Prevalence and determinants of minimum dietary diversity for women of reproductive age in Uganda

BACKGROUND

Globally, over a billion women of reproductive age (WRA) suffer from some kind of undernutrition micronutrient deficiencies, and/or anemia as a result of inadequate dietary diversity. This leads to poor maternal and child health outcomes, however, there is limited research on population level research on minimum dietary diversity for women (MDD-W). This study assessed the prevalence and predictors of MDD-W among WRA in Uganda.

METHODS

This study was a secondary analysis of data from the lot quality assurance sampling (LQAS) survey conducted across 55 Ugandan districts between May and September 2022. Women of various ages were interviewed across 5 study subgroups that this study used to construct its study population (WRA). Descriptive analyses, tests for outcome differences, and multilevel mixed-effects logistic regression were conducted at a 5% statistical significance level using STATA version 17. The results were reported using Adjusted Odds Ratios (aOR) as the measure of the outcome.

RESULTS

The study analyzed responses from 29,802 WRA with a mean age of 27.8 (± 6.8) years. Only 8.8% (95% CI 8.5-9.3) achieved the MDD-W, the least proportion was observed in the South-Central region (3.13%). In the adjusted analysis, WRA who were older than 25 years (aOR 1.1, 95% CI 1.1-1.3, p < 0.001), had secondary education (aOR = 1.4, 95% CI 1.1-1.7, p = 0.003) or above (aOR = 1.7, 95% CI 1.3-2.2, p < 0.001), and used modern contraceptives (aOR = 1.1, 95% CI 1.0-1.3, p = 0.01) were more likely to achieve the MDD-W. Conversely, WRA who travelled longer distances to the nearest household water source (aOR = 0.8, 95% CI 0.7-0.9, p = 0.002) and those residing in larger households (aOR = 0.9, 95% CI 0.8-1.0, p = 0.019) were less likely to achieve the MDD-W.

CONCLUSION

A low proportion of WRA met the MDD-W. Age, education level, household sizes and use of modern contraception were predictors of MDD-W among WRA in Uganda. MDD-W-related program efforts in Uganda should strengthen multisectoral collaboration with prioritization of younger women, education, household sizes and access to safe water sources.

Level of minimum acceptable diet and its associated factors among children aged 12-23 months in Ugandan districts

Uganda has made notable progress in improving child nutrition indicators, albeit not fast enough to meet global targets. Navigating the landscape of child nutrition in Uganda demands attention, particularly in light of the necessity for a minimum acceptable diet (MAD) for children aged 12-23 months. While the focus on local nutritional planning is crucial, the absence of routine-specific nutritional status data creates a significant information gap. To bridge this void, this study used datasets from the 2021 Lot Quality Assurance Sampling (LQAS) survey. Data were analysed using multilevel mixed-effects logistic regression (clustering districts based on regional boundaries) at a 5% statistical significance level using STATA version 17. Of the 7,111 children surveyed, 3,256 (49.20%) received the minimum meal frequency, 695 (9.80%) received the minimum dietary diversity, and only 380 (5.34%) received the MAD. There was a notable variation in the proportion of children that received the MAD across regions and districts. Children living in urban areas, children whose mothers had a higher education, and children whose mothers had a diverse diet were more likely to receive the MAD. Children were less likely to receive the MAD if they lived in a household that did not receive a health worker visit within the year. These findings suggest a need to prioritize initiatives aimed at increasing dietary diversity among children in Uganda. This could be done through a variety of approaches, such as leveraging the use of home gardens to boost nutrition through diverse crop cultivation, demonstration gardens, and offering nutrition counselling through village health teams.

Postpartum family planning uptake in Uganda: findings from the lot quality assurance sampling survey

BACKGROUND

The initiation and use of family planning (FP) services within the first 12 months following childbirth, postpartum family planning (PPFP), promotes safe motherhood by reducing unintended pregnancies and ensuring appropriate pregnancy spacing. However, there is a paucity of information on PPFP uptake from community surveys. This study aimed to quantify the reported use of PPFP and identify predictors and barriers to PPFP uptake from a large community survey.

