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Aizire J, Yende-Zuma N, Hanley S, Nematadzira T, Nyati MM, Dadabhai S, Chinula L, Nakaye C, Fowler MG, Taha T. Unintended pregnancy and contraception use among African women living with HIV: Baseline analysis of the multi-country US PEPFAR PROMOTE cohort. PLoS One 2024; 19:e0290285. [PMID: 38466748 PMCID: PMC10927155 DOI: 10.1371/journal.pone.0290285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 08/04/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND About 90% of unintended pregnancies are attributed to non-use of effective contraception-tubal ligation, or reversible effective contraception (REC) including injectables, oral pills, intra-uterine contraceptive device (IUCD), and implant. We assessed the prevalence of unintended pregnancy and factors associated with using RECs, and Long-Acting-Reversible-Contraceptives (LARCs)-implants and IUCDs, among women living with HIV (WLHIV) receiving antiretroviral therapy (ART). METHODS We conducted cross-sectional analyses of the US-PEPFAR PROMOTE study WLHIV on ART at enrollment. Separate outcome (REC and LARC) modified-Poisson regression models were used to estimate prevalence risk ratio (PRR) and corresponding 95% confidence interval (CI). RESULTS Of 1,987 enrolled WLHIV, 990 (49.8%) reported their last/current pregnancy was unintended; 1,027/1,254 (81.9%) non-pregnant women with a potential to become pregnant reported current use of effective contraception including 215/1,254 (17.1%) LARC users. Compared to Zimbabwe, REC rates were similar in South Africa, aPRR = 0.97 (95% CI: 0.90-1.04), p = 0.355, lower in Malawi, aPRR = 0.84 (95% CI: 0.78-0.91), p<0.001, and Uganda, 0.82 (95% CI: 0.73-0.91), p<0.001. Additionally, REC use was independently associated with education attained, primary versus higher education, aPRR = 1.10 (95% CI: 1.02-1.18), p = 0.013; marriage/stable union, aPRR = 1.10 (95% CI: 1.01-1.21), p = 0.039; no desire for another child, PRR = 1.10 (95% CI: 1.02-1.16), p = 0.016; infrequent sex (none in the last 3 months), aPRR = 1.24 (95% CI: 1.15-1.33), p<0001; and controlled HIV load (≤ 1000 copies/ml), PRR = 1.10 (95% CI: 1.02-1.19), p = 0.014. LARC use was independently associated with country (Zimbabwe ref: South Africa, PRR = 0.39 (95% CI: 0.26-0.57), p<0.001; Uganda, PRR = 0.65 (95% CI: 0.42-1.01), p = 0.054; and Malawi, aPRR = 0.87 (95% CI: 0.64-1.19), p = 0.386; HIV load (≤ 1000 copies/ml copies/ml), aPRR=1.73 (95% CI: 1.26-2.37), p<0.001; and formal/self-employment, aPRR = 1.37 (95% CI: 1.02-1.91), p = 0.027. CONCLUSIONS Unintended pregnancy was common while use of effective contraception methods particularly LARCs was low among these African WLHIV. HIV viral load, education, sexual-activity, fertility desires, and economic independence are pertinent individual-level factors integral to the multi-level barriers to utilization of effective contraception among African WLHIV. National programs should prioritize strategies for effective integration of HIV and reproductive health care in the respective African countries.
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Affiliation(s)
- Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- South Africa Medical Research Council (SAMRC)-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Umlazi Clinical Research Site, Durban, South Africa
| | - Teacler Nematadzira
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Mandisa M. Nyati
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sufia Dadabhai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Lameck Chinula
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- UNC-CH Department of Obstetrics and Gynecology, Chapel Hill, NC, United States of America
| | - Catherine Nakaye
- Makerere University-Johns Hopkins University (MUJHU) Research Collaboration, Kampala, Uganda
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Taha Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Taha TE, Bandala-Jacques A, Yende-Zuma N, Violari A, Stranix-Chibanda L, Atuhaire P, Hanley S, Gadama L, Chinula L, Dadabhai S, Aizire J, Brummel SS, Fowler MG. Breastfeeding Among Women Living With HIV in the Era of Lifelong ART: An Observational Multicountry Study in Eastern and Southern Africa. J Acquir Immune Defic Syndr 2024; 95:10-17. [PMID: 37732877 PMCID: PMC10840656 DOI: 10.1097/qai.0000000000003306] [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: 03/17/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Lifelong antiretroviral treatment (ART) use is recommended for pregnant and breastfeeding (BF) women living with HIV (WLWH) to prevent perinatal HIV transmission and improve maternal health. We address 2 objectives in this analysis: (1) determine timing and factors associated with BF cessation and (2) assess the impact of BF on health of WLWH on ART. SETTING This multicountry study included 8 sites in Uganda, Malawi, Zimbabwe, and South Africa. METHODS This was a prospective study of WLWH on lifelong ART. These women initially participated from 2011 to 2016 in a randomized clinical trial (PROMISE) to prevent perinatal HIV transmission and subsequently reenrolled in an observational study (PROMOTE, 2016-2021) to assess ART adherence, safety, and impact. RESULTS The PROMOTE cohort included 1987 women on ART. Of them, 752 breastfed and were included in analyses of objective 1; all women were included in analyses of objective 2. The median time to BF cessation varied by country (11.2-19.7 months). Country of residence, age, and health status of women were significantly associated with time to BF cessation (compared with Zimbabwe: Malawi, adjusted hazard ratio [aHR] 0.50, 95% confidence interval [95% CI]: 0.40 to 0.62, P < 0.001; South Africa, aHR 1.49, 95% CI: 1.11 to 2.00, P = 0.008; and Uganda, aHR 1.77, 95% CI: 1.37 to 2.29, P < 0.001). Women who breastfed had lower risk of being "unwell" compared with women who never breastfed (adjusted rate ratio 0.87, 95% CI: 0.81 to 0.95 P = 0.030). CONCLUSION Women on lifelong ART should be encouraged to continue BF with no concern for their health. Time to BF cessation should be monitored for proper counseling in each country.
