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van der Wekken-Pas L, Nassiwa S, Malaba T, Lamorde M, Myer L, Waitt C, Reynolds H, Khoo S, He N, van Leeuwen L, Burger D, Wang D, Colbers A. Comparison of dolutegravir and efavirenz on depression, anxiety and sleep disorders in pregnant and postpartum women living with HIV. AIDS 2024; 38:975-981. [PMID: 38277390 PMCID: PMC11064908 DOI: 10.1097/qad.0000000000003852] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Both dolutegravir and efavirenz are known to be effective in pregnancy and postpartum to prevent vertical transmission of HIV and to maintain maternal health. Both drugs have also been associated with neuropsychiatric symptoms. To what extent, these symptoms occur in pregnant and postpartum women, however, is not yet known. METHODS This was a secondary analysis of the DolPHIN2 study, a multicentre randomized trial among women presenting late in pregnancy with untreated HIV - who received either a dolutegravir-containing or efavirenz-containing regimen. Longitudinal measures of depression, anxiety and sleep quality were analysed during pregnancy and up to 48 weeks postpartum. RESULTS Among 268 women, median (IQR) Edinburgh Post Natal Depression Score (EPDS) scores were 8 (3-11) and highest at enrolment. In the dolutegravir and efavirenz arm, respectively, 23.7 and 25.6% had an EPDS score above 9, indicating possible or probable depression. Abnormal Hospital Anxiety Depression scores (HADS) (above 11) were seen at least once during follow-up in 42 of patients (15.7%), although no differences were seen between treatment arms. No association was found between EPDS, suicidality and HADS scores and the assigned regimen ( P = 0.93, 0.97 and 0.18 respectively). Median (IQR) Pittsburgh Sleep Quality index (PSQI) scores for dolutegravir and efavirenz were 6 (5-7) and 5 (5-6.5), respectively, P = 0.70. CONCLUSION No statistically significant differences were observed between efavirenz-containing or dolutegravir-containing regimens. Rates of depression were high, but decreased over the course of time and confirm the need for psychological support after initial HIV diagnosis in pregnancy.
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Affiliation(s)
- Lena van der Wekken-Pas
- Radboud University Medical Center, Department of Pharmacy, Radboud Institute for Medical Innovations (RIMI), Nijmegen, the Netherlands
| | - Sylvia Nassiwa
- Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Thokozile Malaba
- School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Landon Myer
- School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Research Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Pharmacology & Therapeutics, University of Liverpool
| | - Helen Reynolds
- Department of Pharmacology & Therapeutics, University of Liverpool
| | - Saye Khoo
- Department of Pharmacology & Therapeutics, University of Liverpool
| | - Nengjie He
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Liesbeth van Leeuwen
- Department of Obstetrics and Gynecology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - David Burger
- Radboud University Medical Center, Department of Pharmacy, Radboud Institute for Medical Innovations (RIMI), Nijmegen, the Netherlands
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Angela Colbers
- Radboud University Medical Center, Department of Pharmacy, Radboud Institute for Medical Innovations (RIMI), Nijmegen, the Netherlands
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Gausi K, Mugerwa H, Siccardi M, Montanha MC, Lamorde M, Wiesner L, D’Avolio A, McIlleron H, Wilkins E, De Nicolò A, Maartens G, Khoo S, Kityo C, Denti P, Waitt C. Pharmacokinetics and Safety of Twice-daily Ritonavir-boosted Atazanavir With Rifampicin. Clin Infect Dis 2024; 78:1246-1255. [PMID: 37982585 PMCID: PMC11093668 DOI: 10.1093/cid/ciad700] [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: 07/27/2023] [Revised: 10/24/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Critical drug-drug interactions (DDI) and hepatotoxicity complicate concurrent use of rifampicin and protease inhibitors. We investigated whether dose escalation of atazanavir/ritonavir could safely overcome the DDI with rifampicin. METHODS DERIVE (NCT04121195, EDCTP) was a dose-escalation trial in people with human immunodeficiency virus (HIV) on atazanavir/ritonavir-based antiretroviral therapy (ART) in Uganda. Four intensive pharmacokinetic (PK) visits were performed: PK1 300/100 mg OD (baseline); PK2 300/100 mg OD with rifampicin 600 mg; PK3 300/100 mg twice a day (BID) with rifampicin 600 mg OD; PK4 300/100 mg BID with rifampicin 1200 mg OD. Dolutegravir 50 mg BID throughout the study period ensured participants remained protected from subtherapeutic atazanavir concentrations. The data were interpreted with noncompartmental analysis. The target minimum concentration was atazanavir's protein-adjusted IC90 (PA-IC90), 0.014 mg/L. RESULTS We enrolled 26 participants (23 female) with median (range) age 44 (28-61) years and weight 67 (50-75) kg. Compared with PK1, atazanavir Ctau, and AUC were significantly reduced at PK2 by 96% and 85%, respectively. The escalation to BID dosing (PK3) reduced this difference in Ctau, and AUC24 to 18% lower and 8% higher, respectively. Comparable exposures were maintained with double doses of rifampicin. Lowest Ctau during PK1, PK3, and PK4 were 12.7-, 4.8-, and 8.6-fold higher than PA-IC90, respectively, whereas 65% of PK2 Ctau were below the limit of quantification (0.03 mg/L), hence likely below PA-IC90. No participant developed significant elevation of liver enzymes, reported a serious adverse event (SAE) or experienced rebound viraemia. CONCLUSIONS Twice daily atazanavir/ritonavir during rifampicin co-administration was well tolerated and achieved plasma concentrations above the target. CLINICAL TRIALS REGISTRATION NCT04121195. Registered on 09 October 2019, https://clinicaltrials.gov/ct2/show/NCT04121195.
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Affiliation(s)
- Kamunkhwala Gausi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Henry Mugerwa
- Joint Clinical Research Centre, Research Department, Kampala, Uganda
| | - Marco Siccardi
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Maiara Camotti Montanha
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Antonio D’Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Edmund Wilkins
- North Manchester General Hospital, HIV Research Unit, Manchester, United Kingdom
| | - Amedeo De Nicolò
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Cissy Kityo
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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Mayito J, Kibombo D, Olaro C, Nabadda S, Guma C, Nabukenya I, Busuge A, Dhikusooka F, Andema A, Mukobi P, Onyachi N, Watmon B, Obbo S, Yayi A, Elima J, Barigye C, Nyeko FJ, Mugerwa I, Sekamatte M, Bazira J, Walwema R, Lamorde M, Kakooza F, Kajumbula H. Characterization of Antibiotic Resistance in Select Tertiary Hospitals in Uganda: An Evaluation of 2020 to 2023 Routine Surveillance Data. Trop Med Infect Dis 2024; 9:77. [PMID: 38668538 PMCID: PMC11053536 DOI: 10.3390/tropicalmed9040077] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/02/2024] [Accepted: 03/05/2024] [Indexed: 04/29/2024] Open
Abstract
Antimicrobial resistance (AMR) is a public health concern in Uganda. We sought to conduct an extended profiling of AMR burden at selected Ugandan tertiary hospitals. We analyzed routine surveillance data collected between October 2020 and March 2023 from 10 tertiary hospitals. The analysis was stratified according to the hospital unit, age, gender, specimen type, and time. Up to 2754 isolates were recovered, primarily from pus: 1443 (52.4%); urine: 1035 (37.6%); and blood: 245 (8.9%). Most pathogens were Staphylococcus aureus, 1020 (37%), Escherichia coli, 808 (29.3%), and Klebsiella spp., 200 (7.3%). Only 28% of Escherichia coli and 42% of the other Enterobacterales were susceptible to ceftriaxone, while only 44% of Staphylococcus aureus were susceptible to methicillin (56% were MRSA). Enterococcus spp. susceptibility to vancomycin was 72%. The 5-24-year-old had 8% lower ampicillin susceptibility than the >65-year-old, while the 25-44-year-old had 8% lower ciprofloxacin susceptibility than the >65-year-old. The 0-4-year-old had 8% higher ciprofloxacin susceptibility. Only erythromycin susceptibility varied by sex, being higher in males. Escherichia coli ciprofloxacin susceptibility in blood (57%) was higher than in urine (39%) or pus (28%), as was ceftriaxone susceptibility in blood (44%) versus urine (34%) or pus (14%). Klebsiella spp. susceptibility to ciprofloxacin and meropenem decreased by 55% and 47%, respectively, during the evaluation period. During the same period, Escherichia coli ciprofloxacin susceptibility decreased by 40%, while Staphylococcus aureus gentamicin susceptibility decreased by 37%. Resistance was high across the Access and Watch antibiotic categories, varying with time, age, sex, specimen type, and hospital unit. Effective antimicrobial stewardship targeted at the critical AMR drivers is urgently needed.
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Affiliation(s)
- Jonathan Mayito
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala P.O. Box 22418, Uganda; (D.K.); (A.B.)
| | - Daniel Kibombo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala P.O. Box 22418, Uganda; (D.K.); (A.B.)
| | | | | | | | - Immaculate Nabukenya
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala P.O. Box 22418, Uganda; (D.K.); (A.B.)
| | - Andrew Busuge
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala P.O. Box 22418, Uganda; (D.K.); (A.B.)
| | - Flavia Dhikusooka
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala P.O. Box 22418, Uganda; (D.K.); (A.B.)
| | - Alex Andema
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | - Peter Mukobi
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | - Nathan Onyachi
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | - Ben Watmon
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | - Stephen Obbo
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | - Alfred Yayi
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | - James Elima
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | - Celestine Barigye
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | - Filbert J. Nyeko
- Regional Referral Hospital, Ministry of Health, Kampala P.O. Box 7272, Uganda; (A.A.); (P.M.)
| | | | | | - Joel Bazira
- Department of Microbiology, Mbarara University of Science and Technology, Mbarara P.O. Box 1410, Uganda
| | - Richard Walwema
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala P.O. Box 22418, Uganda; (D.K.); (A.B.)
