social context surrounding migration. Interviews were audio-recorded, transcribed, and translated. A version of the 'Push-Pull' theory of migration helped structure a conceptual thematic framework for data analysis. Unfavourable conditions related primarily to stigma, social discrimination, humiliation, rejection or HIV labelling, and violence, induced individuals to leave their home communities. Factors which eventually resulted in migration to fishing communities included anticipating less HIV-related stigma and a safe, friendly environment that accommodates all people. Access to healthy food (fish) and the perceived availability of community-based HIV care services were also attractions. We found that stigma is the major social phenomenon shaping preferential migration to fishing communities in Uganda.
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Affiliation(s)
- Sarah Nakamanya
- Social sciences, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI&LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Neema Nakyanjo
- Department of Social and Behavioural Sciences, Rakai Health Sciences Program (RHSP), Kalisizo, Uganda
| | - Caitlin Kennedy
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - William Ddaaki
- Department of Social and Behavioural Sciences, Rakai Health Sciences Program (RHSP), Kalisizo, Uganda
| | - Christine Ayanga
- Social sciences, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI&LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Richard John Ssemwanga
- Department of Social and Behavioural Sciences, Rakai Health Sciences Program (RHSP), Kalisizo, Uganda
| | - Jade Jackson
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - M Kate Grabowski
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Janet Seeley
- Social sciences, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI&LSHTM), Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Grabowski MK, Mpagazi J, Kiboneka S, Ssekubugu R, Kereba JB, Nakayijja A, Tukundane J, Jackson JC, Peer AD, Kennedy C, Kigozi G, Galiwango RM, Manabe YC, Chang LW, Kalibala S, Gray RH, Wawer MJ, Reynolds SJ, Tobian AAR, Serwadda D, Gaydos CA, Kagaayi J, Quinn TC. The HIV and sexually transmitted infection syndemic following mass scale-up of combination HIV interventions in two communities in southern Uganda: a population-based cross-sectional study. Lancet Glob Health 2022; 10:e1825-e1834. [PMID: 36400088 PMCID: PMC10068679 DOI: 10.1016/s2214-109x(22)00424-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/13/2022] [Accepted: 09/21/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Combination HIV prevention and treatment interventions (CHIs) have led to substantial declines in HIV incidence in sub-Saharan Africa; however, population-level data on non-HIV sexually transmitted infections (STIs) in the context of CHIs are rare. We aimed to assess STI burden following scale-up of CHIs in Uganda. METHODS The Sexually Transmitted Infection Prevalence Study (STIPS) was a cross-sectional study nested within a population-based cohort among inland agrarian and Lake Victoria fishing populations in southern Uganda. STIPS enrolled consenting residents aged 18-49 years in two communities (one inland and one fishing) between May and October, 2019, and measured the prevalence of chlamydia, gonorrhoea, trichomonas, syphilis, and herpes simplex virus 2 (HSV-2). FINDINGS Between May 27, 2019 and Oct 25, 2019, STIPS enrolled 1825 participants. HIV prevalence was 14·0% among the inland population and 39·8% among the fishing population, with about 90% HIV viral load suppression in both communities. Among inland and fishing populations, chlamydia prevalence was 9·6% (95% CI 7·9-11·7) and 9·9% (8·1-12·0), gonorrhoea prevalence 5·0% (3·8-6·7) and 8·4% (6·8-10·5), trichomonas prevalence 9·4% (7·7-11·5) and 12·2% (10·2-14·5), and HSV-2 prevalence 43·0% (39·9-46·3) and 64·4% (61·3-67·6), respectively. In the fishing population, syphilis seropositivity was 24·2% (21·5-27·2) with 9·4% (7·7-11·5) having high-titre (rapid plasma reagin ≥1:8) infection, including 16·9% (11·9-24·0%) of men living with HIV. Prevalence of at least one curable STI (chlamydia, gonorrhoea, trichomonas, or high-titre syphilis) was 51% higher among people living with HIV (vs HIV negative; adjusted prevalence risk ratio [PRR] 1·51; 95% CI 1·27-1·78), including among pregnant women (adjusted PRR 1·87, 1·11-3·17), with no differences by HIV suppression status. INTERPRETATION Despite near universal HIV treatment, STI burden remains extremely high in southern Uganda, particularly among people living with HIV. There is an urgent need to integrate STI care with HIV services in African settings. FUNDING National Institutes of Health.
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Affiliation(s)
- M Kate Grabowski
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Rakai Health Sciences Program, Kalisizo, Uganda.
| | | | | | | | | | | | | | - Jade C Jackson
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Austin D Peer
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Caitlin Kennedy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Rakai Health Sciences Program, Kalisizo, Uganda
| | | | | | - Yukari C Manabe
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Larry W Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Rakai Health Sciences Program, Kalisizo, Uganda; Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Rakai Health Sciences Program, Kalisizo, Uganda
| | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Rakai Health Sciences Program, Kalisizo, Uganda
| | - Steven J Reynolds
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Rakai Health Sciences Program, Kalisizo, Uganda; Department of Medicine, Johns Hopkins University, Baltimore, MD, USA; Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MA, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda; Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | | | - Joseph Kagaayi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Thomas C Quinn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Rakai Health Sciences Program, Kalisizo, Uganda; Department of Medicine, Johns Hopkins University, Baltimore, MD, USA; Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MA, USA
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Ssekubugu R, Makumbi F, Enriquez R, Lagerström SR, Yeh PT, Kennedy CE, Gray RH, Negesa L, Serwadda DM, Kigozi G, Ekström AM, Nordenstedt H. Cardiovascular (Framingham) and type II diabetes (Finnish Diabetes) risk scores: a qualitative study of local knowledge of diet, physical activity and body measurements in rural Rakai, Uganda. BMC Public Health 2022; 22:2214. [PMID: 36447173 PMCID: PMC9706863 DOI: 10.1186/s12889-022-14620-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Non-communicable diseases such as cardiovascular conditions and diabetes are rising in sub-Saharan Africa. Prevention strategies to mitigate non-communicable diseases include improving diet, physical activity, early diagnosis, and long-term management. Early identification of individuals at risk based on risk-score models - such as the Framingham Risk Score (FRS) for 10-year risk of cardiovascular disease and the Finnish type 2 Diabetes risk score (FINDRISC) for type 2 diabetes which are used in high-income settings - have not been well assessed in sub-Saharan Africa. The purpose of this study was to qualitatively assess local knowledge of components of these risk scores in a rural Ugandan setting. METHODS Semi-structured qualitative in-depth interviews were conducted with a purposively selected sample of 15 participants who had responded to the FRS and FINDRISC questionnaires and procedures embedded in the Rakai Community Cohort Study. Data were summarized and categorized using content analysis, with support of Atlas.ti. RESULTS Participants described local terms for hypertension ("pulessa") and type 2 diabetes ("sukaali"). Most participants understood physical activity as leisure physical activity, but when probed would also include physical activity linked to routine farm work. Vegetables were typically described as "plants", "leafy greens", and "side dish". Vegetable and fruit consumption was described as varying seasonally, with peak availability in December after the rainy season. Participants perceived themselves to have good knowledge about their family members' history of type 2 diabetes and hypertension. CONCLUSIONS While most items of the FRS and FINDRISC were generally well understood, physical activity needs further clarification. It is important to consider the seasonality of fruits and vegetables, especially in rural resource-poor settings. Current risk scores will need to be locally adapted to estimate the 10-year risk of cardiovascular diseases and type 2 diabetes in this setting.
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Affiliation(s)
- Robert Ssekubugu
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Fredrick Makumbi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology and Biostatistics-School of Public Health, College of Health Sciences, Makerere University-Kampala, Kampala, Uganda
| | - Rocio Enriquez
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Ping Teresa Yeh
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Caitlin E. Kennedy
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Ronald H. Gray
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - David M. Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology and Biostatistics-School of Public Health, College of Health Sciences, Makerere University-Kampala, Kampala, Uganda
| | | | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Disease Clinic/Venhälsan, South General Hospital Stockholm, Stockholm, Sweden
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine and Infectious Diseases, Danderyd University Hospital, Stockholm, Sweden
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Kankaka EN, Nalugoda F, Serwadda D, Makumbi F, Wawer MJ, Gray RH, Quinn TC, Reynolds SJ, Nakigozi G, Lutalo T, Kigozi G, Sewankambo NK, Kagaayi J. Makerere's contribution to the development of a high impact HIV research population-based cohort in the Rakai Region, Uganda. Afr Health Sci 2022; 22:42-50. [PMID: 36321125 PMCID: PMC9590336 DOI: 10.4314/ahs.v22i2.7s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Longitudinal population-based cohort studies can provide critical insights on temporal, spatial and sociodemographic changes in health status and health determinants that are not obtained by other study designs. However, establishing and maintaining such a cohort study can be challenging and expensive. Here, we describe the role of Makerere University in the development and conduct of such a cohort. We chronicle the first academia-led reports of HIV in East Africa; how this led to initiation of the Rakai Community Cohort Study in 1988, the first and oldest HIV cohort in sub-Saharan Africa; its impact on HIV prevention, care and treatment; how the cohort has been maintained; and opportunities, challenges, and future directions including non-communicable diseases.
