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Enriquez R, Homsi M, Ssekubugu R, Nabukalu D, Zeebari Z, Marrone G, Gigante B, Chang LW, Reynolds SJ, Nalugoda F, Ekström AM, Hagström H, Nordenstedt H. Prevalence and risk factors of metabolic dysfunction-associated steatotic liver disease in south Central Uganda: A cross-sectional survey. Aliment Pharmacol Ther 2024; 59:1111-1121. [PMID: 38459720 DOI: 10.1111/apt.17931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Despite numerous risk factors and serious consequences, little is known about metabolic dysfunction-associated steatotic liver disease (MASLD) at population level in Africa. AIM The aim of the study was to estimate the prevalence and risk factors of MASLD in people living with and without HIV in Uganda. METHODS We collected data from 37 communities in South Central Uganda between May 2016 and May 2018. We estimated MASLD prevalence using the fatty liver index and advanced liver fibrosis using the dynamic aspartate-to-alanine aminotransferase ratio. We collected additional data on sociodemographics, HIV and cardiovascular disease (CVD) risk factors. We used multivariable logistic regression to determine the association between HIV, CVD risk factors and MASLD. RESULTS We included 759 people with HIV and 704 HIV-negative participants aged 35-49. MASLD prevalence was 14% in women and 8% in men; advanced liver fibrosis prevalence was estimated to be <1%. MASLD prevalence was more common in women (15% vs. 13%) and men (9% vs. 6%) with HIV. Being female (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.4-3.3) was associated with a higher odds of MASLD after adjustment for confounders; HIV infection was borderline associated with MASLD (OR = 1.4; 95% CI: 1.0-2.0). CONCLUSIONS In a relatively young cohort in Uganda, 14% of women and 8% of men had MASLD. There was an indication of an association between HIV and MASLD in multivariable analysis. These data are the first to describe the population-level burden of MASLD in sub-Saharan Africa using data from a population-based cohort.
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Affiliation(s)
- Rocio Enriquez
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Mahmoud Homsi
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Zangin Zeebari
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Jönköping International Business School, Jönköping University, Jönköping, Sweden
| | - Gaetano Marrone
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Larry W Chang
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Steven J Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins 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
| | | | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Venhälsan, Södersjukhuset, Stockholm, Sweden
| | - Hannes Hagström
- Unit of Hepatology, Division of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Internal Medicine and Infectious Diseases, Danderyd University Hospital, Stockholm, Sweden
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Nabukalu D, Yiannoutsos CT, Semeere A, Musick BS, Murungi T, Namulindwa JV, Waswa F, Nakigozi G, Sewankambo NK, Reynolds SJ, Lutalo T, Makumbi F, Kigozi G, Nalugoda F, Wools-Kaloustian K. Mortality Among HIV-Infected Adults on Antiretroviral Therapy in Southern Uganda. J Acquir Immune Defic Syndr 2024; 95:268-274. [PMID: 38408217 PMCID: PMC10898547 DOI: 10.1097/qai.0000000000003330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/24/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Monitoring and evaluation of clinical programs requires assessing patient outcomes. Numerous challenges complicate these efforts, the most insidious of which is loss to follow-up (LTFU). LTFU is a composite outcome, including individuals out of care, undocumented transfers, and unreported deaths. Incorporation of vital status information from routine patient outreach may improve the mortality estimates for those LTFU. SETTINGS We analyzed routinely collected clinical and patient tracing data for individuals (15 years or older) initiating antiretroviral treatment between January 2014 and December 2018 at 2 public HIV care clinics in greater Rakai, Uganda. METHODS We derived unadjusted mortality estimates using Kaplan-Meier methods. Estimates, adjusted for unreported deaths, applied weighting through the Frangakis and Rubin method to represent outcomes among LTFU patients who were successfully traced and for whom vital status was ascertained. Confidence intervals were determined through bootstrap methods. RESULTS Of 1969 patients with median age at antiretroviral treatment initiation of 31 years (interquartile range: 25-38), 1126 (57.2%) were female patients and 808 (41%) were lost. Of the lost patients, 640 patient files (79.2%) were found and reviewed, of which 204 (31.8%) had a tracing attempt. Within the electronic health records of the program, 28 deaths were identified with an estimated unadjusted mortality 1 year after antiretroviral treatment initiation of 2.5% (95% CI: 1.8% to 3.3%). Using chart review and patient tracing data, an additional 24 deaths (total 52) were discovered with an adjusted 1-year mortality of 3.8% (95% CI: 2.6% to 5.0%). CONCLUSIONS Data from routine outreach efforts by HIV care and treatment programs can be used to support plausible adjustments to estimates of client mortality. Mortality estimates without active ascertainment of vital status of LTFU patients may significantly underestimate program mortality.