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala P.O. Box 22418, Uganda; (D.K.); (A.B.)
| | - Francis Kakooza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala P.O. Box 22418, Uganda; (D.K.); (A.B.)
| | - Henry Kajumbula
- Department of Microbiology, Makerere University College of Health Sciences, Kampala P.O. Box 7072, Uganda;
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Twimukye A, Alhassan Y, Ringwald B, Malaba T, Myer L, Waitt C, Lamorde M, Reynolds H, Khoo S, Taegtmeyer M. Support, not blame: safe partner disclosure among women diagnosed with HIV late in pregnancy in South Africa and Uganda. AIDS Res Ther 2024; 21:14. [PMID: 38481233 PMCID: PMC10938717 DOI: 10.1186/s12981-024-00600-z] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND HIV partner disclosure rates remain low among pregnant women living with HIV in many African countries despite potential benefits for women and their families. Partner disclosure can trigger negative responses like blame, violence, and separation. Women diagnosed with HIV late in pregnancy have limited time to prepare for partner disclosure. We sought to understand challenges around partner disclosure and non-disclosure faced by women diagnosed with HIV late in pregnancy in South Africa and Uganda and to explore pathways to safe partner disclosure. METHODS We conducted in-depth interviews and focus group discussions with pregnant women and lactating mothers living with HIV (n = 109), disaggregated by antenatal care (ANC) initiation before and after 20 weeks of gestation, male partners (n = 87), and health workers (n = 53). All participants were recruited from DolPHIN2 trial sites in Kampala (Uganda) and Gugulethu (South Africa). Topic guides explored barriers to partner disclosure, effects of non-disclosure, strategies for safe disclosure. Using the framework analysis approach, we coded and summarised data based on a socio-ecological model, topic guides, and emerging issues from the data. Data was analysed in NVivo software. RESULTS Our findings illustrate pregnant women who initiate ANC late experience many difficulties which are compounded by the late HIV diagnosis. Various individual, interpersonal, community, and health system factors complicate partner disclosure among these women. They postpone or decide against partner disclosure mainly for own and baby's safety. Women experience stress and poor mental health because of non-disclosure while demonstrating agency and resilience. We found many similarities and some differences around preferred approaches to safe partner disclosure among female and male participants across countries. Women and male partners preferred healthcare workers to assist with disclosure by identifying the 'right' time to disclose, mentoring women to enhance their confidence and communication skills, and providing professional mediation for partner disclosure and couple testing. Increasing the number of counsellors and training them on safe partner disclosure was deemed necessary for strengthening local health services to improve safe partner disclosure. CONCLUSION HIV diagnosis late in pregnancy amplifies existing difficulties among pregnant women. Late ANC initiation is an indicator for the likelihood that a pregnant woman is highly vulnerable and needs safeguarding. Respective health programmes should be prepared to offer women initiating ANC late in pregnancy additional support and referral to complementary programmes to achieve safe partner disclosure and good health.
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Affiliation(s)
- Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Beate Ringwald
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thokozile Malaba
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Helen Reynolds
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Tropical Infectious Disease Unit, Liverpool University Hospital Foundation Trust, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Tropical Infectious Disease Unit, Liverpool University Hospital Foundation Trust, Liverpool, UK
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Chappell CA, Lamorde M, Nakalema S, Kyohairwe I, Byakika-Kibwika P, Meyn LA, Pham MM, Scarsi KK. A randomized trial of double vs single-dose etonogestrel implant to overcome the interaction with efavirenz-based antiretroviral therapy. Am J Obstet Gynecol 2024:S0002-9378(24)00424-1. [PMID: 38458408 DOI: 10.1016/j.ajog.2024.03.001] [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] [Received: 11/27/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Concomitant use of efavirenz-based antiretroviral therapy and a standard-dose etonogestrel contraceptive implant led to 82% lower etonogestrel exposure when compared with women who do not receive antiretroviral therapy. The clinical impact of this reduced exposure is supported by retrospective cohort evaluations that demonstrated higher rates of unintended pregnancies when contraceptive implants were combined with efavirenz. We hypothesized that placement of 2 etonogestrel implants in those taking efavirenz-based antiretroviral therapy could increase etonogestrel exposure and improve measures of contraceptive efficacy. OBJECTIVE This study compared the rate of ovulation and etonogestrel pharmacokinetics among women on efavirenz-based antiretroviral therapy who received 2 etonogestrel implants (136 mg; double implant group) in comparison with those who received 1 etonogestrel implant (68 mg; control group). STUDY DESIGN This randomized, open-label study enrolled Ugandan women with regular menstrual periods who were receiving efavirenz-based antiretroviral therapy for the treatment of HIV. Participants were randomized 1:1 to the double implant or control group, and the etonogestrel implant(s) were placed in the same arm at enrollment. All participants used a copper intrauterine device to prevent pregnancy. Ovulation was evaluated by weekly serum progesterone concentrations measured over 4 consecutive weeks at months 3 (weeks 9-12), 6 (weeks 21-24), and 12 (weeks 45-48). Progesterone concentrations >3 ng/mL were interpreted as ovulation. The ovulation rate in each group was compared using Fisher's exact tests for each month and generalized estimating equations over 48 weeks. Plasma was collected at day 3 and weeks 1, 4, 12, 24, 36, and 48 after implant placement and analyzed using a validated liquid chromatography-triple quadrupole mass spectrometry method for etonogestrel. Etonogestrel concentrations were summarized as median (interquartile range) and compared between groups by geometric mean ratio with 90% confidence intervals. RESULTS All participants (n=72) were cisgender Ugandan women with a median age of 31 years (interquartile range, 29-36), and 36 participants were enrolled in each study group. Two participants in the control group discontinued the trial; 1 at week 1 because of undetected pregnancy at entry and another at week 45 because of clinically significant depression. There were 47 ovulations over 104 person-months (45%) in 25 of 34 participants in the control group, and 2 ovulations over 108 person-months (2%) in 2 of 36 participants in the double implant group (month 3: 11 [31%] vs 0 [0%]; month 6: 17 [49%] vs 0 [0%]; month 12: 19 [56%] vs 2 [6%], respectively; all P<.001). The odds of ovulation were reduced by 97.7% (95% confidence interval, 90.1-99.5) in the double implant group over 48 weeks. At each time point, etonogestrel concentration was more than 2-fold higher in the double implant group than in the controls (geometric mean ratio, 2.30-2.83) with a geometric mean ratio of 2.83 (90% confidence interval, 1.89-3.35) at week 48. There were no differences in the adverse events between groups and no participant discontinued because of adverse events. CONCLUSION Over 48 weeks of combined use, placing 2 etonogestrel implants suppressed ovulation and increased plasma etonogestrel exposure when compared with 1 etonogestrel implant among women on efavirenz-based antiretroviral therapy. Doubling the dose of etonogestrel during efavirenz-based antiretroviral therapy could improve contraceptive effectiveness.
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Affiliation(s)
- Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA; Magee-Womens Research Institute, Pittsburgh, PA.
| | - Mohammed Lamorde
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | - Shadia Nakalema
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | | | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | - Leslie A Meyn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Michelle M Pham
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE; Quantitative Pharmacology and Pharmacometrics, Merch & Co., Rahway, NJ
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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Koyuncu A, Carter RJ, Musaazi J, Namageyo-Funa A, Carter VM, Lamorde M, Prybylski D, Apondi R, Bakyaita T, Boore AL, Homsy J, Brown VR, Kigozi J, Nabaggala MS, Nakate V, Nkurunziza E, Stowell DF, Walwema R, Olowo A, Jalloh MF. Public perceptions of Ebola vaccines and confidence in health services to treat Ebola, malaria, and tuberculosis: Findings from a cross-sectional household survey in Uganda, 2020. PLOS Glob Public Health 2023; 3:e0001884. [PMID: 38113241 PMCID: PMC10729951 DOI: 10.1371/journal.pgph.0001884] [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] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/30/2023] [Indexed: 12/21/2023]
Abstract
Uganda used Ebola vaccines as part of its preparedness and response during the 2018-2020 10th Ebola virus disease (EVD) outbreak in neighboring Democratic Republic of the Congo (DRC). We evaluated the public's perceptions of Ebola vaccines and compared their confidence in health services to treat Ebola versus malaria and tuberculosis as part of a survey on Ebola knowledge, attitudes, and practices (KAP) conducted in March 2020. A cross-sectional household survey was implemented in six districts in Uganda using multi-stage cluster sampling to randomly select participants. The districts were purposively selected from districts classified by the government as at high- or low-risk for an EVD outbreak. We describe perceptions of Ebola vaccines and confidence in health services to treat Ebola, tuberculosis, and malaria. Modified Poisson regression modeling was used to identify the demographic correlates of these outcomes. Among 3,485 respondents, 18% were aware of Ebola vaccines. Of those, 92% agreed that the vaccines were needed to prevent Ebola. Participants aged 15-24 years were 4% more likely to perceive such need compared to those 60 years and older (adjusted prevalence ratio [aPR] 1.04, 95% confidence interval [CI] 1.0-1.08). The perceived need was 5% lower among participants with at least some secondary education compared to uneducated participants (aPR 0.95; 0.92-0.99). Overall, 81% of those aware of the vaccines believed that everyone or most people in their community would get vaccinated if offered, and 94% said they would likely get vaccinated if offered. Confidence in health services to treat Ebola was lower compared to treating malaria or tuberculosis (55% versus 93% and 77%, respectively). However, participants from the EVD high-risk districts were 22% more likely to be confident in health services to treat Ebola compared to those in low-risk districts (aPR: 1.22; 95% CI: 1.08, 1.38). Our findings suggest that intent to take an Ebola vaccine during an outbreak was strong, but more work needs to be done to increase public awareness of these vaccines. The public's high confidence in health services to treat other health threats, such as malaria and tuberculosis, offer building blocks for strengthening their confidence in health services to treat EVD in the event of an outbreak.