METHODS

We analysed data collected from the 2021 Lot Quality Assurance Sampling (LQAS) survey, a cross-sectional community and household survey that covered 68 districts in Uganda. The survey uses small sample sizes to designate health or administrative geographical areas which are assessed to determine whether they achieved the pre-determined target for defined indicators of interest. We abstracted and analysed data collected from mothers of children aged 12 months or younger on reproductive health and FP. PPFP use was defined as the reported use of modern FP by the mother or their partner. Associations were measured using Pearson's chi-square test at 5% significance. Multivariate logistic regression was performed for variables that were significantly associated with PPFP use to identify the predictors of PPFP.

RESULTS

Overall, 8103 mothers of children aged less than 12 years were included in the analysis; the majority of mothers, 55.8% (4521/8103) were above 24 years while 11.7% (950/8103) were 19 years and under. 98% (7942/8103) of the mothers attended at least one antenatal care (ANC) visit and 86.3% (6997/8103) delivered at a health facility. Only 10% (814/8103) of mothers who participated in the survey reported PPFP use at the time of the survey. Reporting of PPFP use was 5 times higher among mothers of children aged 7-12 months (AOR 4.9; 95%CI 4.1-5.8), 50% higher among mothers with secondary education (AOR 1.5; 95%CI 1.0-2.3), 80% higher among breastfeeding mothers (AOR 1.8; 95%CI 1.3-2.4) and 30% lower among those that didn't receive a health worker visit within 3 months preceding the survey (AOR 0.7; 95% CI 0.5-0.8). Among 4.6% (372/8103) who stated a reason for non-use of PPFP, the most cited reasons for not using were breastfeeding 43% (161/372), fear of side effects 26.9% (100/372), respondent/partner opposition 17.6% (48/372) and infrequent sex 12.1% (48/372).

CONCLUSION

The analysis showed a low proportion of PPFP uptake among mothers of children under 12 years. Possible barriers included child age, education, a health worker visit, and side effects and perceived benefits of possibly improperly implementing lactation amenorrhea method. Integration of social, community and health services could provide a more holistic approach to improving PPFP uptake.

High prevalence of non-dipping patterns among Black Africans with uncontrolled hypertension: a secondary analysis of the CREOLE trial

BACKGROUND

Dipping of blood pressure (BP) at night is a normal physiological phenomenon. However, a non-dipping pattern is associated with hypertension mediated organ damage, secondary forms of hypertension and poorer long-term outcome. Identifying a non-dipping pattern may be useful in assessing risk, aiding the decision to investigate for secondary causes, initiating treatment, assisting decisions on choice and timing of antihypertensive therapy, and intensifying salt restriction.

OBJECTIVES

To estimate the prevalence and factors associated with non-dipping pattern and determine the effect of 6 months of three antihypertensive regimens on the dipping pattern among Black African hypertensive patients.

METHODS

This was a secondary analysis of the CREOLE Study which was a randomized, single blind, three-group trial conducted in 10 sites in 6 Sub-Saharan African countries. The participants were 721 Black African patients, aged between 30 and 79 years, with uncontrolled hypertension and a baseline 24-h ambulatory blood pressure monitoring (ABPM). Dipping was calculated from the average day and average night systolic blood pressure measures.

RESULTS

The prevalence of non-dipping pattern was 78% (564 of 721). Factors that were independently associated with non-dipping were: serum sodium > 140 mmol/l (OR = 1.72, 95% CI 1.17-2.51, p-value 0.005), a higher office systolic BP (OR = 1.03, 95% CI 1.01-1.05, p-value 0.003) and a lower office diastolic BP (OR = 0.97, 95% CI 0.95-0.99, p-value 0.03). Treatment allocation did not change dipping status at 6 months (McNemar's Chi2 0.71, p-value 0.40).

CONCLUSION

There was a high prevalence of non-dipping among Black Africans with uncontrolled hypertension. ABPM should be considered more routinely in Black Africans with uncontrolled hypertension, if resources permit, to help personalise therapy. Further research is needed to understand the mechanisms and causes of non-dipping pattern and if targeting night-time BP improves clinical outcomes. Trial registration ClinicalTrials.gov (NCT02742467).