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Affiliation(s)
- Taha E. Taha
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Antonio Bandala-Jacques
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- SAMRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Avy Violari
- University of the Witwatersrand, Perinatal HIV Research Unit, Johannesburg, South Africa
| | | | - Patience Atuhaire
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Umlazi Clinical Research Site, University of Kwazulu-Natal, Durban, South Africa and University of Kwazulu-Natal, Department of Family Medicine, Durban, South Africa
| | - Luis Gadama
- Kamuzu University of Health Sciences - Johns Hopkins Research Project, Blantyre, Malawi
| | - Lameck Chinula
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- University of North Carolina, Department of Obstetrics and Gynecology, Chapel-Hill, NC, USA
| | - Sufia Dadabhai
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Jim Aizire
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Sean S. Brummel
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research, Boston MA, USA
| | - Mary Glenn Fowler
- Johns Hopkins School of Medicine, Department of Pathology, Baltimore, MD, USA
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Nsibirwa SK, Aizire J, Mugerwa JN, Thomas DL, Ocama P, Kirk GD. The impact of HIV infection on clinical presentation and mortality among persons with hepatocellular carcinoma in Kampala, Uganda. BMC Infect Dis 2023; 23:216. [PMID: 37024807 PMCID: PMC10080890 DOI: 10.1186/s12879-023-08164-5] [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: 10/18/2022] [Accepted: 03/15/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND HIV infection is associated with more rapid progression of some comorbidities. This study assessed the impact of HIV-infection on the presentation and outcome of HCC. METHODS HCC patients attending the Mulago National Referral Hospital in Uganda were enrolled into a natural history study of HCC between March 2015 and February 2019. Standardized methods were used to collect clinical, ultrasound and laboratory data at enrolment. HCC cases were confirmed and enrolled based on a combination of clinical, ultrasound, tumor marker and pathology data. Follow-up contact was made at one, three, six, and twelve months post-enrolment to determine vital status. Symptoms and signs at diagnosis and subsequent survival were compared by HIV status. Kaplan Meier curves were used to assess HCC survival. RESULTS Of 441 persons with HCC, 383 (87.0%) died within 12 months following HCC diagnosis. The median (IQR) survival was 42 (20, 106) days. HIV infection was present in 79 (18%) cases. After adjusting for baseline demographic and clinical characteristics, HIV infection was associated with increased mortality but only among those with severe HIV-associated immunosuppression (CD4 count < 200 cells per cubic milliliter), aHR (95% C) = 2.12 (1.23-3.53), p = 0.004, and not among PLWH with ≥ 200 CD4 cells per cubic milliliter, aHR (95% C) = 1.15 (0.82-1.60), p = 0.417. CONCLUSION Among relatively young Ugandans, HCC is a devastating disease with rapid mortality that is especially rapid among people living with HIV(PLWH). HIV was associated with slightly higher mortality, notably among PLWH with lower CD4 cell counts. As a substantial majority of PLWH diagnosed with HCC were engaged in HIV care, further investigation should determine the effectiveness of incorporating screening and early identification of HCC among high-risk individuals into existing HIV care programs. Concurrent with growing access to curative localized treatment for HCC in sub-Saharan Africa, leveraging HIV care infrastructure affords opportunities for earlier HCC intervention.
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Affiliation(s)
- Sara K Nsibirwa
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda.
- Infectious Diseases Institute (IDI), Makerere University, Kampala, Uganda.
| | - Jim Aizire
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda
- Johns Hopkins University, Baltimore, MD, USA
| | | | - David L Thomas
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda
- Johns Hopkins University, Baltimore, MD, USA
| | - Ponsiano Ocama
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Gregory D Kirk
- HIV and HCC in Uganda (H²U) Consortium, Kampala, Uganda
- Johns Hopkins University, Baltimore, MD, USA
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Mutambanengwe-Jacob MT, Maponga CC, Amico KR, Ngara B, Yende-Zuma N, Chawana TD, Nematadzira T, Gumbo JF, Goverayi T, Matibe P, Malunda BV, Aizire J, Taha TE, Fowler MG, Stranix-Chibanda L. Impact of Motivational Enhanced Adherence Counseling and Point-of-Care Viral Load Monitoring on Viral Load Outcome in Women on Life-Long ART: A Randomized Pilot Study. AIDS Res Treat 2022; 2022:4887202. [PMID: 36105074 PMCID: PMC9467808 DOI: 10.1155/2022/4887202] [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: 03/29/2022] [Revised: 07/13/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
We piloted the combined effectiveness of point-of-care viral load monitoring plus motivational enhanced adherence counseling (intervention) compared with routine care (control) in women identified at risk of virologic failure in the PROMOTE study in Zimbabwe. In an unblinded randomized study, consenting women with last viral load ≥200 copies/ml and/or pill count outside 90-110% range were randomized 1 : 1 to receive the intervention or continue routine care, comprising laboratory-based VL monitoring and standard EAC, from trained nurses and counsellors. Viral load was measured 0, 3, 6, and 12 months after enrolment. We compared viral suppression <200 copies/ml at 6 and 12 months between the arms through Fisher's exact test and sought associated factors by logistic regression with a 95% confidence interval (CI). Between December 2018 and July 2019, 50 women were enrolled (25 intervention and 25 controls) and followed until November 2020. At entry, 60% of the women were virally suppressed, 52% intervention vs. 68% control arm. Viral suppression was balanced between the two arms (p value = 0.248). At month 6 post study entry (primary endpont), 64% of the women retained in care were virally suppressed, 54% intervention vs. 76% control arm (p value = 0.124). At month12 post study entry (secondary endpoint), 69% of the women retained in care were virally suppressed, 67% intervention vs. 71% control arm women (p value = 0.739). More intervention women completed all scheduled sessions by month 6. Control group women were more likely to be virally suppressed at both timepoints. Only 25% had treatment switch by 12 months. Despite intense adherence support and viral load monitoring, sustained viral suppression remained elusive in women identified at risk of viral failure. These findings highlight the continued need for effective adherence intervention for women with unsuppressed HIV viral loads, efficient treatment switch strategies, as well as drug level monitoring.
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Affiliation(s)
- Mercy T. Mutambanengwe-Jacob
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Charles C. Maponga
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Bernard Ngara
- Department of Primary Health Care Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Program of Research in South Africa (CAPRISA), Durban, South Africa
| | - Tariro D. Chawana
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Justice F. Gumbo
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Tendayi Goverayi
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Petronella Matibe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Jim Aizire
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Taha E. Taha
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mary G. Fowler
- Department of Pathology, The Johns Hopkins Medicine, Baltimore, MD, USA
| | - Lynda Stranix-Chibanda
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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Fowler MG, Hanrahan C, Yende N, Stranix-Chibanda L, Chipato T, Maliwichi L, Gadama L, Aizire J, Dadabhai S, Chinula L, Wambuzi-Owang L, Owor M, Violari A, Nyati M, Hanley S, Govender V, Brummel S, Taha T. Neurodevelopmental outcomes of HIV/antiretroviral drug perinatally exposed uninfected children aged 3-6 years. AIDS 2022; 36:1533-1543. [PMID: 35730383 PMCID: PMC9563003 DOI: 10.1097/qad.0000000000003290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/04/2023]
Abstract
OBJECTIVE Given the roll out of maternal antiretroviral therapy (ART) for prevention-of-perinatal-HIV-transmission, increasing numbers of children are perinatally HIV/antiretroviral exposed but uninfected (CAHEU). Some studies suggest CAHEU may be at increased risk for neurodevelopmental (ND) deficits. We aimed to assess ND performance among preschool CAHEU. DESIGN This cross-sectional study assessed ND outcomes among 3-6-year-old CAHEU at entry into a multicountry cohort study. METHODS We used the Mullen Scales of Early Learning (MSEL) and Kaufman Assessment Battery for Children (KABC-II) to assess ND status among 3-6-year-old CAHEU at entry into the PROMISE Ongoing Treatment Evaluation (PROMOTE) study conducted in Uganda, Malawi, Zimbabwe and South Africa. Statistical analyses (Stata 16.1) was used to generate group means for ND composite scores and subscale scores, compared to standardized test score means. We used multivariable analysis to adjust for known developmental risk factors including maternal clinical/socioeconomic variables, child sex, growth-for-age measurements, and country. RESULTS 1647 children aged 3-6 years had baseline ND testing in PROMOTE; group-mean unadjusted Cognitive Composite scores on the MSEL were 85.8 (standard deviation [SD]: 18.2) and KABC-II were 79.5 (SD: 13.2). Composite score group-mean differences were noted by country, with South African and Zimbabwean children having higher scores. In KABC-II multivariable analyses, maternal age >40 years, lower education, male sex, and stunting were associated with lower composite scores. CONCLUSIONS Among a large cohort of 3-6 year old CAHEU from eastern/southern Africa, group-mean composite ND scores averaged within the low-normal range; with differences noted by country, maternal clinical and socioeconomic factors.