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Affiliation(s)
| | | | - David Serwadda
- Rakai Health Sciences Program
- Makerere University College of Health Sciences, School of Public Health
| | - Fredrick Makumbi
- Rakai Health Sciences Program
- Makerere University College of Health Sciences, School of Public Health
| | - Maria J Wawer
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
- Johns Hopkins University School of Medicine
| | - Ronald H Gray
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
| | - Thomas C Quinn
- Johns Hopkins University School of Medicine
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH
| | - Steven J Reynolds
- Johns Hopkins University School of Medicine
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH
| | | | - Tom Lutalo
- Rakai Health Sciences Program
- Uganda Virus Research Institute
| | | | - Nelson K Sewankambo
- Rakai Health Sciences Program
- Makerere University College of Health Sciences, School of Medicine
| | - Joseph Kagaayi
- Rakai Health Sciences Program
- Makerere University College of Health Sciences, School of Public Health
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Ssempijja V, Nakigozi G, Ssekubugu R, Kagaayi J, Kigozi G, Nalugoda F, Nantume B, Batte J, Kigozi G, Yeh PT, Nakawooya H, Serwadda D, Quinn TC, Gray RH, Wawer MJ, Grabowski KM, Chang LW, van't Hoog A, Cobelens F, Reynolds SJ. High Rates of Pre-exposure Prophylaxis Eligibility and Associated HIV Incidence in a Population With a Generalized HIV Epidemic in Rakai, Uganda. J Acquir Immune Defic Syndr 2022; 90:291-299. [PMID: 35259129 PMCID: PMC9177156 DOI: 10.1097/qai.0000000000002946] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The utility of using pre-exposure prophylaxis (PrEP) eligibility assessments to identify eligibility in general populations has not been well studied in sub-Saharan Africa. We used the Rakai Community Cohort Study to conduct a cross-sectional analysis to estimate PrEP eligibility and a cohort analysis to estimate HIV incidence associated with PrEP eligibility. METHODS Based on Uganda's national PrEP eligibility tool, we defined eligibility as reporting at least one of the following HIV risks in the past 12 months: sexual intercourse with more than one partner of unknown HIV status; nonmarital sex act without a condom; sex engagement in exchange for money, goods, or services; or experiencing genital ulcers. We used log-binomial and modified Poisson models to estimate prevalence ratios for PrEP eligibility and HIV incidence, respectively. FINDINGS We identified 12,764 participants among whom to estimate PrEP eligibility prevalence and 11,363 participants with 17,381 follow-up visits and 30,721 person-years (pys) of observation to estimate HIV incidence. Overall, 29% met at least one of the eligibility criteria. HIV incidence was significantly higher in PrEP-eligible versus non-PrEP-eligible participants (0.91/100 pys versus 0.41/100 pys; P < 0.001) and independently higher in PrEP-eligible versus non-PrEP-eligible female participants (1.18/100 pys versus 0.50/100 pys; P < 0.001). Among uncircumcised male participants, HIV incidence was significantly higher in PrEP-eligible versus non-PrEP-eligible participants (1.07/100 pys versus 0.27/100 pys; P = 0.001), but there was no significant difference for circumcised male participants. INTERPRETATION Implementing PrEP as a standard HIV prevention tool in generalized HIV epidemics beyond currently recognized high-risk key populations could further reduce HIV acquisition and aid epidemic control efforts.
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Affiliation(s)
- Victor Ssempijja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
- Rakai Health Sciences Program, Entebbe, Uganda;
| | | | | | | | | | | | | | - James Batte
- Rakai Health Sciences Program, Entebbe, Uganda;
| | | | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda;
- Makerere University School of Public Health, Kampala, Uganda;
| | - Thomas C. Quinn
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Ronald H. Gray
- Rakai Health Sciences Program, Entebbe, Uganda;
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria J. Wawer
- Rakai Health Sciences Program, Entebbe, Uganda;
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kate M. Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda;
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD; and
| | - Larry W. Chang
- Rakai Health Sciences Program, Entebbe, Uganda;
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anja van't Hoog
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda;
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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Byaruhanga A, Mbona NT, Babirye S, Nalugoda F, Kankaka EN, Ampaire L, Migisha R, Kagaayi J. Women’s support for voluntary medical male circumcision in fishing communities on the shores of Lake Victoria, Uganda. BMC Health Serv Res 2022; 22:505. [PMID: 35421972 PMCID: PMC9012010 DOI: 10.1186/s12913-022-07842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Women’s support can improve uptake of voluntary medical male circumcision (VMMC). We assessed the level of women’s support for VMMC and associated factors in fishing settlements on the shores of Lake Victoria in Uganda, to inform interventions aimed at increasing the uptake of safe male circumcision services in such high-risk populations. Methods We conducted a cross-sectional study, employing mixed methods of data collection, at Kasenyi and Kigungu landing sites in April 2018. We included women aged 18–49 years, who had stayed at the landing sites for ≥3 months. We obtained qualitative data using focus group discussions (FGDs), and interviewer-administered semi-structured questionnaires for quantitative data. The tool captured demographic characteristics, community factors including cultural norms and beliefs, women’s experiences, and health facility-related factors. The dependent variable was derived from the response to the question: "Would you encourage your partner/husband to go for VMMC?", and used as a proxy for support of VMMC. We used modified Poisson regression to identify factors associated with women’s support for VMMC. Qualitative data were analysed using thematic content analysis. Results We enrolled 313 women with a mean age of 28 (SD±6.8) years. Of the 313 women, 230 (73.5%) supported VMMC. Belief that VMMC increases penile hygiene (Adjusted prevalence ratio [aPR]=1.9; CI: 1.8–3.2), performing VMMC for religious reasons (aPR=1.9; CI: 1.8–2.9), preference for a circumcised man (aPR=1.3; CI: 1.2–1.5), belief that vaginal fluids facilitate wound healing (aPR=1.9; CI: 1.3–2.7), and knowledge about when a man can resume sex (4 weeks) after circumcision (aPR=2.1; CI: 1.8–3.3) were associated with women’s support for VMMC. FGDs revealed that women were not adequately involved in VMMC activities for decision making. Conclusion The support for VMMC was high among women in the fishing communities. However, women perceived they were not involved in decision-making for VMMC and had several misconceptions, including a belief that vaginal fluids facilitate wound healing. The Ministry of Health and VMMC implementing partners should devise strategies to increase sensitization and involvement of women in VMMC decision-making without slowing service uptake.
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Ssuuna C, Ssempijja V, Kalibbala S, Serwadda D, Yeh PT, Wawer M, Gray R, Chang L, Kagaayi J, Reynolds S. Hepatitis B virus infection and factors associated with its acquisition among adults in a Lake Victoria HIV hyperendemic fishing community in Kyotera district, Uganda: a cross-sectional observation. BMJ Open 2022; 12:e050436. [PMID: 35393306 PMCID: PMC8990708 DOI: 10.1136/bmjopen-2021-050436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/07/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To investigate hepatitis B virus (HBV) prevalence and factors associated with viral acquisition in a HIV-hyperendemic fishing community, we tested sera for anti-hepatitis B core (HBc) and hepatitis B surface antigen (HBsAg). DESIGN Observational cross-sectional study. SETTING Large fishing village on Lake Victoria, one of the HIV-hyperendemic Rakai Community Cohort Study (RCCS) sites (HIV prevalence ~40%). PARTICIPANTS Sample of 460 RCCS participants aged 15-49 years from survey conducted from 5 December 2016 to 13 February 2017. These proportionately included HIV-negative, HIV-positive antiretroviral therapy (ART)-naïve and HIV positive on ART participants. RESULTS Of the 460 participants, 49.6% (95% CI 45.0% to 54.1%) had evidence of prior HBV infection and 3.7% (95% CI 2.3% to 5.9%) were either acutely or chronically infected. HBV risk increased with age, number of lifetime sex partners and HIV seropositivity. HBV risk decreased with HIV ART use among HIV-positive participants. Prevalence of prior HBV infection was 17.1% in participants aged 15-19 years, 43.2%, 55.3% and 70.1% in participants aged 20-39, 30-39 and 40-49 years, respectively (p<0.001). Additionally, the prevalence of prior HBV infection was 23.8% in participants with 0-1 lifetime sex partners, 43.2% and 54.8% in participants with 2-3 lifetime sex partners and 4+ lifetime sex partners, respectively (p<0.001). CONCLUSIONS Findings from this fishing community suggest the need to provide HBV vaccination to adults at risk of sexual transmission who have not been previously immunised.