Increased malaria parasitaemia among adults living with HIV who have discontinued cotrimoxazole prophylaxis in Kitgum district, Uganda

Background

Although WHO recommends cotrimoxazole (CTX) discontinuation among HIV patients who have undergone immune recovery and are living in areas of low prevalence of malaria, some countries including Uganda recommend CTX discontinuation despite having a high malaria burden. We estimated the prevalence and factors associated with malaria parasitaemia among adults living with HIV attending hospital outpatient clinic before and after discontinuation of CTX prophylaxis.

Methods

Between March and April 2019, 599 participants aged 18 years and above, and attending Kitgum hospital HIV clinic in Uganda were enrolled in a cross study. A standardized questionnaire was administered and physical examination conducted. A finger-prick blood sample was collected for identification of malaria parasites by microscopy. The prevalence of parasitaemia was estimated and compared among participants on and those who had discontinued CTX prophylaxis, and factors associated with malaria parasitaemia assessed.

Results

Of the enrolled participants, 27 (4.5%) had malaria parasites and 452 (75.5%) had stopped CTX prophylaxis. Prevalence of malaria parasitaemia was significantly higher in participants who had stopped CTX prophylaxis (5.5% versus 1.4% p = 0.03) and increased with increasing duration since the discontinuation of prophylaxis. Compared to participants taking CTX, those who discontinued prophylaxis for 3–5 months and >5 months were more likely to have malaria parasites (adjusted prevalence ratio (aPR) = 1.64, 95% CI 0.37–7.29, p = 0.51, and aPR = 6.06, 95% CI 1.34–27.3, P = 0.02). Low CD4 count (< 250cells/mm³) was also associated with increased risk of having parasites (aPR = 4.31, 95% CI 2.13–8.73, p <0.001).

Conclusion

People from malaria endemic settings living with HIV have a higher prevalence of malaria parasitaemia following discontinuation of CTX compared to those still on prophylaxis. The risk increased with increasing duration since discontinuation of the prophylaxis. HIV patients should not discontinue CTX prophylaxis in areas of Uganda where the burden of malaria remains high. Other proven malaria control interventions may also be encouraged in HIV patients following discontinuation of CTX prophylaxis.

Spatial overlap links seemingly unconnected genotype-matched TB cases in rural Uganda

Introduction

Incomplete understanding of TB transmission dynamics in high HIV prevalence settings remains an obstacle for prevention. Understanding where transmission occurs could provide a platform for case finding and interrupting transmission.

Methods

From 2012–2015, we sought to recruit all adults starting TB treatment in a Ugandan community. Participants underwent household (HH) contact investigation, and provided names of social contacts, sites of work, healthcare and socializing, and two sputum samples. Mycobacterium tuberculosis culture-positive specimens underwent 24-loci MIRU-VNTR and spoligotyping. We sought to identify epidemiologic links between genotype-matched cases by analyzing social networks and mapping locations where cases reported spending ≥12 hours over the one-month pre-treatment. Sites of spatial overlap (≤100m) between genotype-matched cases were considered potential transmission sites. We analyzed social networks stratified by genotype clustering status, with cases linked by shared locations, and compared network density by location type between clustered vs. non-clustered cases.

Results

Of 173 adults with TB, 131 (76%) were enrolled, 108 provided sputum, and 84/131 (78%) were MTB culture-positive: 52% (66/131) tested HIV-positive. Of 118 adult HH contacts, 105 (89%) were screened and 3 (2.5%) diagnosed with active TB. Overall, 33 TB cases (39%) belonged to 15 distinct MTB genotype-matched clusters. Within each cluster, no cases shared a HH or reported shared non-HH contacts. In 6/15 (40%) clusters, potential epidemiologic links were identified by spatial overlap at specific locations: 5/6 involved health care settings. Genotype-clustered TB social networks had significantly greater network density based on shared clinics (p<0.001) and decreased density based on shared marketplaces (p<0.001), compared to non-clustered networks.

Conclusions

In this molecular epidemiologic study, links between MTB genotype-matched cases were only identifiable via shared locations, healthcare locations in particular, rather than named contacts. This suggests most transmission is occurring between casual contacts, and emphasizes the need for improved infection control in healthcare settings in rural Africa.