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Affiliation(s)
- Aybüke Koyuncu
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Rosalind J. Carter
- National Center for Immunization and Respiratory Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Joseph Musaazi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Apophia Namageyo-Funa
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Victoria M. Carter
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Dimitri Prybylski
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Rose Apondi
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Amy L. Boore
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Jaco Homsy
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Vance R. Brown
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Joanita Kigozi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Maria Sarah Nabaggala
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Vivian Nakate
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Nkurunziza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Daniel F. Stowell
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Richard Walwema
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Apollo Olowo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mohamed F. Jalloh
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Kengo A, Nabisere R, Gausi K, Musaazi J, Buzibye A, Omali D, Aarnoutse R, Lamorde M, Dooley KE, Sloan DJ, Denti P, Sekaggya-Wiltshire C. Dolutegravir pharmacokinetics in Ugandan patients with TB and HIV receiving standard- versus high-dose rifampicin. Antimicrob Agents Chemother 2023; 67:e0043023. [PMID: 37850738 PMCID: PMC10648962 DOI: 10.1128/aac.00430-23] [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: 04/04/2023] [Accepted: 07/13/2023] [Indexed: 10/19/2023] Open
Abstract
Higher rifampicin doses may improve tuberculosis treatment outcomes. This could however exacerbate the existing drug interaction with dolutegravir. Moreover, the metabolism of dolutegravir may also be affected by polymorphism of UGT1A1, a gene that codes for uridine diphosphate glucuronosyltransferase. We used population pharmacokinetic modeling to compare the pharmacokinetics of dolutegravir when coadministered with standard- versus high-dose rifampicin in adults with tuberculosis and HIV, and investigated the effect of genetic polymorphisms. Data from the SAEFRIF trial, where participants were randomized to receive first-line tuberculosis treatment with either standard- 10 mg/kg or high-dose 35 mg/kg rifampicin alongside antiretroviral therapy, were used. The dolutegravir model was developed with 211 plasma concentrations from 44 participants. The median (interquartile range) rifampicin area under the curve (AUC) in the standard- and high-dose arms were 32.3 (28.7-36.7) and 153 (138-175) mg·h/L, respectively. A one-compartment model with first-order elimination and absorption through transit compartments best described dolutegravir pharmacokinetics. For a typical 56 kg participant, we estimated a clearance, absorption rate constant, and volume of distribution of 1.87 L/h, 1.42 h-1, and 12.4 L, respectively. Each 10 mg·h/L increase in the AUC of coadministered rifampicin from 32.3 mg·h/L led to a 2.3 (3.1-1.4) % decrease in dolutegravir bioavailability. Genetic polymorphism of UGT1A1 did not significantly affect dolutegravir pharmacokinetics. Simulations of trough dolutegravir concentrations show that the 50 mg twice-daily regimen attains both the primary and secondary therapeutic targets of 0.064 and 0.3 mg/L, respectively, regardless of the dose of coadministered rifampicin, unlike the once-daily regimen.
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Affiliation(s)
- Allan Kengo
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Ruth Nabisere
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kamunkhwala Gausi
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Joseph Musaazi
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Allan Buzibye
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Denis Omali
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mohammed Lamorde
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kelly E. Dooley
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Derek James Sloan
- Division of Infection and Global Health, School of Medicine, University of St. Andrews, St Andrews, United Kingdom
| | - Paolo Denti
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
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Kengo A, Gausi K, Nabisere R, Musaazi J, Buzibye A, Omali D, Aarnoutse R, Lamorde M, Dooley KE, Sloan DJ, Sekaggya-Wiltshire C, Denti P. Unexpectedly low drug exposures among Ugandan patients with TB and HIV receiving high-dose rifampicin. Antimicrob Agents Chemother 2023; 67:e0043123. [PMID: 37850737 PMCID: PMC10649026 DOI: 10.1128/aac.00431-23] [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: 04/04/2023] [Accepted: 07/13/2023] [Indexed: 10/19/2023] Open
Abstract
We characterized the pharmacokinetics of standard- and high-dose rifampicin in Ugandan adults with tuberculosis and HIV taking dolutegravir- or efavirenz-based antiretroviral therapy. A liver model with saturable hepatic extraction adequately described the data, and the increase in exposure between high and standard doses was 4.7-fold. This was lower than what previous reports of dose-exposure nonlinearity would predict and was ascribed to 38% lower bioavailability of the rifampicin-only top-up formulation compared to the fixed-dose combination.
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Affiliation(s)
- Allan Kengo
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Kamunkhwala Gausi
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Ruth Nabisere
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph Musaazi
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Allan Buzibye
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Denis Omali
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud university medical center, Nijmegen, the Netherlands
| | - Mohammed Lamorde
- Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kelly E. Dooley
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Derek James Sloan
- Division of Infection and Global Health, School of Medicine, University of St. Andrews, Scotland, United Kingdom
| | | | - Paolo Denti
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
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Pratt C, Kesande M, Tusabe F, Medley A, Prentice-Mott G, Lozier M, Trinies V, Yapswale S, Nabatyanga S, Isabirye H, Lamorde M, Berendes D. Access to and Use of Hand Hygiene Resources during the COVID-19 Pandemic in Two Districts in Uganda, January-April 2021. Am J Trop Med Hyg 2023; 109:881-889. [PMID: 37640292 PMCID: PMC10551090 DOI: 10.4269/ajtmh.23-0031] [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] [Received: 01/17/2023] [Accepted: 06/12/2023] [Indexed: 08/31/2023] Open
Abstract
To understand access to and use of hand hygiene in healthcare facilities (HCFs) and community locations during the COVID-19 pandemic, we evaluated factors associated with hand hygiene in 60 priority HCFs and community locations in two border districts in Uganda. We assessed water and hand hygiene resource availability and observed hand hygiene practice by staff or patrons. Regression modeling estimated factors associated with the availability or use of hand hygiene. In HCFs, most inpatient (61%), outpatient (71%), and laboratory or staff (90%) rooms contained hand hygiene materials. Only 38% of community locations had hand hygiene materials at all entrances and exits, 35% of congregation areas had hand hygiene materials. Overall, 38% of healthcare staff, 48% of patrons post-latrine use, and 21% of patrons entering or exiting community locations practiced hand hygiene. HCF hand hygiene access was lower in inpatient rooms (odds ratio [OR] = 0.17, 95% CI: 0.06-0.45) and outpatient rooms (OR = 0.23, 95% CI: 0.07-0.70) compared with laboratory/staff rooms. HCF hand hygiene practice was higher for doctors than nurses (OR = 3.58, 95% CI: 1.15-11.14) and with new versus existing patient encounters (OR = 2.27, 95% CI: 1.20-4.27); it was lower before versus after patient contact for both invasive (OR = 0.03, 95% CI: 0.00-0.20) and noninvasive (OR = 0.66, 95% CI: 0.45-0.95) procedures. In community settings, hand hygiene practice after using the latrine was higher than at an entrances/exits (OR = 3.39, 95% CI: 2.08-5.52). Hand hygiene rates were relatively low in healthcare and community settings. Greater emphasis on hand hygiene before patient interactions (at HCFs) and at community entrances/exits for patrons is also needed.
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Affiliation(s)
- Caroline Pratt
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
- U.S. Epidemic Intelligence Service, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maureen Kesande
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Fred Tusabe
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Alexandra Medley
- Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Graeme Prentice-Mott
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Lozier
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Victoria Trinies
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sauda Yapswale
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | - Herbert Isabirye
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - David Berendes
- U.S. Epidemic Intelligence Service, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
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Bakiika H, Obuku EA, Bukirwa J, Nakiire L, Robert A, Nabatanzi M, Robert M, Moses M, Achan MI, Kibanga JB, Nakanwagi A, Makumbi I, Nabukenya I, Lamorde M. Contribution of the one health approach to strengthening health security in Uganda: a case study. BMC Public Health 2023; 23:1498. [PMID: 37550671 PMCID: PMC10408150 DOI: 10.1186/s12889-023-15670-3] [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: 03/11/2022] [Accepted: 04/13/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND The One Health approach is key in implementing International Health Regulations (IHR, 2005) and the Global Health Security Agenda (GHSA). Uganda is signatory to the IHR 2005 and in 2017, the country conducted a Joint External Evaluation (JEE) that guided development of the National Action Plan for Health Security (NAPHS) 2019-2023. AIM This study assessed the contribution of the One Health approach to strengthening health security in Uganda. METHODS A process evaluation between 25th September and 5th October 2020, using a mixed-methods case study. Participants were Subject Matter Experts (SMEs) from government ministries, departments, agencies and implementing partners. Focus group discussions were conducted for five technical areas (workforce development, real-time surveillance, zoonotic diseases, national laboratory systems and emergency response operations), spanning 18 indicators and 96 activities. Funding and implementation status from the NAPHS launch in August 2019 to October 2020 was assessed with a One Health lens. RESULTS Full funding was available for 36.5% of activities while 40.6% were partially funded and 22.9% were not funded at all. Majority (65%) of the activities were still in progress, whereas 8.6% were fully implemented and14.2% were not yet done. In workforce development, several multisectoral trainings were conducted including the frontline public health fellowship program, the One Health fellowship and residency program, advanced field epidemiology training program, in-service veterinary trainings and 21 district One Health teams' trainings. Real Time Surveillance was achieved through incorporating animal health events reporting in the electronic integrated disease surveillance and response platform. The national and ten regional veterinary laboratories were assessed for capacity to conduct zoonotic disease diagnostics, two of which were integrated into the national specimen referral and transportation network. Multisectoral planning for emergency response and the actual response to prioritized zoonotic disease outbreaks was done jointly. CONCLUSIONS This study demonstrates the contribution of 'One Health' implementation in strengthening Uganda's health security. Investment in the funding gaps will reinforce Uganda's health security to achieve the IHR 2005. Future studies could examine the impacts and cost-effectiveness of One Health in curbing prioritized zoonotic disease outbreaks.