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Affiliation(s)
| | - Victor Ssempijja
- Rakai Health Sciences Program, Kalisizo, Uganda
- Clinical Monitoring Research Program Directorate (CMRPD), Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | | | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda
| | - Ping Teresa Yeh
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Maria Wawer
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ronald Gray
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Larry Chang
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- School of Medicine, Department of Infectious Disease, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Steven Reynolds
- School of Medicine, Department of Infectious Disease, Johns Hopkins University, Baltimore, Maryland, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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23
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
Introduction Men are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. Methods We systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis. Results and discussion We screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. Conclusions Psychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Global Health Institute, Cambridge, Massachusetts, USA
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24
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Mosha NR, Todd J, Mukerebe C, Marston M, Colombe S, Clark B, Beard J, Mtenga B, Slaymaker E, Boerma T, Zaba B, Urassa M. The prevalence and incidence of HIV in the ART era (2006-2016) in North West Tanzania. Int J STD AIDS 2022; 33:337-346. [PMID: 35040735 PMCID: PMC7612632 DOI: 10.1177/09564624211065232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Sub-Saharan countries bears a disproportionate percentage of HIV infections and HIV related deaths despite the efforts to strengthen HIV prevention and treatments services, including ART. It is important to demonstrate how these services have contributed to reducing the epidemic using available population data. Methods We estimated the prevalence and incidence rates from a cohort running over 23 years in Magu District, Mwanza Region-North West Tanzania. Adults 15 years and over who were residents of the Kisesa observational HIV cohort study between 2006 and 2016 were eligible for inclusion. Survival analysis was used to calculate person-time at risk, incidence rates and 95% confidence intervals (CI). Cox regression models were used for the risk factor analyses disaggregated by sex and age group. Results The HIV prevalence in the sero-surveys decreased from 7.2% in 2006/07 to 6.6% in 2016, with a notable decrease of over 50% for both men and women aged 15-24 years. The incidence rate for HIV was estimated to be 5.5 (95% CI 4.6 - 6.6) per 1000 person-years in women compared to 4.6 (95% CI 3.5 – 5.8) in men, with a decrease over time. Despite the availability of ART services, the uptake is still small. Conclusions New infections are still occurring, with high HIV incidence in individuals aged below 45 years. With new guidelines and the 95-95-95 UNAIDS target, prevalence and incidence must be adequately assessed. In addition, there is a need for additional efforts to assess the impact of HIV/AIDS prevention programmes and intervention services, especially in these areas where resources are limited.
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Affiliation(s)
- Neema R Mosha
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, 121470Stellenbosch University, Cape Town, South Africa.,Mwanza Intervention Trials Unit, Mwanza, Tanzania.,119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Jim Todd
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania.,Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Crispin Mukerebe
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Milly Marston
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | | | - Benjamin Clark
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - James Beard
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Baltazar Mtenga
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Emma Slaymaker
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Ties Boerma
- University of Manitoba, Winnipeg, MB, Canada
| | - Basia Zaba
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Urassa
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
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25
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Santelli JS, Chen IS, Nabukalu D, Lutalo T, Spindler EJ, Chang LW, Grabowski MK, Grilo SA, Kreniske P, Wei Y, Nalugoda F, Hoffman S, Maru M, Chu S, Ssewamala FM, Byansi W, Kagaayi J, Wawer MJ, Gray RH, Serwadda D, Makumbi F. HIV combination prevention and declining orphanhood among adolescents, Rakai, Uganda, 2001-18: an observational community cohort study. Lancet HIV 2022; 9:e32-e41. [PMID: 34973171 PMCID: PMC9125395 DOI: 10.1016/s2352-3018(21)00275-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/12/2021] [Accepted: 10/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Orphanhood increased markedly in the 1980s and 1990s in sub-Saharan Africa because of HIV-related mortality. Little is known about the contribution of HIV interventions, such as antiretroviral therapy (ART) and male medical circumcision, to more recent trends in orphanhood. In this study, we examined trends over time in maternal-only, paternal-only, and double orphanhood among adolescents before and after ART and male medical circumcision became widely available in the Rakai region of south-central Uganda. We sought to understand the association between adolescent orphanhood and HIV combination prevention (community-level ART use and prevalence of male medical circumcision). We hypothesised that increasing combination prevention, including greater use of ART and higher prevalence of male medical circumcision, would be associated with a lower probability of orphanhood. METHODS We examined the prevalence of orphanhood among adolescents aged 15-19 years, before and after roll-out of ART in mid-2004 and male medical circumcision in 2007, using data from 28 continuously followed communities within the Rakai Community Cohort Study. We used multinomial logistic regression with clustered SEs to estimate adjusted relative risk ratios (RRs) for maternal-only, paternal-only, and double orphanhood compared with non-orphanhood over 11 survey rounds between 2001 and 2018. Controlling for community HIV prevalence, household socioeconomic status, and adolescent age, we examined the association between community prevalence of ART use among people living with HIV and prevalence of male circumcision, including traditional circumcision. The primary outcome was orphanhood among adolescents aged 15-19 years. FINDINGS Orphanhood declined from 52% (920 of 1768 participants) in 2001-02 to 23% (592 of 2609 participants) by 2016-18 (p<0·0001), while double orphanhood declined from 20% (346 of 1768 participants) to 3% (86 of 2609 participants) (p<0·0001). Community prevalence of ART use among people living with HIV increased from 11% (105 of 945 participants) in 2005-06 to 78% (1163 of 1485 participants) in 2016-18. Male circumcision rates rose from 19% (147 of 790 participants) in 2005-06 to 65% (3535 of 5433 participants) in 2016-18. In the multinomial logistic regression model, a 10% increase in community prevalence of ART use was associated with a decrease in maternal orphanhood (adjusted relative RR 0·90, 95% CI 0·85-0·95) and double orphanhood (0·80, 0·75-0·85). In the post-ART era, a 10% increase in the community prevalence of male circumcision was associated with a decrease in paternal orphanhood (2005-18, adjusted relative RR 0·92, 0·87-0·97) and double orphanhood (0·91, 0·85-0·98). INTERPRETATION Widespread availability and uptake of HIV combination prevention was associated with marked reductions in orphanhood among adolescents. Reductions in orphanhood promise improved health and social outcomes for young people. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases.
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Affiliation(s)
- John S Santelli
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA,Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ivy S Chen
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - Esther J Spindler
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Larry W Chang
- Rakai Health Sciences Program, Kalisizo, Uganda,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mary Kate Grabowski
- Rakai Health Sciences Program, Kalisizo, Uganda,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Stephanie A Grilo
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Philip Kreniske
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, USA
| | - Ying Wei
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Susie Hoffman
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Mahlet Maru
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sofia Chu
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | | | - Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Uganda,Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Maria J Wawer
- Rakai Health Sciences Program, Kalisizo, Uganda,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ronald H Gray
- Rakai Health Sciences Program, Kalisizo, Uganda,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda,Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Fred Makumbi
- Rakai Health Sciences Program, Kalisizo, Uganda,Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
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26
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Ddaaki W, Strömdahl S, Yeh PT, Rosen JG, Jackson J, Nakyanjo N, Kagaayi J, Kigozi G, Nakigozi G, Grabowski MK, Chang LW, Reynolds SJ, Nalugoda F, Ekström AM, Kennedy CE. Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda. AIDS Behav 2021; 25:3547-3562. [PMID: 34240317 DOI: 10.1007/s10461-021-03360-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/19/2022]
Abstract
Uganda piloted HIV pre-exposure prophylaxis (PrEP) for priority populations (sex workers, fishermen, truck drivers, discordant couples) in 2017. To assess facilitators and barriers to PrEP uptake and adherence, we explored perceptions of PrEP before and experiences after rollout among community members and providers in south-central Uganda. We conducted 75 in-depth interviews and 12 focus group discussions. We analyzed transcripts using a team-based thematic framework approach. Partners, family, peers, and experienced PrEP users provided adherence support. Occupational factors hindered adherence for sex workers and fishermen, particularly related to mobility. Pre-rollout concerns about unskilled/untrained volunteers distributing PrEP and price-gouging were mitigated. After rollout, awareness of high community HIV risk and trust in PrEP effectiveness facilitated uptake. PrEP stigma and unexpected migration persisted as barriers. Community-initiated, tailored communication with successful PrEP users may optimize future engagement by addressing fears and rumors, while flexible delivery and refill models may facilitate PrEP continuation and adherence.