Significant rates of risky sexual behaviours among HIV-infected patients failing first-line ART: A sub-study of the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial

There are limited data on the prevalence of risky sexual behaviours in individuals failing first-line antiretroviral therapy (ART) and changes in sexual behaviour after switch to second-line ART. We undertook a sexual behaviour sub-study of Ugandan adults enrolled in the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial. A standardized questionnaire was used to collect sexual behaviour data and, in particular, risky sexual behaviours (defined as additional sexual partners to main sexual partner, inconsistent use of condoms, non-disclosure to sexual partners, and exchange of money for sex). Of the 79 participants enrolled in the sub-study, 62% were female, median age (IQR) was 37 (32-42) years, median CD4 cell count (IQR) was 79 (50-153) cells/µl, and median HIV viral load log was 4.9 copies/ml (IQR: 4.5-5.3) at enrolment. The majority were in long-term stable relationships; 69.6% had a main sexual partner and 87.3% of these had been sexually active in the preceding six months. At enrolment, around 20% reported other sexual partners, but this was higher among men than women (36% versus 6.7 %, p < 0.001). In 50% there was inconsistent condom use with their main sexual partner and a similar proportion with other sexual partners, both at baseline and follow-up. Forty-three per cent of participants had not disclosed their HIV status to their main sexual partner (73% with other sexual partners) at enrolment, which was similar in men and women. Overall, there was no significant change in these sexual behaviours over the 96 weeks following switch to second-line ART, but rate of non-disclosure of HIV status declined significantly (43.6% versus 19.6%, p <0.05). Among persons failing first-line ART, risky sexual behaviours were prevalent, which has implications for potential onward transmission of drug-resistant virus. There is need to intensify sexual risk reduction counselling and promotion of partner testing and disclosure, especially at diagnosis of treatment failure and following switch to second- or third-line ART.

Hazardous alcohol consumption is not associated with CD4+ T-cell count decline among PLHIV in Kampala Uganda: A prospective cohort study

Introduction

There is limited data on the effects of alcohol on immunological response among persons living with HIV (PLHIV) in sub-Saharan Africa. We assessed the relationship between hazardous alcohol use and CD4+ T-cell count, among PLHIV in Uganda.

Methods

PLHIV aged ≥ 18 years were enrolled in a cohort study at the Infectious diseases clinic Kampala, Uganda. Alcohol consumption was assessed at enrolment (baseline) and 6 monthly thereafter using the alcohol use disorders identification test (AUDIT). The CD4+ T-cell counts, assessed at baseline and over the next 12 months were compared between alcohol use strata, using linear mixed effects regression. Using longitudinal mediation analysis methods, we estimated the effect of alcohol induced ART non-adherence on CD4+ T-cell count.

Results

Of the 1566 participants enrolled, 863(44.1%) were non-alcohol users (AUDIT score = 0), 433(27.7%) were non-hazardous (AUDIT score 1–7) alcohol users while 270 (17.2%) were hazardous (AUDIT score ≥ 8) alcohol users.

The overall median (IQR) baseline CD4+ T-cell count was 356 (243–516) cells/μl. There were no differences in the median baseline CD4+ T-cell count between hazardous and non-hazardous alcohol users compared to non-alcohol users in both the non-ART (p = 0.43) and ART group (p = 0.77).

The mean CD4+ T-cell count over 12 months was not different between hazardous alcohol users and non-alcohol users (non-ART group p = 0.88 and ART group p = 0.62), nor between non-hazardous alcohol users and non-alcohol users (and non-ART group p = 0.66 and ART group p = 0.20).

Alcohol use was not associated with a significant natural direct effect on CD4⁺ T-cell count (1.37 95%CI [-1.78, 4.52] cells/μl, p = 0.39) but had a statistically significant natural indirect effect on reduction of CD4⁺ T-cell count (-0.91 cells/μl [-1.36, -0.45], p < 0.001) mediated through ART non-adherence.