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Affiliation(s)
- Herbert Bakiika
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda.
| | - Ekwaro A Obuku
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Justine Bukirwa
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Lydia Nakiire
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Aruho Robert
- Uganda Wildlife Authority, P.O Box 3530, Kampala, Uganda
| | - Maureen Nabatanzi
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Mwebe Robert
- Ministry of Agriculture and Animal Industry and Fisheries, P.O Box 102, Entebbe, Uganda
| | - Mwanja Moses
- Ministry of Agriculture and Animal Industry and Fisheries, P.O Box 102, Entebbe, Uganda
| | | | - John Baptist Kibanga
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Aisha Nakanwagi
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Issa Makumbi
- Public Health Emergency Operation Centre, Ministry of Health, P.O. Box 7272, Kampala, Uganda
| | - Immaculate Nabukenya
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
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11
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Kakooza F, Golparian D, Matoga M, Maseko V, Lamorde M, Krysiak R, Manabe YC, Chen JS, Kularatne R, Jacobsson S, Godreuil S, Hoffman I, Bercot B, Wi T, Unemo M. Genomic surveillance and antimicrobial resistance determinants in Neisseria gonorrhoeae isolates from Uganda, Malawi and South Africa, 2015-20. J Antimicrob Chemother 2023; 78:1982-1991. [PMID: 37352017 DOI: 10.1093/jac/dkad193] [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: 04/26/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023] Open
Abstract
OBJECTIVES Global antimicrobial resistance (AMR) surveillance in Neisseria gonorrhoeae is essential. In 2017-18, only five (10.6%) countries in the WHO African Region reported to the WHO Global Gonococcal Antimicrobial Surveillance Programme (WHO GASP). Genomics enhances our understanding of gonococcal populations nationally and internationally, including AMR strain transmission; however, genomic studies from Africa are extremely scarce. We describe the gonococcal genomic lineages/sublineages, including AMR determinants, and baseline genomic diversity among strains in Uganda, Malawi and South Africa, 2015-20, and compare with sequences from Kenya and Burkina Faso. METHODS Gonococcal isolates cultured in Uganda (n = 433), Malawi (n = 154) and South Africa (n = 99) in 2015-20 were genome-sequenced. MICs were determined using ETEST. Sequences of isolates from Kenya (n = 159), Burkina Faso (n = 52) and the 2016 WHO reference strains (n = 14) were included in the analysis. RESULTS Resistance to ciprofloxacin was high in all countries (57.1%-100%). All isolates were susceptible to ceftriaxone, cefixime and spectinomycin, and 99.9% were susceptible to azithromycin. AMR determinants for ciprofloxacin, benzylpenicillin and tetracycline were common, but rare for cephalosporins and azithromycin. Most isolates belonged to the more antimicrobial-susceptible lineage B (n = 780) compared with the AMR lineage A (n = 141), and limited geographical phylogenomic signal was observed. CONCLUSIONS We report the first multi-country gonococcal genomic comparison from Africa, which will support the WHO GASP and WHO enhanced GASP (EGASP). The high prevalence of resistance to ciprofloxacin (and empirical use continues), tetracycline and benzylpenicillin, and the emerging resistance determinants for azithromycin show it is imperative to strengthen the gonococcal AMR surveillance, ideally including genomics, in African countries.
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Affiliation(s)
- Francis Kakooza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Golparian
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Örebro University, Örebro, Sweden
| | | | - Venessa Maseko
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Yuka C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jane S Chen
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ranmini Kularatne
- Labtests Laboratory and Head Office, Mt Wellington, Auckland, New Zealand
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susanne Jacobsson
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Örebro University, Örebro, Sweden
| | - Sylvain Godreuil
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire de Montpellier, and MIVEGEC, Université de Montpellier, CNRS, IRD, Montpellier, France
| | - Irving Hoffman
- UNC Project Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Beatrice Bercot
- Infectious Agents Department, French National Reference Centre for Bacterial STIs, Associated Laboratory for Gonococci, and APHP, Saint Louis Hospital, Paris, France
| | - Teodora Wi
- Department of the Global HIV, Hepatitis and STI Programmes, WHO, Geneva, Switzerland
| | - Magnus Unemo
- Department of Laboratory Medicine, Faculty of Medicine and Health, WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for STIs, Örebro University, Örebro, Sweden
- Institute for Global Health, University College London, London, UK
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12
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Jorgensen AL, Orrell C, Waitt C, Toh CH, Sekaggya-Wiltshire C, Hughes DA, Allen E, Okello E, Tatz G, Culeddu G, Asiimwe IG, Semakula JR, Mouton JP, Cohen K, Blockman M, Lamorde M, Pirmohamed M. A "Bundle of Care" to Improve Anticoagulation Control in Patients Receiving Warfarin in Uganda and South Africa: Protocol for an Implementation Study. JMIR Res Protoc 2023; 12:e46710. [PMID: 37467034 PMCID: PMC10398551 DOI: 10.2196/46710] [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] [Received: 02/23/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The quality of warfarin anticoagulation among Sub-Saharan African patients is suboptimal. This is due to several factors, including a lack of standardized dosing algorithms, difficulty in providing timely international normalized ratio (INR) results, a lack of patient feedback on their experiences with treatment, a lack of education on adherence, and inadequate knowledge and training of health care workers. Low quality of warfarin anticoagulation, expressed as time in therapeutic range (TTR), is associated with higher adverse event rates, including bleeding and thrombosis, and ultimately, increased morbidity and mortality. Processes and interventions that improve this situation are urgently needed. OBJECTIVE This study aims to evaluate the implementation of the "warfarin bundle," a package of interventions to improve the quality of anticoagulation and thereby clinical outcomes. The primary outcome for this study is TTR over the initial 3 months of warfarin therapy. METHODS Patients aged 18 years or older who are newly initiated on warfarin for venous thromboembolism, atrial fibrillation, or valvular heart disease will be enrolled and followed up for 3 months at clinics in Cape Town, South Africa, and Kampala, Uganda, where the warfarin bundle is implemented. A retrospective review of the clinical records of patients on warfarin treatment before implementation (controls) will be used for comparison. This study uses a mixed methods approach of the implementation of patient- and process-centered activities to improve the quality of anticoagulation. Patient-centered activities include the use of clinical dosing algorithms, adherence support, and root cause analysis, whereas process-centered activities include point-of-care INR testing, staff training, and patient education and training. We will assess the impact of these interventions by comparing the TTR and safety outcomes across the 2 groups, as well as the cost-effectiveness and acceptability of the package. RESULTS We started recruitment in June 2021 and stopped in August 2022, having recruited 167 participants. We obtained ethics approval from the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee, the Provincial Health Research Committees in South Africa, the Joint Clinical Research Centre Institutional Review Board, Kampala, and the University of Liverpool Research Ethics Committee. As of February 2023, data cleaning and formal analysis are underway. We expect to publish the full results by December 2023. CONCLUSIONS We anticipate that the "bundle of care," which includes a clinical algorithm to guide individualized dosing of warfarin, will improve INR control and TTR of patients in Uganda and South Africa. We will use these findings to design a larger, multisite clinical trial across several Sub-Saharan African countries. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46710.