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Affiliation(s)
| | | | - Aggrey Semeere
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | | | | | - Nelson K. Sewankambo
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Steven J. Reynolds
- Division of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
- Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Tom Lutalo
- Rakai Health Sciences Program, Rakai, Uganda
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Nalugoda F, Nabukalu D, Ssekasanvu J, Ssekubugu R, Hoe C, Kagaayi J, Sewankambo NK, Serwadda DM, Wawer MJ, Grabowski KM, Reynolds SJ, Kigozi G, Gray RH, Yeh PT, Chang LW. Smoker characteristics and trends in tobacco smoking in
Rakai, Uganda, 2010–2018. Tob Induc Dis 2022; 20:23. [PMID: 35342383 PMCID: PMC8883481 DOI: 10.18332/tid/144623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Tobacco use is a major public health concern, particularly in low- and middle-income countries where 80% of the world’s smokers reside. There is limited population-based data from rural Africa on patterns of tobacco smoking and smoker characteristics. We assessed trends in rates of smoking, characteristics of smokers, and factors associated with smoking using repeat population-based cross-sectional surveys in south-central Uganda. METHODS Data accrued over five survey rounds (2010–2018) of the Rakai Community Cohort Study (RCCS) from consenting individuals aged 15–49 years including sociodemographic and behavioral characteristics and smoking status. Proportions of smokers per survey were compared using χ2 test for trends, and factors associated with smoking were assessed by multivariable logistic regression. RESULTS The prevalence of tobacco smoking in the general population declined from 7.3% in 2010–2011 to 5.1% in 2016–2018, p<0.001. Smoking rates declined among males (13.9–9.2%) and females (2.2–1.8%) from 2010–2011 to 2016–2018. Smoking prevalence was higher among previously married (11.8–11.7%) compared to currently (8.4–5.3%) and never married persons (3.1–1.8%) from 2010–2011 to 2016–2018. Older age (≥35 years) was associated with higher odds of smoking (AOR=8.72; 95% CI: 5.68–13.39 in 2010–2011 and AOR=9.03; 95% CI: 5.42–15.06 in 2016–2018) compared to those aged <35 years (AOR=4.73; 95% CI: 3.15–7.12 in 2010–2011 and AOR=4.83; 95% CI: 2.95–7.91 in 2016–2018). Primary and secondary/higher education level was significantly associated with lower odds of smoking (AOR=0.20; 95% CI: 0.14–0.29 in 2010–2011 and AOR=0.26; 95% CI: 0.18–0.39 in 2016–2018) compared to no education (AOR=0.43; 95% CI: 0.31–0.59 in 2010–2011 and AOR=0.48; 95% CI: 0.34–0.68 in 2016–2018). Number of sexual partners and HIV status were not associated with smoking. CONCLUSIONS We observed declining trends in tobacco smoking in the Rakai region of rural Uganda. Smoking was more prevalent in men, older individuals, individuals who were previously married, and individuals with lower education. The decline in smoking may be due to tobacco control efforts, but there is a continued need to target sub-populations with higher smoking prevalence.
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Affiliation(s)
| | | | - Joseph Ssekasanvu
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, United States
| | | | - Connie Hoe
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, United States
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nelson K. Sewankambo
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David M. Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Maria J. Wawer
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, United States
| | - Kate M. Grabowski
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, United States
- Department of Pathology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, United States
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, United States
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, United States
| | | | - Ronald H. Gray
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, United States
| | - Ping T. Yeh
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, United States
| | - Larry W. Chang
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, United States
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, United States
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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5
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Enriquez R, Ssekubugu R, Kigozi G, Nabukalu D, Marrone G, Rautiainen S, Gigante B, Reynolds SJ, Nalugoda F, Chang LW, Ekström AM, Sewankambo NK, Serwadda D, Nordenstedt H. ECG Abnormalities and Arterial Stiffness by HIV Status among High-Risk Populations in Rakai, Uganda: A Pilot Study. Glob Heart 2021; 16:83. [PMID: 34909374 PMCID: PMC8663741 DOI: 10.5334/gh.1015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 11/12/2021] [Indexed: 11/20/2022] Open
Abstract
Background People living with HIV are at increased risk for cardiovascular disease (CVD). In sub-Saharan Africa, population-based data on major CVD events such as stroke and myocardial infarction are difficult to collect. The use of proxy measures could be a feasible way to better study CVD in such settings. This study aimed to determine the acceptance of incorporating ECG and arterial function measurements into a population-based cohort study and to assess the prevalence of ECG abnormalities and arterial stiffness. Methods A pilot study was conducted within the Rakai Community Cohort Study in Uganda on two high-risk CVD populations; one determined by age (35-49) and Framingham CVD risk scores and the other by age alone (50+). Data on ECG, arterial function, blood pressure, and HIV status were collected. The acceptability of incorporating ECG and arterial function measurements was established as an acceptance rate difference of no more than 5% to blood pressure measurements. Results A total of 118 participants were enrolled, 57 participants living with HIV and 61 HIV-negative participants. Both ECG measurements and arterial function were well accepted (2% difference). Left ventricular hypertrophy (LVH) and arterial stiffness (>10 m/s) were common in both participants living with HIV and HIV-negative participants across the two high-risk populations. Prevalence rates ranged from 30% to 53% for LVH and 25% to 58% for arterial stiffness. Arterial stiffness at the 11 m/s cutoff (p = 0.03) was found to be more common among participants living with HIV in the 35-49 population. Conclusions The incorporation of ECG and arterial function measurements into routine activities of a population-based cohort was acceptable and incorporating these proxy measures into cohort studies should be explored further. LVH and arterial stiffness were both common irrespective of HIV status with arterial stiffness potentially more common among people living with HIV.