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Affiliation(s)
- Mary Glenn Fowler
- Department of Pathology, The Johns Hopkins University School of Medicine
| | - Colleen Hanrahan
- Department of Epidemiology, the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nonhlanhla Yende
- Centre for the AIDS Program of Research in South Africa (CAPRISA), Durban South Africa
| | | | - Tsungai Chipato
- Department of Obstetrics/Gynaecology, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - Limbika Maliwichi
- Johns Hopkins Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Luis Gadama
- Johns Hopkins Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jim Aizire
- Department of Epidemiology, the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sufia Dadabhai
- Department of Epidemiology, the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Lillian Wambuzi-Owang
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Maxensia Owor
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Avy Violari
- Perinatal HIV Research Unit (PHRU), Johannesburg
| | | | - Sherika Hanley
- CAPRISA - Umlazi Clinical Research Site, Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Vani Govender
- CAPRISA - Umlazi Clinical Research Site, Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Sean Brummel
- Center for Biostatistics AIDS Research, T. H. Chen School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Taha Taha
- Department of Epidemiology, the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Wekesa C, Parkes-Ratanshi R, Kirk GD, Aizire J, Ocama P. Indirect serum biomarkers perform sub optimally in screening for significant liver fibrosis among HIV-infected and uninfected adults in Uganda. Afr Health Sci 2022; 22:416-425. [PMID: 36910378 PMCID: PMC9993309 DOI: 10.4314/ahs.v22i3.45] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Indirect serum bio-markers present an acceptable noninvasive and cheap alternative for screening of significant liver fibrosis (SLF). Evaluation of their use in resource limited settings is important to determine their utility. Methods We conducted a cross sectional study among 520 HIV infected and HIV uninfected adults attending care clinics in Kampala Uganda. Presence of SLF was determined using Fibroscan® liver stiffness measurement of ≥7.2KPa. The diagostic value of indirect serum bio-markers for diagnosis of SLF was evaluated using the area under the receiver operating characteristics curve (AUROC) using Fibroscan® as gold standard. Results Overall AUROC values for Age Platelet Index (API), Aspartate to Alanine Ratio (AAR), AST-to-Platelet Ratio Index (APRI), Fibrosis Index based on 4 Factors (FIB-4) and Gamma glutamyl transferase to Platelet Ratio Index (GPR) were 0.52, 0.49, 0.55, 0.55 and 0.54 respectively. Among HIV-infected participants AUROC values were slightly improved at predicting presence of SLF but still under 70%. Conclusion Despite APRI and FIB-4 being more likely to identify participants with SLF, the overall diagnostic value of all serum bio-markers was poor with and without stratification by HIV status. We recommend the use of Fibroscan® technology as more accurate non-invasive diagnostic method for screening of SLF.
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Affiliation(s)
- Clara Wekesa
- Infectious Diseases Institute, Makerere University Kampala Uganda
| | | | | | | | - Ponsiano Ocama
- Makerere University, College of Health Sciences Kampala Uganda
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Taha TE, Yende-Zuma N, Brummel SS, Stranix-Chibanda L, Wambuzi Ogwang L, Dadabhai S, Chinula L, Nyati MM, Hanley S, Makanani B, Chipato T, Atuhaire P, Aizire J, Fowler MG. Effects of long-term antiretroviral therapy in reproductive-age women in sub-Saharan Africa (the PEPFAR PROMOTE study): a multi-country observational cohort study. Lancet HIV 2022; 9:e394-e403. [PMID: 35489365 PMCID: PMC9639003 DOI: 10.1016/s2352-3018(22)00037-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND We report the long-term impact of ART in women of reproductive age (15-49 years) in Africa who have been using ART for up to 10 years. We assess outcomes of retention, adherence, maternal health, fertility intentions, and safety. METHODS This longitudinal, multicountry study (PROMOTE) enrolled women who initiated ART in an earlier perinatal clinical trial, PROMISE. PROMISE occurred from 2011 to 2016 and PROMOTE follow-up started in 2016 and is ongoing. The PROMOTE study was done at eight sites in four countries: Malawi (Blantyre and Lilongwe), South Africa (Durban and Soweto), Uganda (Kampala), and Zimbabwe (Harare, Seke North, and St Mary's). After baseline enrolment, women and their children are followed up every 6 months to collect information on medical history, antiretroviral therapy (ART) use, adherence, and health information, and to do physical examinations and laboratory tests. Obesity was defined as a body-mass index of 30 kg/m2 or more. Data analyses were restricted to summaries of the main long-term outcomes (retention, adherence, maternal health, fertility intentions, and safety). We used descriptive and stratified analyses, and estimated rates using person-years of follow-up and computed probabilities based on Kaplan-Meier methods. FINDINGS PROMOTE enrolled 1987 mothers and 2522 children. The median follow-up time for mothers was 41·8 (IQR 35·8-42·0) months and for children was 35·7 (23·8-42·0) months. Overall retention rates were 96·5% for mothers and 94·3% for children at 12 months, and, at 42 months, were 88·9% for mothers and 85·4% for children. 1115 (89·1%) of 1252 women had an undetectable viral load at 42 months, which varied by site (81·7-93·8%). Reported maternal health improved over time, with the proportion of women with excellent to very good health increasing from 67·5% at baseline to 87·5% at 42 months, the proportion of unwell participants who visited a health centre declining from 14·7% to 2·8%, and the proportion of those admitted to hospital declining from 1·5% to 1·0%. The desire to have more children was consistently high at some sites. The proportion of women with obesity was high in South Africa and increased over time from 40·2% at baseline to 52·8% at 42 months. The overall pregnancy rate was 17·6 (95% CI 16·5-18·7) per 100 women-years, and mortality rates were 2·4 (1·4-3·9) per 1000 person-years for mothers and 3·4 (2·2-5·10) per 1000 person-years for children (0-9 years). INTERPRETATION The findings from this multicountry study are reassuring. These findings show that African women can consistently use ART for a long period after initiation, and long-term benefits can be maintained. Services to support maternal HIV care, treatment, and reproductive health should be strengthened. FUNDING US President's Emergency Plan for AIDS Relief.