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Affiliation(s)
- Andrea L Jorgensen
- Department of Health Data Science, Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Cheng-Hock Toh
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | | | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, School of Health Sciences, Bangor University, Bangor, United Kingdom
| | - Elizabeth Allen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Gayle Tatz
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Giovanna Culeddu
- Centre for Health Economics and Medicines Evaluation, School of Health Sciences, Bangor University, Bangor, United Kingdom
| | - Innocent G Asiimwe
- The Wolfson Centre for Personalized Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Jerome Roy Semakula
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Johannes P Mouton
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Blockman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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Bochner AF, Makumbi I, Aderinola O, Abayneh A, Jetoh R, Yemanaberhan RL, Danjuma JS, Lazaro FT, Mahmoud HJ, Yeabah TO, Nakiire L, Yahaya AK, Teixeira RA, Lamorde M, Nabukenya I, Oladejo J, Adetifa IMO, Oliveira W, McClelland A, Lee CT. Implementation of the 7-1-7 target for detection, notification, and response to public health threats in five countries: a retrospective, observational study. Lancet Glob Health 2023; 11:e871-e879. [PMID: 37060911 PMCID: PMC10156425 DOI: 10.1016/s2214-109x(23)00133-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/17/2023] [Accepted: 02/27/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Suboptimal detection and response to recent outbreaks, including COVID-19 and mpox (formerly known as monkeypox), have shown that the world is insufficiently prepared for public health threats. Routine monitoring of detection and response performance of health emergency systems through timeliness metrics has been proposed to evaluate and improve outbreak preparedness and contain health threats early. We implemented 7-1-7 to measure the timeliness of detection (target of ≤7 days from emergence), notification (target of ≤1 day from detection), and completion of seven early response actions (target of ≤7 days from notification), and we identified bottlenecks to and enablers of system performance. METHODS In this retrospective, observational study, we conducted reviews of public health events in Brazil, Ethiopia, Liberia, Nigeria, and Uganda with staff from ministries of health and national public health institutes. For selected public health events occurring from Jan 1, 2018, to Dec 31, 2022, we calculated timeliness intervals for detection, notification, and early response actions, and synthesised identified bottlenecks and enablers. We mapped bottlenecks and enablers to Joint External Evaluation (second edition) indicators. FINDINGS Of 41 public health events assessed, 22 (54%) met a target of 7 days to detect (median 6 days [range 0-157]), 29 (71%) met a target of 1 day to notify (0 days [0-24]), and 20 (49%) met a target of 7 days to complete all early response actions (8 days [0-72]). 11 (27%) events met the complete 7-1-7 target, with variation among event types. 25 (61%) of 41 bottlenecks to and 27 (51%) of 53 enablers of detection were at the health facility level, with delays to notification (14 [44%] of 32 bottlenecks) and response (22 [39%] of 56 bottlenecks) most often at an intermediate public health (ie, municipal, district, county, state, or province) level. Rapid resource mobilisation for responses (six [9%] of 65 enablers) from the national level enabled faster responses. INTERPRETATION The 7-1-7 target is feasible to measure and to achieve, and assessment with this framework can identify areas for performance improvement and help prioritise national planning. Increased investments must be made at the health facility and intermediate public health levels for improved systems to detect, notify, and rapidly respond to emerging public health threats. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
| | - Issa Makumbi
- Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Olaolu Aderinola
- Nigeria Centre for Disease Control and Prevention, Abuja, Nigeria
| | | | - Ralph Jetoh
- National Public Health Institute of Liberia, Monrovia, Liberia
| | | | | | | | | | - Trokon O Yeabah
- National Public Health Institute of Liberia, Monrovia, Liberia
| | - Lydia Nakiire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Aperki K Yahaya
- Nigeria Centre for Disease Control and Prevention, Abuja, Nigeria
| | | | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - John Oladejo
- Nigeria Centre for Disease Control and Prevention, Abuja, Nigeria
| | | | - Wanderson Oliveira
- Vital Strategies, São Paulo, Brazil; Ministry of Defense Hospital of the Armed Forces, Brasília, Brazil
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Tusabe F, Nanyondo J, Lozier MJ, Kesande M, Tumuhairwe O, Watsisi M, Twinomugisha F, Medley A, Mutoro J, Lamorde M, Berendes D. Improving Access to WHO Formulations of Alcohol-Based Hand Rub in Healthcare Facilities: A District-Wide Approach. Am J Trop Med Hyg 2023:tpmd220554. [PMID: 37188343 DOI: 10.4269/ajtmh.22-0554] [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] [Received: 08/26/2022] [Accepted: 03/14/2023] [Indexed: 05/17/2023] Open
Abstract
Alcohol-based hand rub (ABHR) is an effective hand hygiene measure to mitigate and prevent infectious disease transmission in healthcare facilities (HCFs); however, availability and affordability in low- and middle-income countries are limited. We sought to establish centralized local production of ABHR using a district-wide approach to increase provider access at all public HCFs in Kabarole and Kasese Districts in Western Uganda. Partner organizations worked with district governments to adapt and implement the WHO protocol for local ABHR production at the district scale. These groups identified and upgraded sites for ABHR production and storage to ensure recommended security, ventilation, and air conditioning. District governments selected technicians for training on ABHR production. Raw materials were sourced within Uganda. Alcohol-based hand rub underwent internal quality control by the production officer and external quality control (EQC) by a trained district health inspector before distribution to HCFs. We assessed ABHR production and demand from March 2019 to December 2020. All ABHR batches (N = 316) met protocol standards (alcohol concentration: 75.0-85.0%) with a mean of 79.9% (range: 78.5-80.5%). Internal quality control measurements (mean alcohol concentration: 80.0%, range: 79.5-81.0%) matched EQC measurements (mean: 79.8%, range: 78.0-80.0%). Production units supplied ABHR to 127 HCFs in Kasese District (100%) and 31 HCFs in Kabarole District (56%); 94% of HCFs were small (dispensary or next higher level). This district-wide production met quality standards and supplied ABHR to many HCFs where facility-level production would be unfeasible. Low- and middle-income countries may consider district models to expand ABHR production and supply to smaller HCFs.
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Affiliation(s)
- Fred Tusabe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Judith Nanyondo
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Matthew J Lozier
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maureen Kesande
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Olive Tumuhairwe
- Kabarole District Health Office, Kabarole District Local Government, Fort Portal, Uganda
| | - Martin Watsisi
- International Water & Sanitation Centre - WASH, Fort Portal, Uganda
| | | | - Alexandra Medley
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David Berendes
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Frieden TR, Lee CT, Lamorde M, Nielsen M, McClelland A, Tangcharoensathien V. The road to achieving epidemic-ready primary health care. Lancet Public Health 2023; 8:e383-e390. [PMID: 37120262 PMCID: PMC10139016 DOI: 10.1016/s2468-2667(23)00060-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 05/01/2023]
Abstract
Millions of avoidable deaths arising from the COVID-19 pandemic emphasise the need for epidemic-ready primary health care aligned with public health to identify and stop outbreaks, maintain essential services during disruptions, strengthen population resilience, and ensure health worker and patient safety. The improvement in health security from epidemic-ready primary health care is a strong argument for increased political support and can expand primary health-care capacities to improve detection, vaccination, treatment, and coordination with public health-needs that became more apparent during the pandemic. Progress towards epidemic-ready primary health care is likely to be stepwise and incremental, advancing when opportunity arises based on explicit agreement on a core set of services, improved use of external and national funds, and payment based in large part on empanelment and capitation to improve outcomes and accountability, supplemented with funding for core staffing and infrastructure and well designed incentives for health improvement. Health-care worker and broader civil society advocacy, political consensus, and bolstering government legitimacy could promote strong primary health care. Epidemic-ready primary health-care infrastructure that is able to help prevent and withstand the next pandemic will require substantial financial and structural reforms and sustained political and financial commitment. Governments, advocates, and bilateral and multilateral agencies should seize this window of opportunity before it closes.
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Affiliation(s)
| | | | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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16
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Achan MI, Nabukenya I, Mitanda S, Nakacwa J, Bakiika H, Nabatanzi M, Bukirwa J, Nakanwagi A, Nakiire L, Aperce C, Schwid A, Okware S, Obuku EA, Lamorde M, Luswata B, Makumbi I, Muruta A, Mwebesa HG, Aceng Ocero JR. COVID-19 and the law in Uganda: a case study on development and application of the public health act from 2020 to 2021. BMC Public Health 2023; 23:761. [PMID: 37098568 PMCID: PMC10126532 DOI: 10.1186/s12889-023-15555-5] [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: 04/13/2022] [Accepted: 03/29/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Despite the discovery of vaccines, the control, and prevention of Coronavirus disease 2019 (COVID-19) relied on non-pharmaceutical interventions (NPIs). This article describes the development and application of the Public Health Act to implement NPIs for COVID-19 pandemic control in Uganda. METHODS This is a case study of Uganda's experience with enacting COVID-19 Rules under the Public Health Act Cap. 281. The study assessed how and what Rules were developed, their influence on the outbreak progress, and litigation. The data sources reviewed were applicable laws and policies, Presidential speeches, Cabinet resolutions, statutory instruments, COVID-19 situation reports, and the registry of court cases that contributed to a triangulated analysis. RESULTS Uganda applied four COVID-19 broad Rules for the period March 2020 to October 2021. The Minister of Health enacted the Rules, which response teams, enforcement agencies, and the general population followed. The Presidential speeches, their expiry period and progress of the pandemic curve led to amendment of the Rules twenty one (21) times. The Uganda Peoples Defense Forces Act No. 7 of 2005, the Public Finance Management Act No. 3 of 2015, and the National Policy for Disaster Preparedness and Management supplemented the enacted COVID-19 Rules. However, these Rules attracted specific litigation due to perceived infringement on certain human rights provisions. CONCLUSIONS Countries can enact supportive legislation within the course of an outbreak. The balance of enforcing public health interventions and human rights infringements is an important consideration in future. We recommend public sensitization about legislative provisions and reforms to guide public health responses in future outbreaks or pandemics.
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Affiliation(s)
| | - Immaculate Nabukenya
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Sarah Mitanda
- Ministry of Justice and Constitutional Affairs, P.O Box 7183, Kampala, Uganda
| | - Joanita Nakacwa
- Ministry of Justice and Constitutional Affairs, P.O Box 7183, Kampala, Uganda
| | - Herbert Bakiika
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Maureen Nabatanzi
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Justine Bukirwa
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Aisha Nakanwagi
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Lydia Nakiire
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Cedric Aperce
- Resolve to Save Lives, New York 100 Broadway, 4th Floor, New York, NY 10005 USA
| | - Aaron Schwid
- Vital Strategies, New York 100 Broadway, 4th Floor, New York, NY 10005 USA
| | - Solome Okware
- World Health Organization, Uganda Country Office, P. O. Box 24578, Kampala, Uganda
| | - Ekwaro A. Obuku
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | | | - Issa Makumbi
- Ministry of Health, P.O. Box 7272, Kampala, Uganda
| | - Allan Muruta
- Ministry of Health, P.O. Box 7272, Kampala, Uganda
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17
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Buzibye A, Wools-Kaloustian K, Olagunju A, Twinomuhwezi E, Yiannoutsos C, Owen A, Neary M, Matovu J, Banturaki G, Castelnuovo B, Lamorde M, Khoo S, Waitt C, Kiragga A. Relating CYP2B6 genotype and efavirenz resistance among post-partum women living with HIV with high viremia in Uganda: a nested cross-sectional study. AIDS Res Ther 2023; 20:20. [PMID: 37004096 PMCID: PMC10064798 DOI: 10.1186/s12981-023-00514-2] [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: 01/03/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND We investigated the association between CYP2B6 polymorphisms and efavirenz drug resistance among women living with HIV who started on antiretroviral therapy during pregnancy and with high viremia during post-partum. METHODS This was a cross-sectional study of women with viral loads greater than 1000 copies/ml who were at least 6 weeks postpartum. Sanger sequencing was used to detect resistant mutations, as well as host genotyping, and efavirenz resistance was compared among the metabolizer genotypes. RESULTS Over the course of one year (July 2017-July 2018), 322 women were screened, with 110 (34.2%) having viral loads of 1000 copies/ml and 62 having whole blood available for genotyping. Fifty-nine of these women had both viral resistance and human host genotypic results. Efavirenz resistance according to metabolizer genotype was; 47% in slow, 34% in extensive and 28% in intermediate metabolizers, but the difference was not statistically significant due to the small sample size. CONCLUSIONS There was no statistically significant difference in EFV resistance between EFV metabolizer genotypes in women who started antiretroviral therapy during pregnancy and had high viremia in the postpartum period. However, a numerical trend was discovered, which calls for confirmation in a large, well-designed, statistically powered study.