Conclusion

Hazardous alcohol use among PLHIV was not directly associated with lower CD4+ T-cell count but had a significant natural indirect effect on CD4+ T-cell count mediated through ART non-adherence. Among PLHIV with lower than expected CD4+ T-cell count, alcohol consumption should be excluded as an underlying factor for non-adherence to ART and any interventions targeting alcohol use should tackle possible ART non-adherence.

Efficacy of a Single, Brief Alcohol Reduction Intervention among Men and Women Living with HIV/AIDS and Using Alcohol in Kampala, Uganda: A Randomized Trial

We evaluated the efficacy of a brief motivational intervention (MI) counseling in reducing alcohol consumption among persons living with HIV/AIDS in Kampala, Uganda. Persons living with HIV/AIDS with Alcohol Use Disorders Identification Tool (AUDIT) score ≥3 points were randomized to either standardized positive prevention counseling alone or in combination with alcohol brief MI counseling. The mean change in AUDIT-C scores over 6 months was compared by treatment arm. The mean (standard deviation [SD]) AUDIT-C scores were 6.3 (2.3) and 6.8 (2.3) for control and MI arms ( P = .1) at baseline, respectively, and change in mean AUDIT-C score was not statistically different between arms over the 6 months ( P = .8). However, there was a statistically significant decrease in mean AUDIT-C score (-1.10; 95% confidence interval: -2.19 to -0.02, P = .046) among women in the MI arm. There was a nondifferential reduction in alcohol consumption overall, but MI appeared effective among women only. Studies with more than 1 counseling session and evaluation of gender differences in treatment response are needed.

Outcomes in a Cohort of Patients Started on Antiretroviral Treatment and Followed up for a Decade in an Urban Clinic in Uganda

BACKGROUND

Short-medium term studies from sub-Saharan Africa show that, despite high early mortality, substantial loss to program, and high rates toxicity, patients on antiretroviral treatment have achieved outcomes comparable to those in developed settings. However, these studies were unable to account for long term outcomes of patients as they stayed longer on treatment.

OBJECTIVES

We aim to describe ten years outcomes of one of the first cohort of HIV positive patients started on antiretroviral treatment (ART) in Sub-Saharan Africa.

METHODS

We report 10-years outcomes including mortality, retention, CD4-count response, virological outcomes, ART regimens change from a prospective cohort of 559 patients initiating ART and followed up for 10 years Uganda.

RESULTS

Of 559 patients, 69.1% were female, median age (IQR) was 38 (33-44) years, median CD4-count (IQR) 98 (21-163) cell/μL; 74% were started on stavudine, lamivudine and nevirapine, 26% on zidovudine, lamivudine and efavirenz. After 10 years 361 (65%) patients were still in the study; 127 (22.7%) had died; 30 (5%) were lost to follow-up; 27 (5%) transferred; 18 (3%) withdrew consent. The probability of death was high in the first year (0.15, 95%, CI 0.12-0.18). The median CD4 count increased from 98 to 589 cell/μL (IQR: 450-739 cell/μL) with a median increase of 357 cells/μL (IQR: 128-600 cells/μL); 7.4% never attained initial viral suppression and of those who did 31.7% experienced viral failure. Three hundred and two patients had at least one drug substitution while on first line after a median of 40 months; 66 (11.9%) of the patients were switched to a second line PI-based regimen due to confirmed treatment failure.

CONCLUSIONS

Despite the high rate of early mortality due to advanced disease at presentation the outcomes from this cohort are encouraging, particularly the remarkable and incremental immune-recovery and a satisfactory rate of virologic suppression.

Alcohol Consumption among HIV-Infected Persons in a Large Urban HIV Clinic in Kampala Uganda: A Constellation of Harmful Behaviors

INTRODUCTION

Alcohol use by persons living with HIV/AIDS (PLWHA) negatively impacts the public health benefits of antiretroviral therapy (ART). Using a standardized alcohol assessment tool, we estimate the prevalence of alcohol use, identify associated factors, and test the association of alcohol misuse with sexual risk behaviors among PLWHA in Uganda.