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27
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Joshi K, Lessler J, Olawore O, Loevinsohn G, Bushey S, Tobian AAR, Grabowski MK. Declining HIV incidence in sub-Saharan Africa: a systematic review and meta-analysis of empiric data. J Int AIDS Soc 2021; 24:e25818. [PMID: 34672104 PMCID: PMC8528667 DOI: 10.1002/jia2.25818] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction UNAIDS models suggest HIV incidence is declining in sub‐Saharan Africa. The objective of this study was to assess whether modelled trends are supported by empirical evidence. Methods We conducted a systematic review and meta‐analysis of adult HIV incidence data from sub‐Saharan Africa by searching Embase, Scopus, PubMed and OVID databases and technical reports published between 1 January 2010 and 23 July 2019. We included prospective and cross‐sectional studies that directly measured incidence from blood samples. Incidence data were abstracted according to population risk group, geographic location, sex, intervention arm and calendar period. Weighted regression models were used to assess incidence trends across general population studies by sex. We also identified studies reporting greater than or equal to three incidence measurements since 2010 and assessed trends within them. Results Total 291 studies, including 22 sub‐Saharan African countries, met inclusion criteria. Most studies were conducted in South Africa (n = 102), Uganda (n = 46) and Kenya (n = 41); there were 26 countries with no published incidence data, most in western and central Africa. Data were most commonly derived from prospective observational studies (n = 163; 56%) and from geographically defined populations with limited demographic or risk‐based enrolment criteria other than age (i.e., general population studies; n = 151; 52%). Across general population studies, average annual incidence declines since 2010 were 0.12/100 person‐years (95% CI: 0.06–0.18; p = 0.001) among men and 0.10/100 person‐years (95% CI: −0.02–0.22; p = 0.093) among women in eastern Africa, and 0.25/100 person‐years (95% CI: 0.17–034; p < 0.0001) among men and 0.42/100 person‐years (95% CI: 0.23–0.62; p = 0.0002) among women in southern Africa. In nine of 10 studies with multiple measurements, incidence declined over time, including in two studies of key populations. Across all population risk groups, the highest HIV incidence estimates were observed among men who have sex with men, with rates ranging from 1.0 to 15.4/100 person‐years. Within general population studies, incidence was typically higher in women than men with a median female‐to‐male incidence rate ratio of 1.47 (IQR: 1.11 to 1.83) with evidence of a growing sex disparity over time. Conclusions Empirical incidence data show the rate of new HIV infections is declining in eastern and southern Africa. However, recent incidence data are non‐existent or very limited for many countries and key populations.
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Affiliation(s)
- Keya Joshi
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Oluwasolape Olawore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Gideon Loevinsohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sophrena Bushey
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M Kate Grabowski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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28
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Loevinsohn G, Kigozi G, Kagaayi J, Wawer MJ, Nalugoda F, Chang LW, Quinn TC, Serwadda D, Reynolds SJ, Nelson L, Mills L, Alamo S, Nakigozi G, Kabuye G, Ssekubugu R, Tobian AAR, Gray RH, Grabowski MK. Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda. Clin Infect Dis 2021; 73:e1946-e1953. [PMID: 33043978 PMCID: PMC8492113 DOI: 10.1093/cid/ciaa1533] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/06/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President's Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. METHODS A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men. RESULTS A total of 3916 non-Muslim men were followed for 17 088 person-years (PY). There were 1338 newly reported VMMCs (9.8/100 PY). Over the study period, the median age of men adopting VMMC declined from 28 years (interquartile range [IQR], 21-35 years) to 22 years (IQR, 18-29 years) (P for trend < .001). HIV incidence was 0.40/100 PY (20/4992.8 PY) among newly circumcised men and 0.98/100 PY (118/12 095.1 PY) among uncircumcised men with an adjusted IRR of 0.47 (95% confidence interval, .28-.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time. CONCLUSIONS VMMC programs are highly effective in preventing HIV acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.
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Affiliation(s)
- Gideon Loevinsohn
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Larry W Chang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- School of Public Health, Makerere University, Kampala, Uganda
| | - Steven J Reynolds
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Nelson
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Lisa Mills
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Stella Alamo
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Geoffrey Kabuye
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Aaron A R Tobian
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - M Kathryn Grabowski
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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29
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Hines JZ, Sachathep K, Pals S, Davis SM, Toledo C, Bronson M, Parekh B, Carrasco M, Xaba S, Mandisarisa J, Kamobyi R, Chituwo O, Kirungi WL, Alamo S, Kabuye G, Awor AC, Mmbando S, Simbeye D, Aupokolo MA, Zemburuka B, Nyirenda R, Msungama W, Tarumbiswa T, Manda R, Nuwagaba-Biribonwoha H, Kiggundu V, Thomas AG, Watts H, Voetsch AC, Williams DB. HIV Incidence by Male Circumcision Status From the Population-Based HIV Impact Assessment Surveys-Eight Sub-Saharan African Countries, 2015-2017. J Acquir Immune Defic Syndr 2021; 87:S89-S96. [PMID: 33765683 PMCID: PMC11187824 DOI: 10.1097/qai.0000000000002658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Male circumcision (MC) offers men lifelong partial protection from heterosexually acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally representative samples. Data from the population-based HIV impact assessments were used to compare HIV incidence by MC status in countries implementing voluntary medical MC (VMMC) programs. METHODS Data were pooled from population-based HIV impact assessments conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2017. Incidence was measured using a recent infection testing algorithm and analyzed by self-reported MC status distinguishing between medical and nonmedical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random-effects logistic regression model using pooled survey weights. Analyses were age stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men. RESULTS Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men [0.04% (95% CI: 0.00% to 0.10%) versus 0.34% (95% CI: 0.10% to 0.57%), respectively; P value = 0.01]; whereas among men 35-59 years, there was no significant incidence difference [1.36% (95% CI: 0.32% to 2.39%) versus 0.55% (95% CI: 0.14% to 0.67%), respectively; P value = 0.14]. DISCUSSION Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa.