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Affiliation(s)
- Rocio Enriquez
- Department of Global Public Health, Karolinska Institutet, Stockholm, SE
| | - Robert Ssekubugu
- Department of Global Public Health, Karolinska Institutet, Stockholm, SE
- Rakai Health Sciences Program, Kalisizo, UG
| | | | | | - Gaetano Marrone
- Department of Global Public Health, Karolinska Institutet, Stockholm, SE
| | - Susanne Rautiainen
- Department of Global Public Health, Karolinska Institutet, Stockholm, SE
| | - Bruna Gigante
- Department of Medicine, Karolinska Institutet, Stockholm, SE
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Kalisizo, UG
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, US
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, US
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, US
| | | | - Larry W. Chang
- Rakai Health Sciences Program, Kalisizo, UG
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, US
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, US
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, SE
- Venhälsan, Södersjukhuset, Stockholm, SE
| | - Nelson K. Sewankambo
- Rakai Health Sciences Program, Kalisizo, UG
- Department of Medicine, Makerere University School of Medicine, Kampala, UG
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, UG
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, UG
| | - Helena Nordenstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, SE
- Division of Internal Medicine, Danderyd University Hospital, Karolinska Institute, Stockholm, SE
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6
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Wynn A, Nabukalu D, Lutalo T, Wawer M, Chang LW, Kiene SM, Serwadda DM, Sewankambo N, Nalugoda F, Kigozi G, Wagman JA. Alcohol use during pregnancy in Rakai, Uganda. PLoS One 2021; 16:e0256434. [PMID: 34437616 PMCID: PMC8389483 DOI: 10.1371/journal.pone.0256434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction Antenatal alcohol use is linked to adverse maternal and neonatal outcomes. Uganda has one of the highest rates of alcohol use in sub-Saharan Africa, but the prevalence of antenatal alcohol use has not been reported in the Rakai region. Methods We used cross-sectional data from pregnant women in the Rakai Community Cohort Study between March 2017 and September 2018. Using bivariate and multivariable analyses, we assessed associations between self-reported antenatal alcohol use and sociodemographic characteristics, intimate partner violence (IPV), and HIV status. Results Among 960 pregnant women, the median age was 26 years, 35% experienced IPV in the past 12 months, 13% were living with HIV, and 33% reported alcohol use during their current pregnancy. After adjusting for marital status, education, smoking, and HIV status; Catholic religion (AOR: 3.54; 95% CI: 1.89–6.64; compared to other), bar/restaurant work (AOR: 2.40; 95% CI: 1.17–4.92; compared to agriculture), >one sex partner in past year (AOR: 1.92; 95% CI: 1.17–3.16), a partner that drank before sex in past year (AOR: 2.01; 95% CI: 1.48–2.74), and past year IPV (AOR: 1.55; 95% CI: 1.14–2.11) were associated with antenatal alcohol use. Conclusion We found that alcohol use during pregnancy was common and associated with religion, occupation, higher numbers of past year sex partners, having a partner who drank before sex in the past 12 months, and IPV experience. More research is needed to understand the quantity, frequency, and timing of antenatal alcohol use; and potential impacts on neonates; and to identify services that are acceptable and effective among pregnant women.
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Affiliation(s)
- Adriane Wynn
- Division of Infectious Diseases & Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, United States of America
- * E-mail:
| | - Dorean Nabukalu
- Rakai Health Sciences Program/Uganda Virus Research Institute, Kalisizo, Uganda
| | - Tom Lutalo
- Rakai Health Sciences Program/Uganda Virus Research Institute, Kalisizo, Uganda
| | - Maria Wawer
- Rakai Health Sciences Program/Uganda Virus Research Institute, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Larry W. Chang
- Rakai Health Sciences Program/Uganda Virus Research Institute, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Department of Medicine, John Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Susan M. Kiene
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA, United States of America
| | | | | | - Fred Nalugoda
- Rakai Health Sciences Program/Uganda Virus Research Institute, Kalisizo, Uganda
| | - Godfrey Kigozi
- Rakai Health Sciences Program/Uganda Virus Research Institute, Kalisizo, Uganda
| | - Jennifer A. Wagman
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA, United States of America
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7
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Risher KA, Cori A, Reniers G, Marston M, Calvert C, Crampin A, Dadirai T, Dube A, Gregson S, Herbst K, Lutalo T, Moorhouse L, Mtenga B, Nabukalu D, Newton R, Price AJ, Tlhajoane M, Todd J, Tomlin K, Urassa M, Vandormael A, Fraser C, Slaymaker E, Eaton JW. Age patterns of HIV incidence in eastern and southern Africa: a modelling analysis of observational population-based cohort studies. Lancet HIV 2021; 8:e429-e439. [PMID: 34197773 PMCID: PMC8258368 DOI: 10.1016/s2352-3018(21)00069-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/10/2021] [Accepted: 03/23/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND As the HIV epidemic in sub-Saharan Africa matures, evidence about the age distribution of new HIV infections and how this distribution has changed over the epidemic is needed to guide HIV prevention. We aimed to assess trends in age-specific HIV incidence in six population-based cohort studies in eastern and southern Africa, reporting changes in mean age at infection, age distribution of new infections, and birth cohort cumulative incidence. METHODS We used a Bayesian model to reconstruct age-specific HIV incidence from repeated observations of individuals' HIV serostatus and survival collected among population HIV cohorts in rural Malawi, South Africa, Tanzania, Uganda, and Zimbabwe, in a collaborative analysis of the ALPHA network. We modelled HIV incidence rates by age, time, and sex using smoothing splines functions. We estimated incidence trends separately by sex and study. We used estimated incidence and prevalence results for 2000-17, standardised to study population distribution, to estimate mean age at infection and proportion of new infections by age. We also estimated cumulative incidence (lifetime risk of infection) by birth cohort. FINDINGS Age-specific incidence declined at all ages, although the timing and pattern of decline varied by study. The mean age at infection was higher in men (cohort mean 27·8-34·6 years) than in women (24·8-29·6 years). Between 2000 and 2017, the mean age at infection per cohort increased slightly: 0·5 to 2·8 years among men and -0·2 to 2·5 years among women. Across studies, between 38% and 63% (cohort medians) of the infections in women were among those aged 15-24 years and between 30% and 63% of infections in men were in those aged 20-29 years. Lifetime risk of HIV declined for successive birth cohorts. INTERPRETATION HIV incidence declined in all age groups and shifted slightly to older ages. Disproportionate new HIV infections occur among women aged 15-24 years and men aged 20-29 years, supporting focused prevention in these groups. However, 40-60% of infections were outside these ages, emphasising the importance of providing appropriate HIV prevention to adults of all ages. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Kathryn A Risher
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - Anne Cori
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Milly Marston
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Clara Calvert
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Amelia Crampin
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Tawanda Dadirai
- The Manicaland Centre for Public Health Research, Harare, Zimbabwe
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Simon Gregson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; Department of Science and Innovation-Medical Research Council South African Population Research Infrastructure Network, Durban, South Africa
| | - Tom Lutalo
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - Louisa Moorhouse
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Baltazar Mtenga
- National Institute for Medical Research, Kisesa HDSS, Mwanza, Tanzania
| | | | - Robert Newton
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda; Department of Health Sciences, University of York, York, UK
| | - Alison J Price
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Malebogo Tlhajoane
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jim Todd
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Keith Tomlin
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark Urassa
- National Institute for Medical Research, Kisesa HDSS, Mwanza, Tanzania
| | - Alain Vandormael
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; KwaZulu-Natal Research Innovation and Sequencing Platform, UKZN, Durban, South Africa; Heidelberg Institute of Global Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Christophe Fraser
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emma Slaymaker
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jeffrey W Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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8
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Nabukalu D, Reniers G, Risher KA, Blom S, Slaymaker E, Kabudula C, Zaba B, Nalugoda F, Kigozi G, Makumbi F, Serwadda D, Reynolds SJ, Marston M, Eaton JW, Gray R, Wawer M, Sewankambo N, Lutalo T. Population-level adult mortality following the expansion of antiretroviral therapy in Rakai, Uganda. Popul Stud (Camb) 2020; 74:93-102. [PMID: 31117928 PMCID: PMC6891159 DOI: 10.1080/00324728.2019.1595099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 02/01/2019] [Indexed: 12/03/2022]
Abstract
There are limited data on the impact of antiretroviral therapy (ART) on population-level adult mortality in sub-Saharan Africa. We analysed data for 2000-14 from the Rakai Community Cohort Study (RCCS) in Uganda, where free ART was scaled up after 2004. Using non-parametric and parametric (Weibull) survival analysis, we estimated trends in average person-years lived between exact ages 15 and 50, per capita life-years lost to HIV, and the mortality hazards of people living with HIV (PLHIV). Between 2000 and 2014, average adult life-years lived before age 50 increased significantly, from 26.4 to 33.5 years for all women and from 28.6 to 33.8 years for all men. As of 2014, life-years lost to HIV had declined significantly, to 1.3 years among women and 0.4 years among men. Following the roll-out of ART, mortality reductions among PLHIV were initially larger in women than men, but this is no longer the case.
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Affiliation(s)
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine
- University of the Witwatersrand
| | | | - Sylvia Blom
- London School of Hygiene and Tropical Medicine
| | | | | | - Basia Zaba
- London School of Hygiene and Tropical Medicine
| | | | | | - Fred Makumbi
- Rakai Health Sciences Program
- Makerere University
| | | | - Steven J Reynolds
- National Institutes of Health
- Johns Hopkins Bloomberg School of Public Health
| | | | | | - Ron Gray
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
| | - Maria Wawer
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
| | | | - Tom Lutalo
- Rakai Health Sciences Program
- Uganda Virus Research Institute
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9
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Kate Grabowski M, Lessler J, Bazaale J, Nabukalu D, Nankinga J, Nantume B, Ssekasanvu J, Reynolds SJ, Ssekubugu R, Nalugoda F, Kigozi G, Kagaayi J, Santelli JS, Kennedy C, Wawer MJ, Serwadda D, Chang LW, Gray RH. Migration, hotspots, and dispersal of HIV infection in Rakai, Uganda. Nat Commun 2020; 11:976. [PMID: 32080169 PMCID: PMC7033206 DOI: 10.1038/s41467-020-14636-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/18/2020] [Indexed: 01/11/2023] Open
Abstract
HIV prevalence varies markedly throughout Africa, and it is often presumed areas of higher HIV prevalence (i.e., hotspots) serve as sources of infection to neighboring areas of lower prevalence. However, the small-scale geography of migration networks and movement of HIV-positive individuals between communities is poorly understood. Here, we use population-based data from ~22,000 persons of known HIV status to characterize migratory patterns and their relationship to HIV among 38 communities in Rakai, Uganda with HIV prevalence ranging from 9 to 43%. We find that migrants moving into hotspots had significantly higher HIV prevalence than migrants moving elsewhere, but out-migration from hotspots was geographically dispersed, contributing minimally to HIV burden in destination locations. Our results challenge the assumption that high prevalence hotspots are drivers of transmission in regional epidemics, instead suggesting that migrants with high HIV prevalence, particularly women, selectively migrate to these areas.