METHODS

A cross-section of PLWHA in Kampala were interviewed regarding their sexual behavior and self-reported alcohol consumption in the previous 6 months. Alcohol use was assessed using the alcohol use disorders identification test (AUDIT). Gender-stratified log binomial regression analyses were used to identify independent factors associated with alcohol misuse and to test whether alcohol misuse was associated with risky sexual behaviors.

RESULTS

Of the 725 subjects enrolled, 235 (33%) reported any alcohol use and 135 (18.6%) reported alcohol misuse, while 38 (5.2%) drank hazardous levels of alcohol. Alcohol misuse was more likely among subjects not yet on ART (adjusted prevalence ratio [aPR] was 1.65 p=0.043 for males and 1.79, p=0.019 for females) and those with self-reported poor adherence (aPR for males=1.56, p=0.052, and for females=1.93, p=0.0189). Belonging to Pentecostal or Muslim religious denominations was protective against alcohol misuse compared to belonging to Anglican and Catholic denominations in both sexes (aPR=0.11 for men, p<0.001, and aPR=0.32 for women, p=0.003). Alcohol misuse was independently associated with reporting risky sexual behaviors (aPR=1.67; 95% CI: 1.07-2.60, p=0.023) among males, but not significant among females (aPR=1.29; 95% CI: 0.95-1.74, p=0.098). Non-disclosure of HIV positive status to sexual partner was significantly associated with risky sex in both males (aPR=1.69; p=0.014) and females (aPR 2.45; p<0.001).

CONCLUSION

Alcohol use among PLWHA was high, and was associated with self-reported medication non-adherence, non-disclosure of HIV positive status to sexual partner(s), and risky sexual behaviors among male subjects. Interventions targeting alcohol use and the associated negative behaviors should be tested in this setting.

Identifying locations of recent TB transmission in rural Uganda: a multidisciplinary approach

OBJECTIVES

Targeting high Tuberculosis (TB) transmission sites may offer a novel approach to TB prevention in sub-Saharan Africa. We sought to characterise TB transmission sites in a rural Ugandan township.

METHODS

We recruited adults starting TB treatment in Tororo, Uganda, over 1 year. Fifty four TB cases provided names of frequent contacts, sites of residence, health care, work and social activities, and two sputum samples. Mycobacterium tuberculosis (MTB) culture-positive specimens underwent spoligotyping to identify strains with shared genotypes. We visualised TB case social networks, and obtained, mapped and geo-coded global positioning system measures for every location that cases reported frequenting 1 month before treatment. Locations of spatial overlap among genotype-clustered cases were considered potential transmission sites.

RESULTS

Six distinct genotypic clusters were identified involving 21 of 33 (64%) MTB culture-positive, genotyped cases; none shared a home. Although 18 of 54 (33%) TB cases shared social network ties, none of the genotype-clustered cases shared social ties. Using spatial analysis, we identified potential sites of within-cluster TB transmission for five of six genotypic clusters. All sites but one were healthcare and social venues, including sites of drinking, worship and marketplaces. Cases reported spending the largest proportion of pre-treatment person-time (22.4%) at drinking venues.

CONCLUSIONS

Using molecular epidemiology, geospatial and social network data from adult TB cases identified at clinics, we quantified person-time spent at high-risk locations across a rural Ugandan community and determined the most likely sites of recent TB transmission to be healthcare and social venues. These sites may not have been identified using contact investigation alone.

Impact of intermittent preventive treatment with dihydroartemisinin-piperaquine on malaria in Ugandan schoolchildren: a randomized, placebo-controlled trial

Dihydroartemisinin-piperaquine administered at monthly intervals, but not that dosed once a school term, is a remarkably effective measure for the prevention of incidence of malaria, prevalence of parasitemia, and prevalence of anemia in schoolchildren living in a high-transmission setting.

Background. Intermittent preventive treatment (IPT) in schoolchildren offers a promising option for malaria control. However, the optimal drug and dosing regimens for IPT remain to be determined.

Methods. We conducted a randomized, double-blind, placebo-controlled trial in 740 schoolchildren aged 6–14 years living in a setting of high malaria transmission in Uganda. Enrolled children were randomized to dihydroartemisinin-piperaquine (DP) given once a month (IPTm), DP given once a school term (4 treatments over 12 months, IPTst), or placebo and followed for 12 months. The primary outcome was the incidence of malaria over 12 months. Secondary outcomes included parasite prevalence and anemia over 12 months. Analyses were conducted on an intention-to-treat basis.