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Affiliation(s)
- Taha E Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; SAMRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Sean S Brummel
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Lynda Stranix-Chibanda
- Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Sufia Dadabhai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Lameck Chinula
- University of North Carolina Project, Lilongwe, Malawi; Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Mandisa M Nyati
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa, Umlazi Clinical Research Site, University of KwaZulu-Natal, Durban, South Africa
| | - Bonus Makanani
- Department of Obstetrics and Gynecology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Tsungai Chipato
- Clinical Trials Research Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Patience Atuhaire
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Glenn Fowler M, Aizire J, Sikorskii A, Atuhaire P, Wambuzi Ogwang L, Mutebe A, Katumbi C, Maliwichi L, Familiar I, Taha T, Boivin MJ. Growth deficits in antiretroviral and HIV-exposed uninfected versus unexposed children in Malawi and Uganda persist through 60 months of age. AIDS 2022; 36:573-582. [PMID: 34750297 PMCID: PMC9097628 DOI: 10.1097/qad.0000000000003122] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare childhood physical growth among antiretroviral drug and maternal HIV-exposed uninfected (AHEU) compared with HIV-unexposed uninfected (HUU) children. DESIGN Longitudinal follow-up of PROMISE trial (NCT01061151) AHEU and age-matched and sex-matched HUU children, enrolled (September 2013 to October 2014) in Malawi and Uganda. METHOD We compared WHO population standardized z-scores [height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ), head-circumference-for-age (HCAZ) at 12, 24, 36, 48, and 60 months of age]. We evaluated HUU versus AHEU [in-utero combination antiretroviral treatment (cART) versus Zidovudine (ZDV) alone]; stratified by country, using longitudinal linear and generalized linear mixed models. RESULTS Of 466 Malawian and 477 Ugandan children, median maternal age at enrollment was 24.5 years (Malawi) and 27.8 years (Uganda); more than 90% were breastfed through 12 months except Uganda AHEU (64.0%). HAZ scores (adjusted for maternal age, breastfed, and socioeconomic status) were lower among AHEU versus HUU children at every time point, significant (P < 0.05) among Ugandan but not Malawian children. Similar patterns were seen for WAZ but not for WHZ or HCAZ scores. High stunting was observed in both countries, significantly higher in Malawi; and higher among AHEU versus HUU children through 48 months of age, significantly (P < 0.05) among Ugandan but not Malawian children. We found no differences in childhood growth trajectories with in-utero exposures to ZDV compared with cART. CONCLUSION AHEU versus HUU children had lower median LAZ and WAZ scores persisting through 60 months of age. However, proportions of children with stunting or underweight decreased after 24 months of age.
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Affiliation(s)
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Alla Sikorskii
- Department of Statistics & Probability, Michigan State University
- Department of Psychiatry, Michigan State University
| | | | | | - Alex Mutebe
- Makerere U.-Johns Hopkins U. Research Collaboration
| | - Chaplain Katumbi
- College of Medicine – Johns Hopkins University Research Project, Blantyre, Malawi
| | - Limbika Maliwichi
- College of Medicine – Johns Hopkins University Research Project, Blantyre, Malawi
| | | | - Taha Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Michael J. Boivin
- Department of Statistics & Probability, Michigan State University
- Department of Psychiatry, Michigan State University
- Department of Neurology & Ophthalmology, Michigan State University
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Mutyoba JN, Surkan PJ, Makumbi F, Aizire J, Kirk GD, Ocama P, Atuyambe LM. Corrigendum to "Hepatitis B birth dose vaccination for newborns in Uganda: A qualitative inquiry on pregnant women's perceptions, barriers and preferences" [J Virus Eradic 7(2) (2021) 100039]. J Virus Erad 2021; 7:100051. [PMID: 34646573 DOI: 10.1016/j.jve.2021.100051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
[This corrects the article DOI: 10.1016/j.jve.2021.100039.].
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Affiliation(s)
- Joan Nankya Mutyoba
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Pamela J Surkan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Fredrick Makumbi
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ponsiano Ocama
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lynn M Atuyambe
- Department of Community Health & Behavioral Sciences, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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Stranix-Chibanda L, Tierney C, Pinilla M, George K, Aizire J, Chipoka G, Mallewa M, Naidoo M, Nematadzira T, Kusakara B, Violari A, Mbengeranwa T, Njau B, Fairlie L, Theron G, Mubiana-Mbewe M, Khadse S, Browning R, Fowler MG, Siberry GK. Effect on growth of exposure to maternal antiretroviral therapy in breastmilk versus extended infant nevirapine prophylaxis among HIV-exposed perinatally uninfected infants in the PROMISE randomized trial. PLoS One 2021; 16:e0255250. [PMID: 34415933 PMCID: PMC8378741 DOI: 10.1371/journal.pone.0255250] [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: 03/03/2021] [Accepted: 07/04/2021] [Indexed: 11/25/2022] Open
Abstract
Background Malnutrition is highly prevalent in HIV-exposed perinatally uninfected infants (HEUs) increasing the risk of morbidity and mortality throughout the life course. We set out to compare the effect of postnatal exposure to maternal antiretroviral therapy (mART) in breastmilk versus infant Nevirapine prophylaxis (iNVP) on somatic growth of HEUs in the randomized PROMISE trial. Methods and findings We randomized 2431 mothers with HIV and their 2444 HEUs from six African countries and India 6–14 days after delivery to mART or iNVP for prevention of breastmilk HIV transmission. The mART regimen contained tenofovir/emtricitabine (99%) plus lopinavir/ritonavir. Infant growth parameters were compared at postnatal week 10, 26, 74 and 104 using World Health Organization (WHO) z-scores for length-for-age (LAZ), weight-for-age (WAZ), and head circumference-for-age (HCAZ). Week 26 LAZ was the primary endpoint measure. Student T-tests compared mean LAZ, WAZ, and HCAZ; estimated mean and 95% confidence interval (CI) are presented. Maternal and infant baseline characteristics were comparable between study arms. The estimated median breastfeeding duration was 70 weeks. After a mean follow-up of 88 weeks, mean LAZ and WAZ were below the WHO reference population mean at all timepoints, whereas mean HCAZ was not. The mART and iNVP arms did not differ for the primary outcome measure of LAZ at week 26 (p-value = 0.39; estimated mean difference (95%CI) of -0.05 (-0.18, 0.07)) or any of the other secondary growth outcome measures or timepoints (all p-values≥0.16). Secondary analyses of the primary outcome measure adjusting for week 0 LAZ and other covariates did not change these results (all p-values≥0.09). However, infants assigned to mART were more likely to have stunting compared to iNVP infants at week 26 (odds ratio (95% CI): 1.28 (1.05, 1.57)). Conclusions In HEUs, growth effects from postnatal exposure to mART compared to iNVP were comparable for measures on length, weight and head circumference with no clinically relevant differences between the groups. Despite breastfeeding into the second year of life, length and weight were below reference population means at all ages in both arms. Further investment is needed to optimize postnatal growth of infants born to women with HIV. Clinical trial registration ClinicalTrials.gov number NCT01061151.