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Affiliation(s)
- Mary Kate Grabowski
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA.
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 627 North Washington St., Baltimore, MD, 21205, USA.
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda.
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 627 North Washington St., Baltimore, MD, 21205, USA
| | - Jeremiah Bazaale
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - Dorean Nabukalu
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - Justine Nankinga
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - Betty Nantume
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - Joseph Ssekasanvu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 627 North Washington St., Baltimore, MD, 21205, USA
| | - Steven J Reynolds
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA
| | - Robert Ssekubugu
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - Fred Nalugoda
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - Godfrey Kigozi
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - John S Santelli
- Heilbrunn Department of Population and Family Health, Columbia University, 60 Haven Avenue, New York, NY, 10032, USA
| | - Caitlin Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 627 North Washington St., Baltimore, MD, 21205, USA
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Larry W Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 627 North Washington St., Baltimore, MD, 21205, USA
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21205, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 627 North Washington St., Baltimore, MD, 21205, USA
- Rakai Health Sciences Program, Old Bukoba Road, P.O. Box 279, Kalisizo, Uganda
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10
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Nelson Kankaka E, Ssekasanvu J, Prodger J, Nabukalu D, Nakawooya H, Ndyanabo A, Kigozi G, Gray R. Sexual risk behaviors following circumcision among HIV-positive men in Rakai, Uganda. AIDS Care 2018; 30:990-996. [PMID: 29433386 PMCID: PMC6284241 DOI: 10.1080/09540121.2018.1437253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine whether circumcision of HIV-positive men is associated with increased subsequent sexual risk behaviors which may place their female partners at risk. METHODS Newly circumcised and uncircumcised HIV-positive men in the Rakai Community Cohort Study were followed from baseline (July 2013-January 2015) to determine trend in sexual risk behaviors and association of circumcision with subsequent sexual risk behaviors at follow up (February 2015-September 2016). Risk behaviors included sexual activity, alcohol before sex, transactional sex, multiple sex partners, casual sex partners, and inconsistent condom use with casual partners. The association was evaluated using modified Poisson regression, and sensitivity analyses were performed after multiple imputation with chained equations for missing data. RESULTS We identified 538 eligible men, of whom 113(21.0%) were circumcised at baseline and 425(79.0%) were uncircumcised. Men in fishing communities were more likely to be circumcised (p = 0.032) as well as those exposed to targeted HIV messaging (p < 0.001). Overall, 188(34.9%) men were lost to follow up and most were uncircumcised (p = 0.020). Among those followed up, behaviors remained largely unchanged with no differences by circumcision status. Transactional sex appeared to be associated with circumcision in unadjusted analyses (PR = 1.58, 95%CI = 1.01,2.48; p = 0.045, p = 0.05) and adjusted analyses (adj.PR = 1.54, 95%CI = 1.06,2.23; p = 0.022). However, the association was no longer significant in sensitivity analyses after accounting for loss to follow up (adj.PR = 1.43, 95%CI = 0.98,2.08; p = 0.066). No association with circumcision was observed for other sexual risk behaviors. CONCLUSION We found no association between circumcision of HIV-positive men and subsequent sexual risk behavior.
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Affiliation(s)
- Edward Nelson Kankaka
- Rakai Health Sciences Program, Rakai, Uganda
- Department of Epidemiology, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA
| | - Joseph Ssekasanvu
- Rakai Health Sciences Program, Rakai, Uganda
- Department of Epidemiology, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jessica Prodger
- Department of Epidemiology, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | - Ronald Gray
- Rakai Health Sciences Program, Rakai, Uganda
- Department of Epidemiology, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA
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11
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Slaymaker E, McLean E, Wringe A, Calvert C, Marston M, Reniers G, Kabudula CW, Crampin A, Price A, Michael D, Urassa M, Kwaro D, Sewe M, Eaton JW, Rhead R, Nakiyingi-Miiro J, Lutalo T, Nabukalu D, Herbst K, Hosegood V, Zaba B. The Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA): Data on mortality, by HIV status and stage on the HIV care continuum, among the general population in seven longitudinal studies between 1989 and 2014. Gates Open Res 2017. [PMID: 29528045 PMCID: PMC5841576 DOI: 10.12688/gatesopenres.12753.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Timely progression of people living with HIV (PLHIV) from the point of infection through the pathway from diagnosis to treatment is important in ensuring effective care and treatment of HIV and preventing HIV-related deaths and onwards transmission of infection. Reliable, population-based estimates of new infections are difficult to obtain for the generalised epidemics in sub-Saharan Africa. Mortality data indicate disease burden and, if disaggregated along the continuum from diagnosis to treatment, can also reflect the coverage and quality of different HIV services. Neither routine statistics nor observational clinical studies can estimate mortality prior to linkage to care nor following disengagement from care. For this, population-based data are required. The Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa brings together studies in Kenya, Malawi, South Africa, Tanzania, Uganda, and Zimbabwe. Eight studies have the necessary data to estimate mortality by HIV status, and seven can estimate mortality at different stages of the HIV care continuum. This data note describes a harmonised dataset containing anonymised individual-level information on survival by HIV status for adults aged 15 and above. Among PLHIV, the dataset provides information on survival during different periods: prior to diagnosis of infection; following diagnosis but before linkage to care; in pre-antiretroviral treatment (ART) care; in the first six months after ART initiation; among people continuously on ART for 6+ months; and among people who have ever interrupted ART.