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Affiliation(s)
- Jonas Z. Hines
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Karampreet Sachathep
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Sherri Pals
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stephanie M. Davis
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carlos Toledo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Megan Bronson
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bharat Parekh
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maria Carrasco
- Office of HIV and AIDS, U.S. Agency for International Development, Washington, District of Columbia
| | | | - John Mandisarisa
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | | | - Omega Chituwo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Stella Alamo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Geoffrey Kabuye
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Anna Colletar Awor
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Susan Mmbando
- National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Daimon Simbeye
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | - Mekondjo A. Aupokolo
- National HIV/AIDS, STI and Hepatitis Control Program, Ministry of Health and Social Services, Windhoek, Namibia
| | - Brigitte Zemburuka
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | | | - Wezi Msungama
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Robert Manda
- U.S. Agency for International Development, Maseru, Lesotho
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia University, Mbabane, Eswatini
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Valerian Kiggundu
- Office of HIV and AIDS, U.S. Agency for International Development, Washington, District of Columbia
| | - Anne G. Thomas
- Defense Health Agency, U.S. Department of Defense, San Diego, California
| | - Heather Watts
- Office of Global AIDS Coordinator, Washington, District of Columbia
| | - Andrew C. Voetsch
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dan B. Williams
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
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Patel EU, Solomon SS, Lucas GM, McFall AM, Srikrishnan AK, Kumar MS, Iqbal SH, Saravanan S, Paneerselvam N, Balakrishnan P, Laeyendecker O, Celentano DD, Mehta SH. Temporal change in population-level prevalence of detectable HIV viraemia and its association with HIV incidence in key populations in India: a serial cross-sectional study. Lancet HIV 2021; 8:e544-e553. [PMID: 34331860 DOI: 10.1016/s2352-3018(21)00098-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 04/14/2021] [Accepted: 04/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Population-level prevalence of detectable HIV viraemia (PDV) has been proposed as a metric for monitoring the population-level effectiveness of HIV treatment as prevention. We aimed to characterise temporal changes in PDV in people who inject drugs (PWID) and men who have sex with men (MSM) in India and evaluate community-level and individual-level associations with cross-sectional HIV incidence. METHODS We did a serial cross-sectional study in which baseline (from Oct 1, 2012, to Dec 19, 2013) and follow-up (from Aug 1, 2016, to May 28, 2017) respondent-driven sampling (RDS) surveys were done in MSM (ten community sites) and PWID (12 community sites) across 21 cities in India. Eligible participants were those aged 18 years or older who provided informed consent and possessed a valid RDS referral coupon. Annualised HIV incidence was estimated with validated multiple-assay algorithms. PDV was calculated as the percentage of people with detectable HIV RNA (>150 copies per mL) in a community site. Community-level associations were determined by linear regression. Multivariable, multilevel Poisson regression was used to assess associations with recent HIV infection. FINDINGS We recruited 21 990 individuals in the baseline survey and 21 726 individuals in the follow-up survey. The median community-level HIV incidence estimate increased from 0·9% (range 0·0-2·2) at baseline to 1·5% (0·5-3·0) at follow-up in MSM and from 1·6% (0·5-12·4) to 3·6% (0·0-18·4) in PWID. At the community-level, every 1 percentage point increase in baseline PDV and temporal change in PDV between surveys was associated with higher annualised HIV incidence at follow-up: for baseline PDV β=0·41 (95% CI 0·18-0·63) and for change in PDV β=0·52 (0·38-0·66). After accounting for individual-level risk factors, every 10 percentage point increase in baseline PDV and temporal change in PDV was associated with higher individual-level risk of recent HIV infection at follow-up: adjusted risk ratio 1·85 (95% CI 1·44-2·37) for baseline PDV and 1·81 (1·43-2·29) for change in PDV. INTERPRETATION PDV was temporally associated with community-level and individual-level HIV incidence. These data support scale-up of treatment as prevention programmes to reduce HIV incidence and the programmatic use of PDV to monitor community HIV risk potential. FUNDING US National Institutes of Health, Elton John AIDS Foundation.
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Affiliation(s)
- Eshan U Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sunil S Solomon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Gregory M Lucas
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allison M McFall
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Syed H Iqbal
- YR Gaitonde Centre for AIDS Research and Education, Chennai, India
| | | | | | | | - Oliver Laeyendecker
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - David D Celentano
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Matovu JKB, Nambuusi A, Wanyenze RK, Serwadda D. Peer-leaders' experiences and challenges in distributing HIV self-test kits in a rural fishing community, Rakai, Uganda. BMC Public Health 2021; 21:708. [PMID: 33845811 PMCID: PMC8042983 DOI: 10.1186/s12889-021-10804-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background Distribution of HIV self-test kits by trained lay people in the community has resulted in increased uptake of HIV testing services among the targeted populations. However, little data exists on the experiences and challenges faced by trained lay people while distributing the kits. Methods This qualitative study was conducted in Kasensero fishing community, Rakai, Uganda, in September 2019. We purposely selected 18 out of 34 peer-leaders that participated in a peer-led HIV self-testing intervention to participate in a post-intervention qualitative evaluation. The main intervention included identification and training of lay people in the community (‘peer-leaders’) to distribute HIV self-test kits to pre-selected members of their social network. Data for this study were collected at the end of the intervention. Data were collected on peer-leaders’ experiences in distributing the kits, challenges experienced during distribution and suggestions on how to improve peer-led HIV self-testing in typical fishing communities in the future. Data were analyzed manually following a thematic framework approach. Results Of the 18 peer-leaders, eleven (61.1%) were aged 20–24 years while thirteen (72.2%) had secondary education. Most (n = 15) of the peer-leaders reported that they found it easier to distribute the kits to their social network members, with most of them distributing the kits at the social network members’ homes or at their own homes. HIV self-test kits were distributed at varying times (e.g. in the afternoon) depending on the agreement reached between the peer-leader and their social network member. A few peer-leaders reported that some of their social network members initially hesitated to accept the kits while other peer-leaders reported that they spent a ‘lot of time’ explaining the HIV self-testing procedures to some of their illiterate members. Peer-leaders argued for supervised HIV self-testing for illiterate people and the need to continuously follow-up social network members to check if they tested for HIV. Conclusion A majority of the peer-leaders successfully distributed the kits to their social network members save for a few who experienced challenges. These findings suggest that lay people can be trained as effective HIV self-test kits distributors to improve the distribution of kits in the community. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10804-x.
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Affiliation(s)
- Joseph K B Matovu
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda. .,Busitema University Faculty of Health Sciences, Mbale, Uganda.
| | - Aminah Nambuusi
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - David Serwadda
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
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Mastro TD, Bateganya M, Mahler H. The Need to Optimize Human Immunodeficiency Virus Test-and-Treat Programs in Africa. J Infect Dis 2021; 223:1117-1119. [PMID: 33474562 DOI: 10.1093/infdis/jiab022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 01/03/2023] Open
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Grabowski MK, Patel EU, Nakigozi G, Ssempijja V, Ssekubugu R, Ssekasanvu J, Ndyanabo A, Kigozi G, Nalugoda F, Gray RH, Kalibbala S, Serwadda DM, Laeyendecker O, Wawer MJ, Chang LW, Quinn TC, Kagaayi J, Tobian AAR, Reynolds SJ. Prevalence and Predictors of Persistent Human Immunodeficiency Virus Viremia and Viral Rebound After Universal Test and Treat: A Population-Based Study. J Infect Dis 2021; 223:1150-1160. [PMID: 33471100 PMCID: PMC8030722 DOI: 10.1093/infdis/jiab021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/13/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND There are limited data on individual human immunodeficiency virus (HIV) viral load (VL) trajectories at the population-level after the introduction of universal test and treat (UTT) in sub-Saharan Africa. METHODS Human immunodeficiency virus VLs were assessed among HIV-positive participants through 3 population-based surveys in 4 Ugandan fishing communities surveyed between November 2011 and August 2017. The unit of analysis was a visit-pair (2 consecutive person-visits), which were categorized as exhibiting durable VL suppression, new/renewed VL suppression, viral rebound, or persistent viremia. Adjusted relative risks (adjRRs) and 95% confidence intervals (CIs) of persistent viremia were estimated using multivariate Poisson regression. RESULTS There were 1346 HIV-positive participants (n = 1883 visit-pairs). The population-level prevalence of durable VL suppression increased from 29.7% to 67.9% during UTT rollout, viral rebound declined from 4.4% to 2.7%, and persistent viremia declined from 20.8% to 13.3%. Younger age (15-29 vs 40-49 years; adjRR = 1.80; 95% CI = 1.19-2.71), male sex (adjRR = 2.09, 95% CI = 1.47-2.95), never being married (vs currently married; adjRR = 1.88, 95% CI = 1.34-2.62), and recent migration to the community (vs long-term resident; adjRR = 1.91, 95% CI = 1.34-2.73) were factors associated with persistent viremia. CONCLUSIONS Despite increases in durable VL suppression during roll out of UTT in hyperendemic communities, a substantial fraction of the population, whose risk profile tended to be younger, male, and mobile, remained persistently viremic.
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Affiliation(s)
- M Kate Grabowski
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Victor Ssempijja
- Rakai Health Sciences Program, Entebbe, Uganda
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Sponsored by the National Cancer Institute, Bethesda, Maryland, USA
| | | | - Joseph Ssekasanvu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | - David M Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Oliver Laeyendecker
- Makerere University School of Public Health, Kampala, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Larry W Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, Bethesda, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, Bethesda, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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HIV epidemic in fishing communities in Uganda: A scoping review. PLoS One 2021; 16:e0249465. [PMID: 33793652 PMCID: PMC8016276 DOI: 10.1371/journal.pone.0249465] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/18/2021] [Indexed: 11/26/2022] Open
Abstract
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.