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Affiliation(s)
- Lynda Stranix-Chibanda
- University of Zimbabwe Faculty of Medicine and Health Sciences, Child and Adolescent Health Unit, Harare, Zimbabwe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
- * E-mail: ,
| | - Camlin Tierney
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research in the Department of Biostatistics, Boston, MA, United States of America
| | - Mauricio Pinilla
- Harvard T.H. Chan School of Public Health, Center for Biostatistics in AIDS Research in the Department of Biostatistics, Boston, MA, United States of America
| | | | - Jim Aizire
- Makerere University—Johns Hopkins University Research Programme, Kampala, Uganda
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | | | - Megeshinee Naidoo
- University of KwaZulu-Natal, Centre Aids Prevention Research South Africa (CAPRISA), Durban, South Africa
| | | | - Bangani Kusakara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Avy Violari
- Perinatal HIV Research Unit, Johannesburg, South Africa
| | - Tapiwa Mbengeranwa
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Boniface Njau
- Kilimanjaro Christian Medical Center, Moshi, United Republic of Tanzania
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Gerard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
| | | | - Sandhya Khadse
- Department of Obstetrics and Gynaecology, BJ Government Medical College, Pune, India
| | - Renee Browning
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - George K. Siberry
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, United States of America
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Mutyoba JN, Surkan PJ, Makumbi F, Aizire J, Kirk GD, Ocama P, Atuyambe LM. Hepatitis B birth dose vaccination for newborns in Uganda: A qualitative inquiry on pregnant women's perceptions, barriers and preferences. J Virus Erad 2021; 7:100039. [PMID: 34026246 PMCID: PMC8122110 DOI: 10.1016/j.jve.2021.100039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Sub-Saharan Africa continues with very low hepatitis B (HBV) birth dose vaccination coverage. To guide policy on HBV vaccine for newborns, we explored perceptions, barriers and preferences of pregnant women regarding HBV and the HBV birth dose vaccination. METHODS We conducted eight focus groups discussions (FGDs) among 70 pregnant women, stratified by rural-urban residence, age and education level, using a structured focus group discussion guide to explore birth dose awareness, perceptions, barriers and preferences. Data were transcribed, coded and analysed using framework analysis. RESULTS Perceptions related to HBV and liver cancer causes and prevention were diverse; most FGD participants did not perceive illnesses as distinctly different. Older women-groups, both urban and rural, had never heard about HBV, but were aware of liver cancer, viewing the disease as fatal. No FGD participants were aware of HBV birth dose. Concerns included vaccine safety, its availability to women who deliver outside the health system and mistrust in health-care worker (HCWs) when handling newborns. Rural-dwelling groups perceived absence of HBV services, while FGDs with young participants believed vaccine side-effects hampered birth dose planning. Most women-groups preferred (i) oral to injectable vaccines; (ii) receiving birth dose education during antenatal, to media-based education; (iii) that newborns receive the birth dose immediately after delivery in the mother's presence. CONCLUSION Although the birth dose is acceptable among pregnant women, planners need to continuously engage them as key stakeholders during planning to address concerns, in order to raise confidence, maximize uptake and strengthen HBV eradication efforts.
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Affiliation(s)
- Joan Nankya Mutyoba
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Pamela J. Surkan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Fredrick Makumbi
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Gregory D. Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ponsiano Ocama
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lynn M. Atuyambe
- Department of Community Health & Behavioral Sciences, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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Wekesa C, Kirk GD, Aizire J, Benson EM, Karabarinde A, Parkes-Ratanshi R, Ocama P. Prevalence and Factors Associated With Liver Fibrosis Among Adult HIV-Infected Patients Attending Urban and Rural Care Clinics in Uganda. Open Forum Infect Dis 2020; 7:ofaa483. [PMID: 33241065 PMCID: PMC7676506 DOI: 10.1093/ofid/ofaa483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 09/08/2020] [Accepted: 10/07/2020] [Indexed: 12/25/2022] Open
Abstract
Background Liver fibrosis is common among HIV-infected patients. Risk factors vary by location. Understanding this variation may inform prevention strategies. We compared the prevalence and correlates of liver fibrosis among HIV-infected patients attending care clinics in Uganda. Methods This was a cross-sectional study involving 2030 HIV-infected patients attending care clinics in urban and rural Uganda. Liver fibrosis was defined as liver stiffness measurement (LSM) >7.1 KPa. Proportions and correlates of liver fibrosis were assessed and compared using logistic regression stratified by gender and site. Results Prevalence of liver fibrosis was higher among participants in the rural clinic (15% vs 11%; P = .017). History of tobacco use (urban P = .022; rural P = .035) and serologic evidence of hepatitis C infection (HCV; urban P = .028; rural P = .03) was associated with liver fibrosis in all men. Elevated liver transaminases (urban P = .002; rural P = .028) and increasing age (urban P = .008; rural P = .052) were risk factors among all women. Tobacco use among women was only a risk factor in those attending the rural clinic (P = .003), and detectable HIV viral load (P = .002) for men in the urban clinic. Conclusions Liver fibrosis is prevalent among HIV-infected persons in Uganda. HIV viral suppression and avoiding tobacco may be strategies to prevent liver fibrosis and cancer risk.