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Affiliation(s)
- Emma Slaymaker
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Estelle McLean
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Alison Wringe
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Clara Calvert
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Milly Marston
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, 2000, South Africa
| | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2000, South Africa
| | - Amelia Crampin
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Alison Price
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Denna Michael
- National Institute for Medical Research, Mwanza, Tanzania
| | - Mark Urassa
- National Institute for Medical Research, Mwanza, Tanzania
| | | | | | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, W2 1PG, UK
| | - Rebecca Rhead
- Department of Infectious Disease Epidemiology, Imperial College London, London, W2 1PG, UK
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | - Kobus Herbst
- Africa Health Research Institute, Durban, 4001, South Africa
| | - Victoria Hosegood
- Africa Health Research Institute, Durban, 4001, South Africa.,Department of Social Statistics & Demography, University of Southampton, Southhampton, SO17 1BJ, UK
| | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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12
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Kankaka EN, Kigozi G, Kayiwa D, Kighoma N, Makumbi F, Murungi T, Nabukalu D, Nampijja R, Watya S, Namuguzi D, Nalugoda F, Nakigozi G, Serwadda D, Wawer M, Gray RH. Efficacy of knowledge and competence-based training of non-physicians in the provision of early infant male circumcision using the Mogen clamp in Rakai, Uganda. BJU Int 2016; 119:631-637. [PMID: 27753243 DOI: 10.1111/bju.13685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess acquisition of knowledge and competence in performing Early Infant Male Circumcision (EIMC) by non-physicians trained using a structured curriculum. SUBJECTS AND METHODS Training in provision of EIMC using the Mogen clamp was conducted for 10 Clinical Officers (COs) and 10 Registered Nurse Midwives (RNMWs), in Rakai, Uganda. Healthy infants whose mothers consented to study participation were assigned to the trainees, each of whom performed at least 10 EIMCs. Ongoing assessment and feedback for competency were done, and safety assessed by adverse events. RESULTS Despite similar baseline knowledge, COs acquired more didactic knowledge than RNMWs (P = 0.043). In all, 100 EIMCs were assessed for gain in competency. The greatest improvement in competency was between the first and third procedures, and all trainees achieved 80% competency and retention of skills by the seventh procedure. The median (interquartile range) time to complete a procedure was 14.5 (10-47) min for the COs, and 15 (10-50) min for the RNMWs (P = 0.180). The procedure times declined by 2.2 min for each subsequent EIMC (P = 0.005), and rates of improvement were similar for COs and RNMWs. Adverse events were comparable between providers (3.5%), of which 1% were of moderate severity. CONCLUSION Competence-based training of non-physicians improved knowledge and competency in EIMC performed by COs and RNMWs in Uganda.
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Affiliation(s)
| | | | | | | | - Frederick Makumbi
- Rakai Health Sciences Program, Kalisizo, Uganda.,School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | | | | | - Daniel Namuguzi
- Rakai Health Sciences Program, Kalisizo, Uganda.,Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda.,School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maria Wawer
- Rakai Health Sciences Program, Kalisizo, Uganda.,Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ronald H Gray
- Rakai Health Sciences Program, Kalisizo, Uganda.,Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Kankaka EN, Murungi T, Kigozi G, Makumbi F, Nabukalu D, Watya S, Kighoma N, Nampijja R, Kayiwa D, Nalugoda F, Serwadda D, Wawer M, Gray RH. Randomised trial of early infant circumcision performed by clinical officers and registered nurse midwives using the Mogen clamp in Rakai, Uganda. BJU Int 2016; 119:164-170. [PMID: 27597563 DOI: 10.1111/bju.13589] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the safety and acceptability of early infant circumcision (EIC) provided by trained clinical officers (COs) and registered nurse midwives (RNMWs) in rural Uganda. SUBJECTS AND METHODS We conducted a randomised trial of EIC using the Mogen clamp provided by newly trained COs and RNMWs in four health centres in rural Rakai, Uganda. The trial was registered with clinicaltrials.gov # NCT02596282. In all, 501 healthy neonates aged 1-28 days with normal birth weight and gestational age were randomised to COs (n = 256) and RNMWs (n = 245) for EIC, and were followed-up at 1, 7 and 28 days. RESULTS In all, 701 mothers were directly invited to participate in the trial, 525 consented to circumcision (74.9%) and 23 were found ineligible on screening (4.4%). The procedure took an average of 10.5 min. Adherence to follow-up was >90% at all scheduled visits. The rates of moderate/severe adverse events were 2.4% for COs and 1.6% for RNMWs (P = 0.9). All wounds were healed by 28 days after circumcision. Maternal satisfaction with the procedure was 99.6% for infants circumcised by COs and 100% among infants circumcised by RNMWs. CONCLUSIONS EIC was acceptable in this rural Ugandan population and can be safely performed by RNMWs who have direct contact with the mothers during pregnancy and delivery. EIC services should be made available to parents who are interested in the service.