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Affiliation(s)
- Allan Buzibye
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda.
| | | | - Adeniyi Olagunju
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Ellon Twinomuhwezi
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | | | - Andrew Owen
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Megan Neary
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Joshua Matovu
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | - Grace Banturaki
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | - Barbara Castelnuovo
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | - Mohammed Lamorde
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Catriona Waitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Agnes Kiragga
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O. Box 22418, Kampala, Uganda
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18
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Lamorde M, Castelnuovo B. Pregnancy outcomes for new ART regimens. The Lancet HIV 2023; 10:e274-e275. [PMID: 37001537 DOI: 10.1016/s2352-3018(23)00077-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
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Nabatanzi M, Bakiika H, Nabukenya I, Lamorde M, Bukirwa J, Achan MI, Babigumira PA, Nakiire L, Lubanga T, Mbabazi E, Taremwa RB, Mayinja H, Nakinsige A, Makanga DK, Muruta A, Okware S, Komakech I, Makumbi I, Wetaka MM, Kayiwa J, Ocom F, Ario AR, Nabatanzi S, Ojwang J, Boore A, Yemanaberhan R, Lee CT, Obuku E, Stowell D. Building National Health Security Through a Rapid Self-Assessment and Annual Operational Plan in Uganda, May to September 2021. Health Secur 2023; 21:130-140. [PMID: 36940291 PMCID: PMC10701509 DOI: 10.1089/hs.2022.0107] [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: 08/05/2022] [Revised: 12/19/2022] [Accepted: 01/05/2023] [Indexed: 03/22/2023] Open
Abstract
Uganda established a National Action Plan for Health Security in 2019, following a Joint External Evaluation (JEE) of International Health Regulations (2005) capacities in 2017. The action plan enhanced national health security awareness, but implementation efforts were affected by limited funding, excess of activities, and challenges related to monitoring and evaluation. To improve implementation, Uganda conducted a multisectoral health security self-assessment in 2021 using the second edition of the JEE tool and developed a 1-year operational plan. From 2017 to 2021, Uganda's composite ReadyScore improved by 20%, with improvement in 13 of the 19 technical areas. Indicator scores showing limited capacity declined from 30% to 20%, and indicators with no capacity declined from 10% to 2%. More indicators had developed (47% vs 40%), demonstrated (29% vs 20%), and sustained (2% vs 0%) capacities in 2021 compared with 2017. Using the self-assessment JEE scores, 72 specific activities from the International Health Regulations (2005) benchmarks tool were selected for inclusion in a 1-year operational plan (2021-2022). In contrast to the 264 broad activities in the 5-year national action plan, the operational plan prioritized a small number of activities to enable sectors to focus limited resources on implementation. While certain capacities improved before and during implementation of the action plan, countries may benefit from using short-term operational planning to develop realistic and actionable health security plans to improve health security capacities.
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Affiliation(s)
- Maureen Nabatanzi
- Maureen Nabatanzi, MPHN, FETP, is an Epidemiologist, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Herbert Bakiika
- Herbert Bakiika MPH, is a One Health Specialist, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Immaculate Nabukenya
- Immaculate Nabukenya, PhD, is an Epidemiologist, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Mohammed Lamorde
- Mohammed Lamorde, MD, PhD, is Head of Department, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Justine Bukirwa
- Justine Bukirwa is a Technical Officer, Laboratory Systems, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Martha I. Achan
- Martha I. Achan, LLB, LLM, is a Legal Advisor, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Peter A. Babigumira
- Peter A. Babigumira, BPharm, is Technical Advisor, Emergency Preparedness and Response, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Lydia Nakiire
- Lydia Nakiire, MPH, FETP, is an Epidemiologist, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Timothy Lubanga
- Timothy Lubanga is Commissioner, Monitoring and Evaluation Department, Office of the Prime Minister, Kampala, Uganda
| | - Enid Mbabazi
- Enid Mbabazi, MD, is a Medical Officer, Office of the Prime Minister, Kampala, Uganda
| | - Roland B. Taremwa
- Roland B. Taremwa is a Monitoring and Evaluation Specialist, Office of the Prime Minister, Kampala, Uganda
| | - Harriet Mayinja
- Harriet Mayinja is a Research Officer, Integrated Epidemiology, Surveillance and Public Health Emergencies Department, Ministry of Health, Kampala, Uganda
| | - Anne Nakinsige
- Anne Nakinsige, MD, is Principal Epidemiologist, Integrated Epidemiology, Surveillance and Public Health Emergencies Department, Ministry of Health, Kampala, Uganda
| | - Douglas K. Makanga
- Douglas K. Makanga, MD, is a Medical Officer, Integrated Epidemiology, Surveillance and Public Health Emergencies Department, Ministry of Health, Kampala, Uganda
| | - Allan Muruta
- Allan Muruta, MD, MPH, is Commissioner, Integrated Epidemiology, Surveillance and Public Health Emergencies Department, Ministry of Health, Kampala, Uganda
| | - Solome Okware
- Solome Okware, MD, MPH, is an Epidemiologist, World Health Emergencies Cluster, World Health Organization, Uganda Country Office, Kampala, Uganda
| | - Innocent Komakech
- Innocent Komakech, MD, MPH, is an Emergency Readiness Officer, World Health Emergencies Cluster, World Health Organization, Uganda Country Office, Kampala, Uganda
| | - Issa Makumbi
- Issa Makumbi, MD, MSc, is Director, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Milton M. Wetaka
- Milton M. Wetaka is a Laboratory and Logistics Specialist, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Joshua Kayiwa
- Joshua Kayiwa, MSc, is a Data Analyst, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Felix Ocom
- Felix Ocom, MD, is Deputy Manager, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Alex R. Ario
- Alex R. Ario, MD, PhD, is Managing Director, Uganda National Institute for Public Health, Ministry of Health, Kampala, Uganda
| | - Sandra Nabatanzi
- Sandra Nabatanzi, MSC, is an Emergency Management and Response Specialist and Outbreak Coordinator, Division of Global Health Protection, US Centers for Disease Control and Prevention Uganda Country Office, Kampala, Uganda
| | - Joseph Ojwang
- Joseph Ojwang, MD, MPH, is a Public Health Specialist, Division of Global Health Protection, US Centers for Disease Control and Prevention Uganda Country Office, Kampala, Uganda
| | - Amy Boore
- Amy Boore, MD, PhD, is Director, Division of Global Health Protection, US Centers for Disease Control and Prevention Uganda Country Office, Kampala, Uganda
| | - Rahel Yemanaberhan
- Rahel Yemanaberhan, MSc, is Regional Technical Advisor (East Africa), Resolve to Save Lives Ethiopia Country Office, Addis Ababa, Ethiopia
| | - Christopher T. Lee
- Christopher T. Lee, MD, MPH, is Director of Global Preparedness and Response, Resolve to Save Lives, New York, NY
| | - Ekwaro Obuku
- Ekwaro Obuku, MD, PhD, is Senior Technical Advisor, Data and Policy, Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Daniel Stowell
- Daniel Stowell, MPH, is a Global Health Security Specialist, US Centers for Disease Control and Prevention, Atlanta, GA
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20
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Sekaggya-Wiltshire C, Nabisere R, Musaazi J, Otaalo B, Aber F, Alinaitwe L, Nampala J, Najjemba L, Buzibye A, Omali D, Gausi K, Kengo A, Lamorde M, Aarnoutse R, Denti P, Dooley KE, Sloan DJ. Decreased Dolutegravir and Efavirenz Concentrations With Preserved Virological Suppression in Patients With Tuberculosis and Human Immunodeficiency Virus Receiving High-Dose Rifampicin. Clin Infect Dis 2023; 76:e910-e919. [PMID: 35861296 DOI: 10.1093/cid/ciac585] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/27/2022] [Accepted: 07/13/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Higher doses of rifampicin may improve treatment outcomes and reduce the duration of tuberculosis (TB) therapy. However, drug-drug interactions with antiretroviral therapy (ART) and safety in people with human immunodeficiency virus (HIV) have not been evaluated. METHODS This was a randomized, open-label trial where newly diagnosed TB patients were randomized to higher (35 mg/kg) or standard (10 mg/kg) daily-dose rifampicin. ART treatment-naive patients were randomized to dolutegravir- or efavirenz-based ART. At week 6, trough dolutegravir or mid-dose efavirenz plasma concentrations were assayed. HIV viral load was measured at week 24. RESULTS Among 128 patients randomized, the median CD4 count was 191 cells/mm3. The geometric mean ratio (GMR) for trough dolutegravir concentrations on higher- vs standard-dose rifampicin was 0.57 (95% confidence interval [CI], .34-.97; P = .039) and the GMR for mid-dose efavirenz was 0.63 (95% CI, .38-1.07; P = .083). There was no significant difference in attainment of targets for dolutegravir trough or efavirenz mid-dose concentrations between rifampicin doses. The incidence of HIV treatment failure at week 24 was similar between rifampicin doses (14.9% vs 14.0%, P = .901), as was the incidence of drug-related grade 3-4 adverse events (9.8% vs 6%). At week 8, fewer patients remained sputum culture positive on higher-dose rifampicin (18.6% vs 37.0%, P = .063). CONCLUSIONS Compared with standard-dose rifampicin, high-dose rifampicin reduced dolutegravir and efavirenz exposures, but HIV suppression was similar across treatment arms. Higher-dose rifampicin was well tolerated among people with HIV and associated with a trend toward faster sputum culture conversion. CLINICAL TRIALS REGISTRATION NCT03982277.