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Affiliation(s)
- Clara Wekesa
- MRC/UVRI and London School of Hygiene and Tropical Medicine Uganda Research, Entebbe, Uganda.,HIV and HCC in Uganda (H2U) Consortium, Infectious Diseases Institute, Kampala, Uganda
| | - Gregory D Kirk
- John Hopkins University, Baltimore, Maryland, USA.,HIV and HCC in Uganda (H2U) Consortium, Infectious Diseases Institute, Kampala, Uganda
| | - Jim Aizire
- John Hopkins University, Baltimore, Maryland, USA.,HIV and HCC in Uganda (H2U) Consortium, Infectious Diseases Institute, Kampala, Uganda
| | - Eve-Marie Benson
- John Hopkins University, Baltimore, Maryland, USA.,HIV and HCC in Uganda (H2U) Consortium, Infectious Diseases Institute, Kampala, Uganda
| | - Alex Karabarinde
- MRC/UVRI and London School of Hygiene and Tropical Medicine Uganda Research, Entebbe, Uganda
| | | | - Ponsiano Ocama
- HIV and HCC in Uganda (H2U) Consortium, Infectious Diseases Institute, Kampala, Uganda.,Makerere University, College of Health Sciences, Kampala, Uganda
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13
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Nankya-Mutyoba J, Aizire J, Makumbi F, Ocama P, Kirk GD. Correction to: Hepatitis B virus perceptions and health seeking behaviors among pregnant women in Uganda: implications for prevention and policy. BMC Health Serv Res 2019; 19:982. [PMID: 31856820 PMCID: PMC6923970 DOI: 10.1186/s12913-019-4767-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Joan Nankya-Mutyoba
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Fredrick Makumbi
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Ponsiano Ocama
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Nankya-Mutyoba J, Aizire J, Makumbi F, Ocama P, Kirk GD. Hepatitis B virus perceptions and health seeking behaviors among pregnant women in Uganda: implications for prevention and policy. BMC Health Serv Res 2019; 19:760. [PMID: 31655575 PMCID: PMC6815411 DOI: 10.1186/s12913-019-4516-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 01/28/2019] [Accepted: 09/09/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND With most countries in sub-Saharan Africa (SSA) lagging behind schedule to implement a comprehensive viral hepatitis elimination strategy, several barriers to accurate information and hepatitis B virus (HBV) services still exist, that are unique to different regions. In an obstetric population of a high HBV burden SSA setting without antenatal HBV services, we systematically evaluated perceptions and prevention behavioral intentions in relation to HBV and liver cancer. METHODS Eligible consenting pregnant women were recruited from public health care facilities in the central and northern regions of Uganda, between October 2016 and December 2017. Standardized procedures and instruments based on the health belief model and theory of planned behavior were used to collect data on socio-demographic characteristics, HBV perceptions and behavioral intentions. Descriptive analysis using Chi-square tests was done to obtain distribution of respondents by levels of perceived risk of HBV and liver cancer for themselves, their child under 5 years and their spouse. Modified Poisson regression analyses were used to evaluate relationships between perception variables and different behavioral outcomes (intention to screen, vaccinate and treat HBV). RESULTS Perceived risk (PRR = 0.95(0.90-1.00), p = 0.055) was inversely associated with intention to screen for HBV. Conversely, perceived self-efficacy showed a consistent association with intention to screen for HBV (PRR = 1.18(1.10-1.23) p = 0.005), to vaccinate (PRR = 1.20(1.05-1.36) p = 0.006) and to seek treatment for HBV (PRR = 1.40(1.18-1.67) p < 0.001). Women from the north, compared to the central region (PRR = 1.76 (1.13-2.72) p = 0.012), and those who self-identified as Catholic (PRR = 1.85 (0.99-3.56) p = 0.056), and as Protestant, (PRR = 2.22 (1.22-4.04) p = 0.002), were more likely to have higher perceived self-efficacy, compared to Muslims. Age and education were not related to perceived self-efficacy. CONCLUSION Women in both regions hold incorrect perceptions of HBV and liver cancer risk, with women from the central reporting higher perceived risk than those from the north. High perceived self-efficacy influenced intention to participate in HBV prevention. Programs and policies geared towards enhancing HBV prevention in this sub-population may consider socio-cultural factors observed to influence prevention behaviors. These findings may guide HBV interventions aimed at improving capacity to seek HBV prevention services, thereby promoting HBV micro-elimination in this sub-population.
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Affiliation(s)
- Joan Nankya-Mutyoba
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Fredrick Makumbi
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Ponsiano Ocama
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Atuhaire P, Hanley S, Yende-Zuma N, Aizire J, Stranix-Chibanda L, Makanani B, Milala B, Cassim H, Taha T, Fowler MG. Factors associated with unsuppressed viremia in women living with HIV on lifelong ART in the multi-country US-PEPFAR PROMOTE study: A cross-sectional analysis. PLoS One 2019; 14:e0219415. [PMID: 31647806 PMCID: PMC6812809 DOI: 10.1371/journal.pone.0219415] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 06/21/2019] [Accepted: 10/10/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite recent efforts to scale-up lifelong combination antiretroviral therapy (cART) in sub-Saharan Africa, high rates of unsuppressed viremia persist among cART users, and many countries in the region fall short of the UNAIDS 2020 target to have 90% virally suppressed. We sought to determine the factors associated with unsuppressed viremia (defined for the purpose of this study as >200 copies/ml) among sub-Saharan African women on lifelong cART. METHODS This cross-sectional analysis was based on baseline data of the PROMOTE longitudinal cohort study at 8 sites in Uganda, Malawi, Zimbabwe and South Africa. The study enrolled 1987 women living with HIV who initiated lifelong cART at least 1-5 years ago. Socio-demographic, clinical, and cART adherence data were collected. We used multivariable Poisson regression with robust variance to identify factors associated with unsuppressed viremia. RESULTS At enrolment, 1947/1987 (98%) women reported taking cART. Of these, HIV-1 remained detectable in 293/1934 (15%), while 216/1934 (11.2%) were considered unsuppressed (>200 copies/ml). The following factors were associated with an increased risk of unsuppressed viremia: not having household electricity (adjusted prevalence risk ratio (aPRR) 1.74, 95% confidence interval (CI) 1.28-2.36, p<0.001); not being married (aPRR 1.32, 95% CI 0.99-1.78, p = 0.061), self-reported missed cART doses (aPRR 1.63, 95% CI 1.24-2.13, p<0.001); recent hospitalization (aPRR 2.48, 95% CI 1.28-4.80, p = 0.007) and experiencing abnormal vaginal discharge in the last three months (aPRR 1.88; 95% CI 1.16-3.04, p = 0.010). Longer time on cART (aPRR 0.75, 95% CI 0.64-0.88, p<0.001) and being older (aPRR 0.77, 95% CI 0.76-0.88, p<0.001) were associated with reduced risk of unsuppressed viremia. CONCLUSION Socioeconomic barriers such as poverty, and individual barriers like not being married, young age, and self-reported missed doses are key predictors of unsuppressed viremia. Targeted interventions are needed to improve cART adherence among women living with HIV with this risk factor profile.