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Affiliation(s)
| | - Teddy Murungi
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda
| | | | - Frederick Makumbi
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda.,College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | | | - Stephen Watya
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda
| | | | | | - Daniel Kayiwa
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda
| | - Fred Nalugoda
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda.,College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Maria Wawer
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ronald H Gray
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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14
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Reniers G, Wamukoya M, Urassa M, Nyaguara A, Nakiyingi-Miiro J, Lutalo T, Hosegood V, Gregson S, Gómez-Olivé X, Geubbels E, Crampin AC, Wringe A, Waswa L, Tollman S, Todd J, Slaymaker E, Serwadda D, Price A, Oti S, Nyirenda MJ, Nabukalu D, Nyamukapa C, Nalugoda F, Mugurungi O, Mtenga B, Mills L, Michael D, McLean E, McGrath N, Martin E, Marston M, Maquins S, Levira F, Kyobutungi C, Kwaro D, Kasamba I, Kanjala C, Kahn K, Kabudula C, Herbst K, Gareta D, Eaton JW, Clark SJ, Church K, Chihana M, Calvert C, Beguy D, Asiki G, Amri S, Abdul R, Zaba B. Data Resource Profile: Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA Network). Int J Epidemiol 2016; 45:83-93. [PMID: 26968480 DOI: 10.1093/ije/dyv343] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2015] [Indexed: 11/14/2022] Open
Affiliation(s)
- Georges Reniers
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa,
| | | | - Mark Urassa
- Tazama Project, Tanzania National Institute for Medical Research, Mwanza, Tanzania
| | - Amek Nyaguara
- Kenya Medical Research Institute and the Centers for Disease Control, Kisumu, Kenya
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Uganda Virus Research Institute, Rakai, Uganda
| | - Vicky Hosegood
- Africa Centre for Population Health, Mtubatuba, South Africa, Department of Social Statistics and Demography, Southampton University, Southampton, UK
| | - Simon Gregson
- Manicaland Centre for Public Health Research, Harare, Zimbabwe, Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Xavier Gómez-Olivé
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Amelia C Crampin
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Alison Wringe
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Laban Waswa
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Stephen Tollman
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Centre for Global Health Research, Umea° University, Umea°, Sweden
| | - Jim Todd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Emma Slaymaker
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David Serwadda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Rakai, Uganda, School of Public Health, Makerere University, Kampala, Uganda
| | - Alison Price
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Samuel Oti
- African Population and Health Research Center, Nairobi, Kenya
| | - Moffat J Nyirenda
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Dorean Nabukalu
- Rakai Health Sciences Program, Uganda Virus Research Institute, Rakai, Uganda
| | - Constance Nyamukapa
- Manicaland Centre for Public Health Research, Harare, Zimbabwe, Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Fred Nalugoda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Rakai, Uganda
| | - Owen Mugurungi
- Manicaland Centre for Public Health Research, Harare, Zimbabwe, Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - Baltazar Mtenga
- Tazama Project, Tanzania National Institute for Medical Research, Mwanza, Tanzania
| | - Lisa Mills
- Kenya Medical Research Institute and the Centers for Disease Control, Kisumu, Kenya, Division of HIV/AIDS Prevention, CDC, Atlanta GA, USA and
| | - Denna Michael
- Tazama Project, Tanzania National Institute for Medical Research, Mwanza, Tanzania
| | - Estelle McLean
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Nuala McGrath
- Africa Centre for Population Health, Mtubatuba, South Africa, Department of Social Statistics and Demography, Southampton University, Southampton, UK
| | - Emmanuel Martin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Milly Marston
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sewe Maquins
- Kenya Medical Research Institute and the Centers for Disease Control, Kisumu, Kenya
| | | | | | - Daniel Kwaro
- Kenya Medical Research Institute and the Centers for Disease Control, Kisumu, Kenya
| | - Ivan Kasamba
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Chifundo Kanjala
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kathleen Kahn
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Centre for Global Health Research, Umea° University, Umea°, Sweden
| | - Chodziwadziwa Kabudula
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kobus Herbst
- Africa Centre for Population Health, Mtubatuba, South Africa
| | - Dickman Gareta
- Africa Centre for Population Health, Mtubatuba, South Africa
| | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Samuel J Clark
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Department of Sociology, University of Washington, Seattle WA, USA
| | - Kathryn Church
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Menard Chihana
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Clara Calvert
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Donatien Beguy
- African Population and Health Research Center, Nairobi, Kenya
| | - Gershim Asiki
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Shamte Amri
- Ifakara Health Institute, Dar-Es-Salaam, Tanzania
| | | | - Basia Zaba
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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15
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Reniers G, Slaymaker E, Nakiyingi-Miiro J, Nyamukapa C, Crampin AC, Herbst K, Urassa M, Otieno F, Gregson S, Sewe M, Michael D, Lutalo T, Hosegood V, Kasamba I, Price A, Nabukalu D, Mclean E, Zaba B. Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA). AIDS 2014; 28 Suppl 4:S533-42. [PMID: 25406756 PMCID: PMC4251911 DOI: 10.1097/qad.0000000000000496] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 09/22/2014] [Accepted: 09/22/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The rollout of antiretroviral therapy (ART) is one of the largest public health interventions in Eastern and Southern Africa of recent years. Its impact is well described in clinical cohort studies, but population-based evidence is rare. METHODS We use data from seven demographic surveillance sites that also conduct community-based HIV testing and collect information on the uptake of HIV services. We present crude death rates of adults (aged 15-64) for the period 2000-2011 by sex, HIV status, and treatment status. Parametric survival models are used to estimate age-adjusted trends in the mortality rates of people living with HIV (PLHIV) before and after the introduction of ART. RESULTS The pooled ALPHA Network dataset contains 2.4 million person-years of follow-up time, and 39114 deaths (6893 to PLHIV). The mortality rates of PLHIV have been relatively static before the availability of ART. Mortality declined rapidly thereafter, with typical declines between 10 and 20% per annum. Compared with the pre-ART era, the total decline in mortality rates of PLHIV exceeds 58% in all study sites with available data, and amounts to 84% for women in Masaka (Uganda). Mortality declines have been larger for women than for men; a result that is statistically significant in five sites. Apart from the early phase of treatment scale up, when the mortality of PLHIV on ART was often very high, mortality declines have been observed in PLHIV both on and off ART. CONCLUSION The expansion of treatment has had a large and pervasive effect on adult mortality. Mortality declines have been more pronounced for women, a factor that is often attributed to women's greater engagement with HIV services. Improvements in the timing of ART initiation have contributed to mortality reductions in PLHIV on ART, but also among those who have not (yet) started treatment because they are increasingly selected for early stage disease.