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Wandera SO, Tumwesigye NM, Walakira EJ, Kisaakye P, Wagman J. Alcohol use, intimate partner violence, and HIV sexual risk behavior among young people in fishing communities of Lake Victoria, Uganda. BMC Public Health 2021; 21:544. [PMID: 33740935 PMCID: PMC7978165 DOI: 10.1186/s12889-021-10595-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/08/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Stephen Ojiambo Wandera
- Department of Population Studies (DPS), School of Statistics and Planning (SSP), College of Business and Management Sciences (CoBAMS), Makerere University, Kampala, Uganda. .,Postdoctoral Research Fellow, Fogarty International Center of the National Institutes of Health (NIH) and the University of California Global Health Institute (UCGHI), San Francisco, USA.
| | - Nazarius Mbona Tumwesigye
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Eddy J Walakira
- Department of Social Work and Social Administration, School of Social Sciences, College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - Peter Kisaakye
- Department of Population Studies (DPS), School of Statistics and Planning (SSP), College of Business and Management Sciences (CoBAMS), Makerere University, Kampala, Uganda
| | - Jennifer Wagman
- School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
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Shiha G, Soliman R, Mikhail NNH, Easterbrook P. Reduced incidence of hepatitis C in 9 villages in rural Egypt: Progress towards national elimination goals. J Hepatol 2021; 74:303-311. [PMID: 32931878 DOI: 10.1016/j.jhep.2020.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 08/01/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Egypt has a major HCV burden and a well established treatment programme, with an ambitious goal of HCV elimination. Our aim was to assess the impact of a comprehensive HCV prevention, test and treat programme on the incidence of new HCV infections in 9 villages in rural Egypt. METHODS An HCV "educate, test and treat" project was implemented in 73 villages across 7 governorates in Egypt between 06/2015 and 06/2018. In 2018, in 9 of the villages we re-tested individuals who originally tested HCV antibody (HCV-Ab) and HBsAg negative using rapid diagnostic tests (RDTs); confirmatory HCV RNA testing was performed for positive cases. The incidence rate per 1,000 person-years (py) was calculated, and risk factors for incident HCV infections assessed through an interviewer-administered questionnaire in 1:3 age- and gender-matched cases and controls. RESULTS Out of 20,490 individuals who originally tested HCV-Ab negative in the 9 villages during the 2015-2016 implementation of the "educate, test and treat" programme, 19,816 (96.7%) were re-tested in 2018. Over a median of 2.4 years (IQR 2.1-2.7), there were 19 new HCV infections all of which were HCV RNA positive (incidence rate 0.37/1,000 py) (95% CI 0.24-0.59). Compared to a previous estimate of incidence in the Nile Delta region (2.4/1,000 py) from 2006, there was a substantial reduction in overall incidence of new HCV infections. Exposures through surgery (odds ratio 51; 95% CI 3.5-740.1) and dental procedures (odds ratio 23.8; 95% CI 2.9-194.9) were significant independent predictors of incident infections. CONCLUSIONS This is the first study to show a substantial reduction in incidence of new HCV infections in a sample of the general population in Egypt following attainment of high testing and treatment coverage. New infections were significantly associated with healthcare-associated exposures. LAY SUMMARY Egypt has a major national HCV testing and treatment programme with the goal of eliminating HCV infection. We assessed the impact of a comprehensive HCV prevention, test and treat programme in 73 villages that achieved high coverage of testing and treatment on the subsequent incidence of new HCV infections in nine of the villages. We re-tested people who were previously HCV antibody negative and found that the rate of new HCV infections was greatly reduced compared to previous estimates. We also found that exposure through surgery and dental procedures were associated with these new infections. This highlights the importance of continued strengthening of infection control and prevention measures, alongside treatment scale-up.
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Affiliation(s)
- Gamal Shiha
- Egyptian Liver Research Institute and Hospital (ELRIAH), Sherbin, El-Mansoura, Egypt; Hepatology and Gastroenterology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Egypt.
| | - Reham Soliman
- Egyptian Liver Research Institute and Hospital (ELRIAH), Sherbin, El-Mansoura, Egypt; Tropical Medicine Department, Faculty of Medicine, Port Said University, Port Said, Egypt
| | - Nabiel N H Mikhail
- Egyptian Liver Research Institute and Hospital (ELRIAH), Sherbin, El-Mansoura, Egypt; Biostatistics and Cancer Epidemiology Department, South Egypt Cancer Institute, Assiut University, Egypt
| | - Philippa Easterbrook
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
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Chang LW, Mbabali I, Hutton H, Amico KR, Kong X, Mulamba J, Anok A, Ssekasanvu J, Long A, Thomas AG, Thomas K, Bugos E, Pollard R, van Wickle K, Kennedy CE, Nalugoda F, Serwadda D, Bollinger RC, Quinn TC, Reynolds SJ, Gray RH, Wawer MJ, Nakigozi G. Novel community health worker strategy for HIV service engagement in a hyperendemic community in Rakai, Uganda: A pragmatic, cluster-randomized trial. PLoS Med 2021; 18:e1003475. [PMID: 33406130 PMCID: PMC7787382 DOI: 10.1371/journal.pmed.1003475] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/30/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Effective implementation strategies are needed to increase engagement in HIV services in hyperendemic settings. We conducted a pragmatic cluster-randomized trial in a high-risk, highly mobile fishing community (HIV prevalence: approximately 38%) in Rakai, Uganda, to assess the impact of a community health worker-delivered, theory-based (situated Information, Motivation, and Behavior Skills), motivational interviewing-informed, and mobile phone application-supported counseling strategy called "Health Scouts" to promote engagement in HIV treatment and prevention services. METHODS AND FINDINGS The study community was divided into 40 contiguous, randomly allocated clusters (20 intervention clusters, n = 1,054 participants at baseline; 20 control clusters, n = 1,094 participants at baseline). From September 2015 to December 2018, the Health Scouts were deployed in intervention clusters. Community-wide, cross-sectional surveys of consenting 15 to 49-year-old residents were conducted at approximately 15 months (mid-study) and at approximately 39 months (end-study) assessing the primary programmatic outcomes of self-reported linkage to HIV care, antiretroviral therapy (ART) use, and male circumcision, and the primary biologic outcome of HIV viral suppression (<400 copies/mL). Secondary outcomes included HIV testing coverage, HIV incidence, and consistent condom use. The primary intent-to-treat analysis used log-linear binomial regression with generalized estimating equation to estimate prevalence risk ratios (PRR) in the intervention versus control arm. A total of 2,533 (45% female, mean age: 31 years) and 1,903 (46% female; mean age 32 years) residents completed the mid-study and end-study surveys, respectively. At mid-study, there were no differences in outcomes between arms. At end-study, self-reported receipt of the Health Scouts intervention was 38% in the intervention arm and 23% in the control arm, suggesting moderate intervention uptake in the intervention arm and substantial contamination in the control arm. At end-study, intention-to-treat analysis found higher HIV care coverage (PRR: 1.06, 95% CI: 1.01 to 1.10, p = 0.011) and ART coverage (PRR: 1.05, 95% CI: 1.01 to 1.10, p = 0.028) among HIV-positive participants in the intervention compared with the control arm. Male circumcision coverage among all men (PRR: 1.05, 95% CI: 0.96 to 1.14, p = 0.31) and HIV viral suppression among HIV-positive participants (PRR: 1.04, 95% CI: 0.98 to 1.12, p = 0.20) were higher in the intervention arm, but differences were not statistically significant. No differences were seen in secondary outcomes. Study limitations include reliance on self-report for programmatic outcomes and substantial contamination which may have diluted estimates of effect. CONCLUSIONS A novel community health worker intervention improved HIV care and ART coverage in an HIV hyperendemic setting but did not clearly improve male circumcision coverage or HIV viral suppression. This community-based, implementation strategy may be a useful component in some settings for HIV epidemic control. TRIAL REGISTRATION ClinicalTrials.gov NCT02556957.