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Affiliation(s)
- Patience Atuhaire
- Makerere University-Johns Hopkins University (MU-JHU) Kampala, Uganda
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Umlazi Clinical Research Site, Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Jim Aizire
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, United States of America
| | - Lynda Stranix-Chibanda
- University of Zimbabwe College of Health Sciences Department of Paediatrics and Child Health, Harare, Zimbabwe
| | - Bonus Makanani
- Malawi College of Medicine-John's Hopkins Research Project, Blantyre, Malawi
| | - Beteniko Milala
- University of North Carolina (UNC) Project, Lilongwe, Malawi
| | - Haseena Cassim
- Perinatal HIV Research Unit (PHRU), Chris Hani Baragwanath Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Taha Taha
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins University, Departments of Pathology and Epidemiology, Baltimore, MD, United States of America
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Nankya-Mutyoba J, Aizire J, Makumbi F, Atuyambe L, Ocama P, Kirk GD. Correlates of hepatitis B awareness and disease-specific knowledge among pregnant women in Northern and Central Uganda: a cross-sectional study. Hepatol Med Policy 2018; 3:14. [PMID: 30598844 PMCID: PMC6299568 DOI: 10.1186/s41124-018-0043-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 12/05/2018] [Indexed: 02/08/2023]
Abstract
Introduction Countries in sub-Saharan Africa with a high hepatitis B burden also have limited resources to identify underlying drivers of disease among key at-risk populations. To improve prioritization and strengthen prevention of mother to child transmission of HBV, it is imperative to understand disease awareness, knowledge and related factors among pregnant women. Objectives This study assessed HBV disease awareness, knowledge and related factors among pregnant women in public health facilities in two regions with diverse HBV disease epidemiology. Methods From October 2016 through December 2017, a random sample of 455 pregnant women attending antenatal clinics were surveyed to assess HBV awareness, knowledge and associated factors. Participants responded to an 18-item questionnaire with themes on HBV awareness, knowledge of disease signs and symptoms, transmission, prevention and misconceptions about the disease. Results were analysed in STATA (version 14.0). Results Of 455 participants enrolled, about two thirds reported having heard about HBV disease. By region, nearly half (47%) of participants from the central region, compared to only 16% from the north, reported that they had never heard of HBV. Region of residence had a moderating effect on the education- HBV awareness relationship. Only 162/455 (36%) of participants had adequate HBV knowledge. More than half 256/455 (56%) and 242/455 (53%) were not knowledgeable about horizontal and mother to child HBV transmission, respectively. About two thirds 298/455 (66%) and 281/455 (62%) believed HBV was spread via sharing of utensils and mosquito bites respectively. In multiple regression analysis, residing in the north, (PR=1.91(1.53 -2.38), p < 0.001) compared to central region and having a secondary education (PR=1.87(1.37 -2.55), p < 0.001) compared to primary were statistically significantly related to being knowledgeable about HBV. Conclusion We demonstrated marked regional differences in HBV disease awareness and knowledge in this high HBV prevalence setting. However, most pregnant women displayed unacceptably low HBV knowledge and a significant proportion still hold misconceptions about HBV. Interventions to improve HBV prevention through antenatal education will need to be tailored to existing differences in comprehensive HBV knowledge.
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Affiliation(s)
- Joan Nankya-Mutyoba
- 1Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Jim Aizire
- 2Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA
| | - Fredrick Makumbi
- 1Department of Epidemiology & Biostatistics, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Lynn Atuyambe
- 3Department of Community Health & Behavioral Sciences, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ponsiano Ocama
- 4Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gregory D Kirk
- 2Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA.,5Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland USA
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Taha TE, Yende-Zuma N, Aizire J, Chipato T, Wambuzi Ogwang L, Makanani B, Chinula L, Nyati MM, Hanley S, Brummel SS, Fowler MG. The multi-country PROMOTE HIV antiretroviral treatment observational cohort in Sub-Saharan Africa: Objectives, design, and baseline findings. PLoS One 2018; 13:e0208805. [PMID: 30543692 PMCID: PMC6292608 DOI: 10.1371/journal.pone.0208805] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 07/12/2018] [Accepted: 11/25/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The PROMOTE study aims to measure long-term antiretroviral treatment (ART) safety and adherence; compare HIV disease progression; assess subsequent adverse pregnancy outcomes; evaluate effect of ART exposure on growth and development in HIV-exposed uninfected children; and assess long-term survival of mothers and children. This report primarily describes cohort characteristics at baseline to better understand long-term outcomes. METHODS AND FINDINGS This is a prospective study. HIV-infected mothers and their children originally recruited in a multisite randomized clinical trial for prevention of perinatal HIV transmission were re-enrolled in PROMOTE. A total of 1987 mothers and 1784 children were enrolled from eight sites in Uganda, Malawi, Zimbabwe and South Africa. Most women (≥75%) reported being married in Malawi and Zimbabwe compared to low proportions in South Africa (4.4% in Durban and 15% in Soweto), and 43.5% in Uganda (p<0.001). There were variabilities in contraceptive practices: injectable contraceptive was the commonest reported method (40.9% overall); implant was the second commonest (15.7% overall); oral contraceptives were common in Zimbabwe; and tubal ligation was common in Malawi and South Africa. At baseline, 97.8% of women reported currently using ART; 96.4% were in WHO clinical class 1 or 2; median CD4 cell count was 825 cells per uL; and viral load was undetectable in 1637 (~85%) of the women. Approximately, 14% of women did not inform their primary partners of their own HIV status, 18% reported that they knew their partners were not HIV tested, and 9% did not know if partner was tested. Overall mean age of children at enrollment was 3.5 years; and 5.7% and 25.0% had weight-for-age and height-for-age z-scores <2 standard deviations, respectively. CONCLUSIONS These baseline data show high adherence to ART use. However, issues of HIV disclosure and reproductive intentions remain important. In addition to ART and ensuring high adherence, other preventive measures should be included.