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Affiliation(s)
- Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Emma Slaymaker
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jessica Nakiyingi-Miiro
- Research Unit on AIDS, Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Constance Nyamukapa
- Manicaland HIV/STD prevention project, Bio-medical Research and Training Institute, Harare, Zimbabwe
| | - Amelia Catharine Crampin
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Karonga Prevention Study, London School of Hygiene and Tropical Medicine, Chilumba, Malawi
| | - Kobus Herbst
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, Somkhele, South Africa
| | - Mark Urassa
- TAZAMA project, National Institute for Medical Research, Mwanza, Tanzania
| | - Fred Otieno
- Kenya Medical Research Institute / Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Simon Gregson
- Manicaland HIV/STD prevention project, Bio-medical Research and Training Institute, Harare, Zimbabwe
- School of Public Health, Faculty of Medicine, Imperial College, London, UK
| | - Maquins Sewe
- Kenya Medical Research Institute / Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Denna Michael
- TAZAMA project, National Institute for Medical Research, Mwanza, Tanzania
| | - Tom Lutalo
- Rakai Health Sciences Program, Makerere University School of Public Health, Rakai, Uganda
| | - Victoria Hosegood
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, Somkhele, South Africa
- Department of Social Statistics and Demography, Southampton University, Southampton, UK
| | - Ivan Kasamba
- Research Unit on AIDS, Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Alison Price
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Karonga Prevention Study, London School of Hygiene and Tropical Medicine, Chilumba, Malawi
| | - Dorean Nabukalu
- Rakai Health Sciences Program, Makerere University School of Public Health, Rakai, Uganda
| | - Estelle Mclean
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Basia Zaba
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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16
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Nabukalu D, Klipstein-Grobusch K, Herbst K, Newell ML. Mortality in women of reproductive age in rural South Africa. Glob Health Action 2013; 6:22834. [PMID: 24360403 PMCID: PMC3869952 DOI: 10.3402/gha.v6i0.22834] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 11/24/2013] [Accepted: 11/25/2013] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To determine causes of death and associated risk factors in women of reproductive age in rural South Africa. METHODS Deaths and person-years of observation (pyo) were determined for females (aged 15-49 years) resident in 15,526 households in a rural South African Demographic and Health Surveillance site from 2000 to 2009. Cause of death was ascertained by verbal autopsy and ICD-10 coded; causes were categorized as HIV/TB, non-communicable, communicable/maternal/perinatal/nutrition, injuries, and undetermined (unknown). Characteristics of women were obtained from regularly updated household visits, while HIV and self-reported health status was obtained from the annual HIV surveillance. Overall and cause-specific mortality rates (MRs) with 95% confidence intervals (CI) were calculated. The Weibull regression model (HR, 95%CI) was used to determine risk factors associated with mortality. RESULTS A total of 42,703 eligible women were included; 3,098 deaths were reported for 212,607 pyo. Overall MRwas 14.6 deaths/1,000 pyo (95% CI: 14.1-15.1), peaking in 2003 (MR 18.2/1,000 pyo, 95% CI: 16.4-20.1) and declining thereafter (2009: MR 9.6/1,000 pyo, 95% CI: 8.410.9). Mortality was highest for HIV/TB (MR 10.6/1,000 pyo, 95% CI: 10.211.1), accounting for 73.1% of all deaths, ranging from 61.2% in 2009 to 82.7% in 2002. Adjusting for education level, marital status, age, employment status, area of residence, and migration, all-cause mortality was associated with external migration (adjusted hazard ratio, or aHR), 1.70, 95% CI: 1.41-2.05), self-reported poor health status (aHR 8.26, 95% CI: 2.94-23.15), and HIV-infection (aHR 7.84, 95% CI: 6.26-9.82); external migration and HIV infection were also associated with causes of mortality other than HIV/TB (aHR 1.62 CI: 1.12-2.34 and aHR 2.59, CI: 1.79-3.75). CONCLUSION HIV/TB was the leading cause of death among women of reproductive age, although rates declined with the rollout of HIV treatment in the area from 2004. Women's age, external migration status, and HIV-positive status were significantly associated with all-cause and cause-specific mortality.
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Affiliation(s)
- Dorean Nabukalu
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda
| | - Kerstin Klipstein-Grobusch
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands;
| | - Kobus Herbst
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Marie-Louise Newell
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa; Faculty of Medicine and Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
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