Results. In the placebo arm, the incidence of malaria was 0.34 episodes per person-year and the prevalence of parasitemia and anemia was 38% and 20%, respectively. IPTm reduced the incidence of malaria by 96% (95% confidence interval [CI], 88%–99%, P < .0001), the prevalence of asymptomatic parasitemia by 94% (95% CI, 92%–96%, P < .0001), and the prevalence of anemia by 40% (95% CI, 19%–56%, P < .0001). IPTst had no significant effect on the incidence of symptomatic malaria or the prevalence of anemia, but reduced the prevalence of asymptomatic parasitemia by 54% (95% CI, 47%–60%, P < .0001).

Conclusions. Monthly IPT with DP offered remarkable protection against clinical malaria, parasitemia, and anemia in schoolchildren living in a high-malaria-transmission setting.

Clinical Trials Registration.  NCT01231880.

Household ventilation and tuberculosis transmission in Kampala, Uganda

OBJECTIVE

To test the feasibility of measuring household ventilation and evaluate whether ventilation is associated with tuberculosis (TB) in household contacts in Kampala, Uganda.

DESIGN

Adults with pulmonary TB and their household contacts received home visits to ascertain social and structural household characteristics. Ventilation was measured in air changes per hour (ACH) in each room by raising carbon dioxide (CO₂) levels using dry ice, removing the dry ice, and measuring changes in the natural log of CO₂ (lnCO2) over time. Ventilation was compared in homes with and without co-prevalent TB.

RESULTS

Members of 61 of 66 (92%) households approached were enrolled. Households averaged 5.4 residents/home, with a median of one room/home. Twelve homes (20%) reported co-prevalent TB in household contacts. Median ventilation for all rooms was 14 ACH (interquartile range [IQR] 10-18). Median ventilation was 12 vs. 15 ACH in index cases' sleeping rooms in households with vs. those without co-prevalent TB (P = 0.12). Among smear-positive indexes not infected by the human immunodeficiency virus (HIV), median ventilation was 11 vs. 17 ACH in index cases' sleeping rooms in homes with vs. those without co-prevalent TB (P = 0.1).

CONCLUSION

Our findings provide evidence that a simple CO₂ decay method used to measure ventilation in clinical settings can be adapted to homes, adding a novel tool and a neglected variable, ventilation, to the study of household TB transmission.

Asymptomatic Plasmodium infection and cognition among primary schoolchildren in a high malaria transmission setting in Uganda

Asymptomatic parasitemia is common among schoolchildren living in areas of high malaria transmission, yet little is known about its effect on cognitive function in these settings. To investigate associations between asymptomatic parasitemia, anemia, and cognition among primary schoolchildren living in a high malaria transmission setting, we studied 740 children enrolled in a clinical trial in Tororo, Uganda. Parasitemia, measured by thick blood smears, was present in 30% of the children. Infected children had lower test scores for abstract reasoning (adjusted mean difference [AMD] -0.6, 95% confidence interval [CI] -1.01 to -0.21) and sustained attention (AMD -1.6 95% CI -2.40 to -0.81) compared with uninfected children. There was also evidence for a dose-response relationship between parasite density and scores for sustained attention. No associations were observed between anemia and either test of cognition. Schoolchildren in high transmission settings may experience cognitive benefits, from interventions aimed at reducing the prevalence of asymptomatic parasitemia.

Belief in divine healing can be a barrier to antiretroviral therapy adherence in Uganda

Although recent data suggest high levels of adherence to expanding antiretroviral therapy (ART) programmes in resource-limited settings, the culture-specific barriers to adherence are poorly understood. In a prospective observational study, we found that 1.2% of patients discontinued ART because of a belief in spiritual healing. Spiritual beliefs should be an important part of ART adherence counselling in resource-limited settings, requiring close collaboration between HIV care programmes and religious leaders to identify common goals and ensure successful treatment.