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Affiliation(s)
- Christine Sekaggya-Wiltshire
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | - Ruth Nabisere
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joseph Musaazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Brian Otaalo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Florence Aber
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lucy Alinaitwe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Juliet Nampala
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Letisha Najjemba
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Denis Omali
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kamunkhwala Gausi
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Allan Kengo
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rob Aarnoutse
- Department of Pharmacy and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegene, The Netherlands
| | - Paolo Denti
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Department of Medicine, Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Derek J Sloan
- Division of Infection and Global Health, School of Medicine, University of St. Andrews, St. Andrews, United Kingdom
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21
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Omali D, Buzibye A, Kwizera R, Byakika-Kibwika P, Namakula R, Matovu J, Mbabazi O, Mande E, Sekaggya-Wiltshire C, Nakanjako D, Gutteck U, McAdam K, Easterbrook P, Kambugu A, Fehr J, Castelnuovo B, Manabe YC, Lamorde M, Mueller D, Merry C. Building clinical pharmacology laboratory capacity in low- and middle-income countries: Experience from Uganda. Afr J Lab Med 2023; 12:1956. [PMID: 36873289 PMCID: PMC9982508 DOI: 10.4102/ajlm.v12i1.1956] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/30/2022] [Indexed: 02/05/2023] Open
Abstract
Background Research and clinical use of clinical pharmacology laboratories are limited in low- and middle-income countries. We describe our experience in building and sustaining laboratory capacity for clinical pharmacology at the Infectious Diseases Institute, Kampala, Uganda. Intervention Existing laboratory infrastructure was repurposed, and new equipment was acquired. Laboratory personnel were hired and trained to optimise, validate, and develop in-house methods for testing antiretroviral, anti-tuberculosis and other drugs, including 10 high-performance liquid chromatography methods and four mass spectrometry methods. We reviewed all research collaborations and projects for which samples were assayed in the laboratory from January 2006 to November 2020. We assessed laboratory staff mentorship from collaborative relationships and the contribution of research projects towards human resource development, assay development, and equipment and maintenance costs. We further assessed the quality of testing and use of the laboratory for research and clinical care. Lessons learnt Fourteen years post inception, the clinical pharmacology laboratory had contributed significantly to the overall research output at the institute by supporting 26 pharmacokinetic studies. The laboratory has actively participated in an international external quality assurance programme for the last four years. For clinical care, a therapeutic drug monitoring service is accessible to patients living with HIV at the Adult Infectious Diseases clinic in Kampala, Uganda. Recommendations Driven primarily by research projects, clinical pharmacology laboratory capacity was successfully established in Uganda, resulting in sustained research output and clinical support. Strategies implemented in building capacity for this laboratory may guide similar processes in other low- and middle-income countries.
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Affiliation(s)
- Denis Omali
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Allan Buzibye
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Kwizera
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda Namakula
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joshua Matovu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Olive Mbabazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Emmanuel Mande
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Damalie Nakanjako
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ursula Gutteck
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Keith McAdam
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Philippa Easterbrook
- Department of Human Immunodeficiency Virus, World Health Organization, Geneva, Switzerland
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jan Fehr
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Mueller
- Department of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Concepta Merry
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
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22
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Tusabe F, Lamorde M, Medley A, Kesande M, Lozier MJ, Yapswale S, Ociti F, Isabirye H, Nuwamanya E, Nanyondo J, Boore A, Vosburgh W, Kasule JN, Pratt C, Berendes D. Establishment of District-Led Production of WHO-Recommended Alcohol-based Hand Rub (ABHR) during the COVID-19 Pandemic: A Model for Improving Access to ABHR during Health Emergencies. J Water Sanit Hyg Dev 2023; 13:847-856. [PMID: 38410156 PMCID: PMC10896262 DOI: 10.2166/washdev.2023.143] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
In response to the COVID-19 pandemic, we established and sustained local production of alcohol-based handrub (ABHR) at district scale for healthcare facilities and community, public locations in four districts in Uganda. District officials provided space and staff for production units. The project renovated space for production, trained staff on ABHR production, and transported ABHR to key locations. The production officer conducted internal ABHR quality assessments while trained district health inspectors conducted external quality assessments prior to distribution. Information, education, and communication materials accompanied ABHR distribution. Onsite ABHR consumption was monitored by site staff using stock cards. On average, it took 11 days (range: 8-14) and 5,760 USD (range: 4,400-7,710) to set up a production unit. From March-December 2021, 21,600L of quality-controlled ABHR were produced for 111 healthcare facilities and community locations at an average cost of 4.30 USD/L (range: 3.50-5.76). All ABHR passed both internal and external quality control (average ethanol concentration of 80%, range: 78-81%). This case study demonstrated that establishing centralized, local production of quality-controlled, affordable ABHR at a district-wide scale is feasible and strengthens the ability of healthcare workers and community locations to access and use ABHR during infectious disease outbreaks in low-resource countries.
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Affiliation(s)
- Fred Tusabe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Alexandra Medley
- Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd. Mailstop H24-11, Atlanta, GA, USA, 30329
| | - Maureen Kesande
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Matthew J. Lozier
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd. Mailstop H24-11, Atlanta, GA, USA, 30329
| | - Sauda Yapswale
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Francis Ociti
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Herbert Isabirye
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Elly Nuwamanya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Judith Nanyondo
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Amy Boore
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention (CDC), Country Office Kampala, Uganda
| | - Waverly Vosburgh
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention (CDC), Country Office Kampala, Uganda
| | - Juliet N. Kasule
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention (CDC), Country Office Kampala, Uganda
| | - Caroline Pratt
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd. Mailstop H24-11, Atlanta, GA, USA, 30329
| | - David Berendes
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd. Mailstop H24-11, Atlanta, GA, USA, 30329
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Blair PW, Mehta R, Som T, Okello S, Tsalik EL, Wailagala A, Woods CW, Prouty M, Chenoweth J, Letizia A, Faix D, Adams N, Ko ER, Duplessis C, Lamorde M, Owusu-Ofori A, Naluyima P, Kayiira M, Oppong C, Rozo M, Fox A, Lawler J, Waitt P, Prouty A, Vantha T, Beckett C, Kibuuka H, Oduro G, Schully K, Clark D, Clark D, Clark D. 1169. Derivation And Validation of an International Clinical Prognostication Model for 28-day Sepsis Mortality. Open Forum Infect Dis 2022. [PMCID: PMC9752634 DOI: 10.1093/ofid/ofac492.1006] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Survival prediction models have largely been derived and validated only in high-resource Western countries or in single center studies. We sought to create a prediction model for 28-day mortality using laboratory and physiologic parameters from 3 international sepsis cohorts and externally validated the model. Methods During 2014 to 2021, adult hospitalized patients with suspected infection were enrolled in Durham, United States (N=180) and those with suspected infection and ≥2 SIRS (Systemic Inflammatory Response Syndrome) criteria in Takeo, Cambodia (N=200), and Kumasi, Ghana (N=187). Twenty-five clinical laboratory and physiologic parameters were candidate covariates and sepsis screening scores included as comparators. First, bivariate Cox regression models were performed to determine risk of individual parameters. Then, a 10-fold cross-validated forward stepwise model selection technique was used to eliminate nonsignificant variables using a p-value < 0.10 and the cross-validated C-statistic was estimated. Lastly, this model was applied to an external cohort of hospitalized adults with suspected infection and ≥2 SIRS in Fort Portal, Uganda (N=331 with 9.3% 28-day mortality). Results Among 567 participants, overall mortality was 16.4% at 28-days. Mortality rate highest in Ghana (31.0%), followed by Cambodia (11.0%) and the United States (7.2%). Bivariate analyses identified hypernatremia ( >145 mEq/L) being associated with the highest risk of death (hazard ratio: 7.42; 95% CI: 3.65 to 15.10; Figure 1). On multivariable analysis, a 28-day mortality model including mean arterial pressure, Glasgow Coma score, blood sodium, lactate, and blood urea nitrogen (Table 1) resulted in a 10-fold cross-validated C-statistic of 0.80 (95% CI: 0.61 to 0.88). This model predicted mortality accurately in the validation cohort with a C-statistic of 0.74 (95%CI: 0.69 to 0.79).
![]() Forest plot for bivariate analyses for one month survival across United States, Cambodia, and Ghana cohorts. ![]() Conclusion Hypotension, altered mental status, serum sodium, serum BUN, and plasma lactate accurately identified risk of death by 28-days among those with suspected sepsis in 3 international derivation cohorts and in a validation cohort in Uganda. Our findings emphasize the importance of clinical laboratory results for sepsis risk stratification. Disclosures Ephraim L. Tsalik, MD PhD, Danaher Diagnostics, Predigen, and Biomeme: In the past 3 years, I have had held equity and consulted for Predigen and Biomeme. Currently, I am an employee of Danaher Diagnostics. Christopher W. Woods, MD MPH, Predigen, Inc: Co-founder.