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Affiliation(s)
- Larry W. Chang
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Rakai, Uganda
- * E-mail:
| | | | - Heidi Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - K. Rivet Amico
- Department of Health Behavior Health Education, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Xiangrong Kong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | | | - Aggrey Anok
- Rakai Health Sciences Program, Rakai, Uganda
| | | | - Amanda Long
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Alvin G. Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kristin Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Eva Bugos
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Rose Pollard
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kimiko van Wickle
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Rakai, Uganda
| | | | | | - Robert C. Bollinger
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Thomas C. Quinn
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Steven J. Reynolds
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Rakai, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Ronald H. Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Rakai, Uganda
| | - Maria J. Wawer
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Rakai, Uganda
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Nanteza BM, Gray RH, Serwadda D, Kennedy C, Makumbi F. VMMC clients' perception of increased risk of HIV infection, circumcision preferred choice of method, providers' socio-demographics and mode of service delivery. Afr Health Sci 2020; 20:1562-1572. [PMID: 34394216 PMCID: PMC8351818 DOI: 10.4314/ahs.v20i4.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Voluntary medical male circumcision (VMMC) is a scientifically proven HIV prevention intervention. Uganda, like many countries has been implementing VMMC for over 10 years but uptake is still low especially in northern Uganda. To attain 80% needed for public health impact, scale-up was recommended with many innovations implemented with sub-optimal results. This study therefore wanted to find out some of the correlates of VMMC uptake in Gulu district, northern Uganda. Methods Two studies were conducted separately but data was analyzed for this study. For the quantitative study, proportions and frequencies were used to measure perception of increased risk of HIV infection using age, gender, occupation, marital and circumcision status. Qualitative study provided data from FGDs, IDIs and KIIs were first transcribed in Acholi and then translated in English. Transcripts were uploaded in MAXDQA software for data management. A code book for emerging themes was developed. Results A total of 548 respondents were interviewed for the quantitative study, where two thirds (66%) of the participants perceived themselves to be at increased risk of HIV infection. For the qualitative study, 149 participants from 19 FGDs, 11 KIIs and 9 IDIs were interviewed. Data were analyzed thematically using both inductive and deductive approaches. Devices were preferred to conventional surgery while mobile services were preferred to static services. However, there were divergent views regarding circumcision service providers' socio-demographics and these were influenced mainly by age, level of education and location. Conclusion People in Northern Uganda perceived themselves to be at an increased risk of HIV infection. They preferred devices to conventional surgery, mobile services to static services but had varying views about the socio-demographics of the service providers.
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Affiliation(s)
- Barbara M Nanteza
- Makerere University College of Health Sciences, School of Public Health, Department of Epidemiology & Bio statistics
| | - Ronald H Gray
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology
| | - David Serwadda
- Makerere University College of Health Sciences, School of Public Health, Department of Disease Control and Environment Health
| | - C Kennedy
- Johns Hopkins University, Bloomberg School of Public Health, Department of International Health
| | - Fredrick Makumbi
- Makerere University College of Health Sciences, School of Public Health, Department of Epidemiology & Bio statistics
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Prevalence and correlates of men's and women's alcohol use in agrarian, trading and fishing communities in Rakai, Uganda. PLoS One 2020; 15:e0240796. [PMID: 33125397 PMCID: PMC7598464 DOI: 10.1371/journal.pone.0240796] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 10/03/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Uganda has one of the highest rates of alcohol use in sub-Saharan Africa but prevalence and correlates of drinking are undocumented in the Rakai region, one of the earliest epicenters of the HIV/AIDS epidemic in East Africa. METHODS We analyzed cross-sectional data from 18,700 persons (8,690 men, 10,010 women) aged 15-49 years, living in agrarian, trading and fishing communities and participating in the Rakai Community Cohort Study (RCCS) between March 2015 and September 2016. Logistic regression models assessed associations between past year alcohol use and sociodemographic characteristics, other drug use and HIV status, controlling for age, religion, education, occupation, marital status, and household socioeconomic status. RESULTS Past year alcohol prevalence was 45%. Odds of drinking were significantly higher in men (versus women) and fishing communities (versus agrarian areas). Odds of drinking increased with age, previous (versus current) marriage and past year drug use. By occupation, highest odds of drinking were among fishermen and (in women) bar/restaurant workers. Alcohol-related consequences were more commonly reported by male (vs. females) drinkers, among whom up to 35% reported alcohol dependence symptoms (e.g., unsteady gait). HIV status was strongly associated with alcohol use in unadjusted but not adjusted models. CONCLUSIONS Alcohol use differed by gender, community type and occupation. Being male, living in a fishing community and working as a fisherman or restaurant/bar worker (among women) were associated with higher odds of drinking. Alcohol reduction programs should be implemented in Uganda's fishing communities and among people working in high risk occupations (e.g., fishermen and restaurant/bar workers).
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Matovu JKB, Nambuusi A, Nakabirye S, Wanyenze RK, Serwadda D. Formative research to inform the development of a peer-led HIV self-testing intervention to improve HIV testing uptake and linkage to HIV care among adolescents, young people and adult men in Kasensero fishing community, Rakai, Uganda: a qualitative study. BMC Public Health 2020; 20:1582. [PMID: 33081735 PMCID: PMC7576713 DOI: 10.1186/s12889-020-09714-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/15/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite efforts to improve HIV testing and linkage to HIV care among adolescents, young people and adult men, uptake rates remain below global targets. We conducted formative research to generate data necessary to inform the design of a peer-led HIV self-testing (HIVST) intervention intended to improve HIV testing uptake and linkage to HIV care in Kasensero fishing community in rural Uganda. METHODS This qualitative study was conducted in three study communities in Kasensero fishing community in Rakai district, Uganda, in May 2019. Six single-sex focus group discussions (FGDs) comprising 7-8 participants were conducted with adolescents and young people (15-24 years) and adult men (25+ years). We collected data on people's perceptions about peer-led HIVST; potential acceptability of a peer-led HIVST intervention and suggestions on how to improve linkage to HIV care after a positive HIVST result. Peer-led HIVST was defined as an approach where trained lay people distribute HIVST kits to other people in the community. FGDs were audio-recorded with permission from the participants, transcribed verbatim and analysed manually following a thematic framework approach. RESULTS Forty-seven participants (31 men and 16 women) participated in the FGDs. Across communities and age-groups, most participants mentioned that peer-led HIVST would be generally acceptable to people in the fishing community but people will need support in performing the test due to fear of performing the test wrongly or failing to cope with HIV-positive results. Most participants felt that peer-led HIVST would bring HIV testing services closer to the community "because [the peer-leader] could be my immediate neighbour", making it easier for people to obtain the kits at any time of their convenience. To improve linkage to HIV care, participants felt that the use of peer-leaders to deliver the initial ART dose to self-tested HIV-positive individuals would be more preferable to the use of community-based ART groups or home-based ART initiation. CONCLUSION Our study shows that peer-led HIVST is potentially acceptable in the fishing community. These findings suggest that this approach can improve uptake of HIV testing and linkage to HIV care services among populations that are usually missed through conventional HIV testing services.
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Affiliation(s)
- Joseph K. B. Matovu
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
- Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Aminah Nambuusi
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Scovia Nakabirye
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - David Serwadda
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
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Feasibility and acceptability of a pilot, peer-led HIV self-testing intervention in a hyperendemic fishing community in rural Uganda. PLoS One 2020; 15:e0236141. [PMID: 32764751 PMCID: PMC7413506 DOI: 10.1371/journal.pone.0236141] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/29/2020] [Indexed: 12/22/2022] Open
Abstract
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.
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Farley TMM, Samuelson J, Grabowski MK, Ameyan W, Gray RH, Baggaley R. Impact of male circumcision on risk of HIV infection in men in a changing epidemic context - systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25490. [PMID: 32558344 PMCID: PMC7303540 DOI: 10.1002/jia2.25490] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/10/2020] [Accepted: 03/17/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION WHO/UNAIDS recommended Voluntary Medical Male Circumcision in 2007 based on systematic review of observational studies prior to 1999 and three randomized controlled trials (RCTs). To inform updated WHO guidance, we conducted a systematic review and meta-analysis of impact of circumcision on the risk of HIV infection among heterosexual men. METHODS Studies in PubMed of HIV incidence and changes in prevalence in heterosexual men by circumcision status were identified. Pooled incidence rate ratios were computed using fixed- and random-effects meta-analysis and risk of bias was assessed using the ROBINS-I tool. RESULTS AND DISCUSSION In three RCTs, the pooled incidence ratio was 0.41 (95% CI 0.30 to 0.56), with risk difference 10 (8 to 12) fewer infections per 1000 person-years (py). Pooled incidence ratios were 0.34 (0.24 to 0.49) in two post-RCT follow-up studies, 0.29 (0.19 to 0.43) in men at high HIV risk (five cohorts), 0.48 (0.33 to 0.70) in four community-based cohorts before circumcision scale-up, and 0.56 (0.49 to 0.64) (7 [6 to 8] fewer per 1000 py) in six community-based cohorts during circumcision and antiretroviral treatment scale-up. Heterogeneity between studies was low except in men at high HIV risk. We estimated 520,000 (425,000 to 605,000) fewer infections occurred in men by end of 2018 from 22.7 million circumcisions performed since 2008 and increasing by 155,000 (125,000 to 180,000) annually if epidemic conditions remain similar. After exclusion of studies with high risk of bias and those conducted outside Africa, pooled incidence ratios were similar. There was no evidence of confounding nor changes in risk behaviour following circumcision. In post-hoc exploratory analyses we observed a trend of decreasing effectiveness of circumcision in cohorts with lower HIV incidence. CONCLUSIONS Efficacy of medical male circumcision on HIV incidence from randomized controlled trials was supported by effectiveness from observational studies in populations with diverse HIV risk and changing epidemic contexts. Voluntary Medical Male Circumcision remains an important evidence-based intervention for control of generalized HIV epidemics.