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Affiliation(s)
- Taha E. Taha
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jim Aizire
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Tsungai Chipato
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Lillian Wambuzi Ogwang
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Bonus Makanani
- University of Malawi College of Medicine, Blantyre, Malawi
| | - Lameck Chinula
- UNC Project-Malawi, Lilongwe, Malawi; UNC-CH Department of Obstetrics and Gynecology, Chapel Hill, NC, United States of America
| | - Mandisa M. Nyati
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Umlazi Clinical Research Site, Durban, South Africa
| | - Sean S. Brummel
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins School of Medicine, Baltimore, MD, United States of America
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Aizire J, Dadabhai S, Taulo F, Makanani B, Gadama L, Sun J, Tsui A, Taha TE. Use of effective family planning methods and frequency of sex among HIV-infected and HIV-uninfected African women. Contracept Reprod Med 2018; 3:10. [PMID: 30002871 PMCID: PMC6036664 DOI: 10.1186/s40834-018-0063-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Received: 12/01/2017] [Accepted: 04/26/2018] [Indexed: 11/30/2022] Open
Abstract
Background Frequency of sex, contraceptive use and HIV infection are key determinants of fertility. Use of an effective family planning (EFP) method (injectable, oral, intra-uterine contraceptive device (IUCD), or Norplant) potentially eliminates women’s concerns of unintended pregnancy. We report the association between EFP and frequency of sex among HIV-infected and HIV-uninfected non-pregnant African women. Methods Prospective fertility intentions study nested within a phase 3 randomized double-masked placebo-controlled trial (2003-2005) to treat genital tract infections in HIV-infected and HIV-uninfected non-pregnant women. Enrollment of study participants was stratified by HIV infection status. Data on demographics, family planning and sexual history were obtained at baseline and at 3, 6, 9 and 12 months. Chi square and Wilcoxon Rank-Sum tests were used to compare categorical and continuous variables, respectively. Generalized Estimating Equations method was used to estimate relative risk (RR) of frequent sex (≥ 2 acts/week) among users of different EFP methods (injectable, oral, implant or intra-uterine contraceptive device). Results After adjusting for age, current health status, and fertility intentions, EFP use was significantly associated with frequent sex among HIV-infected women (RR 1.32; 95% Confidence Interval [CI] 1.14-1.52); this association was not statistically significant among HIV-uninfected women (RR 1.10; 95% CI 0.96-1.24). Fertility intentions among HIV-infected, and education among HIV-uninfected womenwere independent predictors of sex frequency. Conclusion These data suggest that the association between EFP use and frequency of sex among women varies by HIV infection status. Service-delivery of diverse EFP methods should be integrated within HIV counseling, testing and treatment facilities. Trial registration Registration number NCT00140764 under the clinicaltrials.gov, first Posted: September 1, 2005, last Update Posted: August 10, 2011.
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Affiliation(s)
- Jim Aizire
- 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA
| | - Sufia Dadabhai
- 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA
| | - Frank Taulo
- 2Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Bonus Makanani
- 2Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luis Gadama
- 2Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jin Sun
- 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA
| | - Amy Tsui
- 3Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Taha E Taha
- 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA.,3Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe recent clinical trial, laboratory and observational findings that highlight both the progress that can be achieved in elimination of new pediatric infections in international clinical trial settings among HIV-infected breastfeeding women while also describing recent safety concerns related to currently used antiretroviral regimens. The article will also address the ongoing adherence challenges for HIV-infected mothers in taking their antiretroviral drugs. This information is timely and relevant as new regimens are being considered for both prevention of mother-to-child transmission (PMTCT) of HIV and HIV treatment options worldwide. RECENT FINDINGS The main themes described in this article include both efficacy of different antiretroviral therapy (ART) regimens currently being rolled out internationally for PMTCT as well as safety findings from recent research including a large multisite international trial, PROMISE. SUMMARY The findings from the IMPAACT PROMISE trial as well as other recent trial and observational findings suggest that while progress has been steady in reducing PMTCT worldwide, the goal of virtual elimination of pediatric HIV worldwide will require careful attention to optimizing safety of new regimens which are less dependent on maternal daily ART adherence and safer in preventing certain toxicities.
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Affiliation(s)
- Mary G Fowler
- Department of Pathology, Johns Hopkins U. School of Medicine, Baltimore, Maryland
| | - Patricia Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jim Aizire
- Department of Epidemiology, Johns Hopkins U. Bloomberg School of Public Health, Baltimore, Maryland, USA
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Aizire J, G. Fowler M, M. Coovadia H. Operational Issues and Barriers to Implementation of Prevention of Mother-to-Child Transmission of HIV (PMTCT) Interventions in Sub- Saharan Africa. Curr HIV Res 2013; 11:144-59. [DOI: 10.2174/1570162x11311020007] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 02/12/2013] [Accepted: 02/13/2013] [Indexed: 11/22/2022]
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Nakanjako D, Byakika-Kibwika P, Kintu K, Aizire J, Nakwagala F, Luzige S, Namisi C, Mayanja-Kizza H, Kamya MR. Mentorship needs at academic institutions in resource-limited settings: a survey at Makerere University College of Health Sciences. BMC Med Educ 2011; 11:53. [PMID: 21801406 PMCID: PMC3170866 DOI: 10.1186/1472-6920-11-53] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Accepted: 07/29/2011] [Indexed: 05/10/2023]
Abstract
BACKGROUND Mentoring is a core component of medical education and career success. There is increasing global emphasis on mentorship of young scientists in order to train and develop the next leaders in global health. However, mentoring efforts are challenged by the high clinical, research and administrative demands. We evaluated the status and nature of mentoring practices at Makerere University College of Health Sciences (MAKCHS). METHODS Pre-tested, self-administered questionnaires were sent by email to all Fogarty alumni at the MAKCHS (mentors) and each of them was requested to complete and email back the questionnaire. In addition to training level and number of mentors, the questionnaires had open-ended questions covering themes such as; status of mentorship, challenges faced by mentors and strategies to improve and sustain mentorship within MAKCHS. Similarly, open-ended questionnaires were sent and received by email from all graduate students (mentees) registered with the Uganda Society for Health Scientists (USHS). Qualitative data from mentors and mentees was analyzed manually according to the pre-determined themes. RESULTS Twenty- two out of 100 mentors responded (14 email and 8 hard copy responses). Up to 77% (17/22) of mentors had Master's-level training and only 18% (4/22) had doctorate-level training. About 40% of the mentors had ≥ two mentees while 27% had none. Qualitative results showed that mentors needed support in terms of training in mentoring skills and logistical/financial support to carry out successful mentorship. Junior scientists and students reported that mentorship is not yet institutionalized and it is currently occurring in an adhoc manner. There was lack of awareness of roles of mentors and mentees. The mentors mentioned the limited number of practicing mentors at the college and thus the need for training courses and guidelines for faculty members in regard to mentorship at academic institutions. CONCLUSIONS Both mentors and mentees were willing to improve mentorship practices at MAKCHS. There is need for institutional commitment to uphold and sustain the mentorship best practices. We recommend a collaborative approach by the stakeholders in global health promotion to build local capacity in mentoring African health professionals.
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Affiliation(s)
- Damalie Nakanjako
- Department of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | - Pauline Byakika-Kibwika
- Department of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | - Kenneth Kintu
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
| | - Jim Aizire
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
| | - Fred Nakwagala
- Department of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
| | - Simon Luzige
- Department of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
| | - Charles Namisi
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
| | - Harriet Mayanja-Kizza
- Department of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
| | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Fogarty Alumni Association, P.O. Box 7072, Kampala, Uganda
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Gray R, Aizire J, Azire J, Serwadda D, Kiwanuka N, Kigozi G, Kiddugavu M, Nalugoda F, Li X, Wawer M. Male circumcision and the risk of sexually transmitted infections and HIV in Rakai, Uganda. AIDS 2004; 18:2428-30. [PMID: 15622320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- Ronald Gray
- Department of Population and Family Health Sciences, Bloomberg School of Public Health, Baltimore, MD 21205, USA
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