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Affiliation(s)
| | - Julia Samuelson
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - M Kate Grabowski
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMDUSA
| | - Wole Ameyan
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - Ronald H Gray
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Rakai Health Sciences ProgramKalisizoUganda
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
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Phylogenetic and Demographic Characterization of Directed HIV-1 Transmission Using Deep Sequences from High-Risk and General Population Cohorts/Groups in Uganda. Viruses 2020; 12:v12030331. [PMID: 32197553 PMCID: PMC7150763 DOI: 10.3390/v12030331] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022] Open
Abstract
Across sub-Saharan Africa, key populations with elevated HIV-1 incidence and/or prevalence have been identified, but their contribution to disease spread remains unclear. We performed viral deep-sequence phylogenetic analyses to quantify transmission dynamics between the general population (GP), fisherfolk communities (FF), and women at high risk of infection and their clients (WHR) in central and southwestern Uganda. Between August 2014 and August 2017, 6185 HIV-1 positive individuals were enrolled in 3 GP and 10 FF communities, 3 WHR enrollment sites. A total of 2531 antiretroviral therapy (ART) naïve participants with plasma viral load >1000 copies/mL were deep-sequenced. One hundred and twenty-three transmission networks were reconstructed, including 105 phylogenetically highly supported source–recipient pairs. Only one pair involved a WHR and male participant, suggesting that improved population sampling is needed to assess empirically the role of WHR to the transmission dynamics. More transmissions were observed from the GP communities to FF communities than vice versa, with an estimated flow ratio of 1.56 (95% CrI 0.68–3.72), indicating that fishing communities on Lake Victoria are not a net source of transmission flow to neighboring communities further inland. Men contributed disproportionally to HIV-1 transmission flow regardless of age, suggesting that prevention efforts need to better aid men to engage with and stay in care.
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Ratmann O, Kagaayi J, Hall M, Golubchick T, Kigozi G, Xi X, Wymant C, Nakigozi G, Abeler-Dörner L, Bonsall D, Gall A, Hoppe A, Kellam P, Bazaale J, Kalibbala S, Laeyendecker O, Lessler J, Nalugoda F, Chang LW, de Oliveira T, Pillay D, Quinn TC, Reynolds SJ, Spencer SEF, Ssekubugu R, Serwadda D, Wawer MJ, Gray RH, Fraser C, Grabowski MK. Quantifying HIV transmission flow between high-prevalence hotspots and surrounding communities: a population-based study in Rakai, Uganda. Lancet HIV 2020; 7:e173-e183. [PMID: 31953184 PMCID: PMC7167508 DOI: 10.1016/s2352-3018(19)30378-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/11/2019] [Accepted: 11/15/2019] [Indexed: 06/02/2023]
Abstract
BACKGROUND International and global organisations advocate targeting interventions to areas of high HIV prevalence (ie, hotspots). To better understand the potential benefits of geo-targeted control, we assessed the extent to which HIV hotspots along Lake Victoria sustain transmission in neighbouring populations in south-central Uganda. METHODS We did a population-based survey in Rakai, Uganda, using data from the Rakai Community Cohort Study. The study surveyed all individuals aged 15-49 years in four high-prevalence Lake Victoria fishing communities and 36 neighbouring inland communities. Viral RNA was deep sequenced from participants infected with HIV who were antiretroviral therapy-naive during the observation period. Phylogenetic analysis was used to infer partial HIV transmission networks, including direction of transmission. Reconstructed networks were interpreted through data for current residence and migration history. HIV transmission flows within and between high-prevalence and low-prevalence areas were quantified adjusting for incomplete sampling of the population. FINDINGS Between Aug 10, 2011, and Jan 30, 2015, data were collected for the Rakai Community Cohort Study. 25 882 individuals participated, including an estimated 75·7% of the lakeside population and 16·2% of the inland population in the Rakai region of Uganda. 5142 participants were HIV-positive (2703 [13·7%] in inland and 2439 [40·1%] in fishing communities). 3878 (75·4%) people who were HIV-positive did not report antiretroviral therapy use, of whom 2652 (68·4%) had virus deep-sequenced at sufficient quality for phylogenetic analysis. 446 transmission networks were reconstructed, including 293 linked pairs with inferred direction of transmission. Adjusting for incomplete sampling, an estimated 5·7% (95% credibility interval 4·4-7·3) of transmissions occurred within lakeside areas, 89·2% (86·0-91·8) within inland areas, 1·3% (0·6-2·6) from lakeside to inland areas, and 3·7% (2·3-5·8) from inland to lakeside areas. INTERPRETATION Cross-community HIV transmissions between Lake Victoria hotspots and surrounding inland populations are infrequent and when they occur, virus more commonly flows into rather than out of hotspots. This result suggests that targeted interventions to these hotspots will not alone control the epidemic in inland populations, where most transmissions occur. Thus, geographical targeting of high prevalence areas might not be effective for broader epidemic control depending on underlying epidemic dynamics. FUNDING The Bill & Melinda Gates Foundation, the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, the National Institute of Child Health and Development, the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases, the World Bank, the Doris Duke Charitable Foundation, the Johns Hopkins University Center for AIDS Research, and the President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.
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Affiliation(s)
- Oliver Ratmann
- Department of Mathematics, Imperial College London, London, UK.
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda
| | - Matthew Hall
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tanya Golubchick
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Godfrey Kigozi
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda
| | - Xiaoyue Xi
- Department of Mathematics, Imperial College London, London, UK
| | - Chris Wymant
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Lucie Abeler-Dörner
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - David Bonsall
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Astrid Gall
- European Molecular Biology Laboratory-European Bioinformatics Institute, Wellcome Genome Campus, Hinxton, UK
| | - Anne Hoppe
- Division of Infection and Immunity, University College London, London, UK
| | - Paul Kellam
- Department of Medicine, Imperial College London, London, UK
| | - Jeremiah Bazaale
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda
| | - Sarah Kalibbala
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda
| | - Oliver Laeyendecker
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Fred Nalugoda
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda
| | - Larry W Chang
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda; Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Deenan Pillay
- Division of Infection and Immunity, University College London, London, UK
| | - Thomas C Quinn
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Steven J Reynolds
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda; Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | | | - Robert Ssekubugu
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda; Makerere University School of Public Health, Kampala, Uganda
| | - Maria J Wawer
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ronald H Gray
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christophe Fraser
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M Kate Grabowski
- Rakai Health Sciences Program, Kalisizo, Old-Bukoba Road, Uganda; Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA; KwaZulu-Natal Research Innovation and Sequencing Platform College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
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Geng EH, Holmes CB, Moshabela M, Sikazwe I, Petersen ML. Personalized public health: An implementation research agenda for the HIV response and beyond. PLoS Med 2019. [PMID: 31891581 DOI: 10.1371/journal.pmed.1002809,16,5,(e1002809)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Affiliation(s)
- Elvin H Geng
- Division of Infectious Diseases, Department of Medicine and Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Charles B Holmes
- Center for Global Health and Quality, Georgetown University Department of Medicine, Washington, DC
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu Natal, Republic of South Africa
| | - Izukanji Sikazwe
- Center for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Maya L Petersen
- Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
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Geng EH, Holmes CB, Moshabela M, Sikazwe I, Petersen ML. Personalized public health: An implementation research agenda for the HIV response and beyond. PLoS Med 2019; 16:e1003020. [PMID: 31891581 PMCID: PMC6938296 DOI: 10.1371/journal.pmed.1003020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Elvin H. Geng
- Division of Infectious Diseases, Department of Medicine and Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Charles B. Holmes
- Center for Global Health and Quality, Georgetown University Department of Medicine, Washington, DC
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu Natal, Republic of South Africa
| | - Izukanji Sikazwe
- Center for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Maya L. Petersen
- Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
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HIV control in hyperendemic communities in east Africa. Lancet HIV 2019; 6:e643-e644. [PMID: 31533895 DOI: 10.1016/s2352-3018(19)30241-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/25/2019] [Indexed: 11/24/2022]
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