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Affiliation(s)
- Paul W Blair
- Austere environments Consortium for Enhanced Sepsis Outcomes (ACESO), Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | | | - Tin Som
- Takeo Provincial Referral Hospital, Takeo, Takeo, Cambodia
| | - Stephen Okello
- Makerere University Walter Reed Project, Kampala, Kampala, Uganda
| | - Ephraim L Tsalik
- Duke University Division of Infectious Diseases, Duke University School of Medicine, Durham, Durham, North Carolina
| | | | | | - Michael Prouty
- Naval Medical Research Unit-2, Phnom Penh, Phnom Penh, Cambodia
| | | | - Andrew Letizia
- Naval Medical Research Unit-3 Ghana Detachment, Accra, Greater Accra, Ghana
| | - Dennis Faix
- Naval Medical Research Unit-2, Phnom Penh, Phnom Penh, Cambodia
| | - Nehkonti Adams
- Naval Medical Research Center Infectious Diseases Directorate, Bethesda, Maryland
| | - Emily R Ko
- Duke University School of Medicine, Durham, Durham, NC
| | - Chris Duplessis
- Naval Medical Research Center Infectious Diseases Directorate, Bethesda, Maryland
| | | | | | - Prossy Naluyima
- Makerere University Walter Reed Project, Kampala, Kampala, Uganda
| | - Mubaraka Kayiira
- Infectious Diseases Institute, Kampala, Kampala, Kampala, Uganda
| | - Chris Oppong
- Komfo Anokye Teaching Hospital, bethesda, Maryland
| | - Michelle Rozo
- Austere environments Consortium for Enhanced Sepsis Outcomes (ACESO), Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Ann Fox
- Naval Medical Research Unit-3 Ghana Detachment, Accra, Greater Accra, Ghana
| | - James Lawler
- Global Center for Health Security at Nebraska and Division of Infectious Disease, Department of Internal Medicine, Omaha, Nebraska
| | - Peter Waitt
- Infectious Diseases Institute, Kampala, Kampala, Uganda
| | - Angela Prouty
- Naval Medical Research Unit-2, Phnom Penh, Phnom Penh, Cambodia
| | - Te Vantha
- Takeo Provincial Referral Hospital, Takeo, Takeo, Cambodia
| | - Charmagne Beckett
- Naval Medical Research Center Infectious Diseases Directorate, Bethesda, Maryland
| | - Hannah Kibuuka
- Makerere University Walter Reed Project, Kampala, Kampala, Uganda
| | - George Oduro
- Komfo Anokye Teaching Hospital, bethesda, Maryland
| | - Kevin Schully
- Naval Medical Research Center Infectious Diseases Directorate, Bethesda, Maryland
| | - Danielle Clark
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, Bethesda, Maryland
| | - Danielle Clark
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, Bethesda, Maryland
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Mbabazi L, Nabaggala MS, Kiwanuka S, Kiguli J, Laker E, Kiconco A, Okoboi S, Lamorde M, Castelnuovo B. Factors associated with uptake of contraceptives among HIV positive women on dolutegravir based anti-retroviral treatment-a cross sectional survey in urban Uganda. BMC Womens Health 2022; 22:262. [PMID: 35761248 PMCID: PMC9238171 DOI: 10.1186/s12905-022-01842-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In May 2018, following the preliminary results of a study in Botswana that reported congenital anomalies in babies born to HIV-positive women taking dolutegravir drug, the WHO issued a teratogenicity alert. However, there are scarce data on the impact of this guidance on contraceptive uptake among women taking dolutegravir. We assessed the uptake of contraceptives in HIV-positive women of reproductive age on dolutegravir regimens.
Methods
We conducted a cross-sectional survey from April 2019 to July 2019 in five government health facilities in central Uganda, where dolutegravir-based regimens were offered as the preferred first-line antiretroviral treatment. We randomly selected 359 non-pregnant women aged 15–49 years taking dolutegravir-based regimens and interviewed them using semi-structured interviewer-administered questionnaires. We collected data on demographics, contraceptive use, individual, social, and health system factors. We described patients’ characteristics using descriptive statistics and assessed factors associated with contraceptive uptake using a modified Poisson regression model.
Results
A total of 359 women were included in the study. The mean age was 37 years (standard deviation = 6.8) and overall contraceptive uptake was 38.4%. The most utilized method was injectable method at 58.4% followed by condoms (15%), intrauterine device (10.7%), pills (6.4%), implants (5.4%), and sterilization (0.7%). Predictors for contraceptive uptake were parity of 3–4 children (Adjusted Prevalence Ratio (APR) = 1.48, 95% confidence interval (CI): 1.14, 1.92) in reference to those with 1–2 children. There was reduced contraceptive uptake in women of the age range 40–49 years (APR = 0.45, CI: 0.21–0.94) compared to those aged 15–24 years. Unemployed women were less likely to use contraceptives (APR: 0.6, CI: 0.42- 0.94) than the formally employed. Contraceptive uptake was lower among women who did not discuss family planning with their partners (APR = 0.39, CI: 0.29–0.52) than those who discussed family planning with their partners and women who did not receive family planning counseling (APR = 0.56, CI: 0.34–0.92) than those who received family planning counselling.
Conclusion
We observed a low-level uptake of contraceptives, with injectables as the most used method. Family planning counseling and partner discussion on family planning were associated with contraceptive uptake among the women who used dolutegravir-based regimens. There is a need for more strategies to integrate FP services and increase male involvement in HIV care programs.
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25
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Gomes DJ, Hazim C, Safstrom J, Herzig C, Luvsansharav U, Dennison C, Ahmed Y, Wesangula E, Hokororo J, Amone J, Tekle B, Owiso G, Mutayoba R, Lamorde M, Akello E, Kassa G, Feleke B, Ndegwa L, Kazaura K, Musisi D, Date A, Park BJ, Bancroft E. Infection Prevention and Control Initiatives to Prevent Healthcare-Associated Transmission of SARS-CoV-2, East Africa. Emerg Infect Dis 2022; 28:S255-S261. [PMID: 36502401 DOI: 10.3201/eid2813.212352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The coronavirus disease pandemic has highlighted the need to establish and maintain strong infection prevention and control (IPC) practices, not only to prevent healthcare-associated transmission of SARS-CoV-2 to healthcare workers and patients but also to prevent disruptions of essential healthcare services. In East Africa, where basic IPC capacity in healthcare facilities is limited, the US Centers for Disease Control and Prevention (CDC) supported rapid IPC capacity building in healthcare facilities in 4 target countries: Tanzania, Ethiopia, Kenya, and Uganda. CDC supported IPC capacity-building initiatives at the healthcare facility and national levels according to each country's specific needs, priorities, available resources, and existing IPC capacity and systems. In addition, CDC established a multicountry learning network to strengthen hospital level IPC, with an emphasis on peer-to-peer learning. We present an overview of the key strategies used to strengthen IPC in these countries and lessons learned from implementation.
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Blair PW, Kobba K, Kakooza F, Robinson ML, Candia E, Mayito J, Ndawula EC, Kandathil AJ, Matovu A, Aniku G, Manabe YC, Lamorde M. Aetiology of hospitalized fever and risk of death at Arua and Mubende tertiary care hospitals in Uganda from August 2019 to August 2020. BMC Infect Dis 2022; 22:869. [PMID: 36411415 PMCID: PMC9680122 DOI: 10.1186/s12879-022-07877-3] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Epidemiology of febrile illness in Uganda is shifting due to increased HIV treatment access, emerging viruses, and increased surveillance. We investigated the aetiology and outcomes of acute febrile illness in adults presenting to hospital using a standardized testing algorithm of available assays in at Arua and Mubende tertiary care hospitals in Uganda. METHODS We recruited adults with a ≥ 38.0 °C temperature or history of fever within 48 h of presentation from August 2019 to August 2020. Medical history, demographics, and vital signs were recorded. Testing performed included a complete blood count, renal and liver function, malaria smears, blood culture, and human immunodeficiency virus (HIV). When HIV positive, testing included cryptococcal antigen, CD4 count, and urine lateral flow lipoarabinomannan assay for tuberculosis. Participants were followed during hospitalization and at a 1-month visit. A Cox proportional hazard regression was performed to evaluate for baseline clinical features and risk of death. RESULTS Of 132 participants, the median age was 33.5 years (IQR 24 to 46) and 58.3% (n = 77) were female. Overall, 73 (55.3%) of 132 had a positive microbiologic result. Among those living with HIV, 31 (68.9%) of 45 had at least one positive assay; 16 (35.6%) had malaria, 14 (31.1%) tuberculosis, and 4 (8.9%) cryptococcal antigenemia. The majority (65.9%) were HIV-negative; 42 (48.3%) of 87 had at least one diagnostic assay positive; 24 (27.6%) had positive malaria smears and 1 was Xpert MTB/RIF Ultra positive. Overall, 16 (12.1%) of 132 died; 9 (56.3%) of 16 were HIV-negative, 6 died after discharge. High respiratory rate (≥ 22 breaths per minute) (hazard ratio [HR] 8.05; 95% CI 1.81 to 35.69) and low (i.e., < 92%) oxygen saturation (HR 4.33; 95% CI 1.38 to 13.61) were identified to be associated with increased risk of death. CONCLUSION In those with hospitalized fever, malaria and tuberculosis were common causes of febrile illness, but most deaths were non-malarial, and most HIV-negative participants did not have a positive diagnostic result. Those with respiratory failure had a high risk of death.
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Affiliation(s)
- Paul W. Blair
- grid.21107.350000 0001 2171 9311John Hopkins University School of Medicine Division of Infectious Diseases, Baltimore, MD USA ,grid.201075.10000 0004 0614 9826Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., Bethesda, MD USA
| | - Kenneth Kobba
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Francis Kakooza
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Matthew L. Robinson
- grid.21107.350000 0001 2171 9311John Hopkins University School of Medicine Division of Infectious Diseases, Baltimore, MD USA
| | - Emmanuel Candia
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jonathan Mayito
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edgar C. Ndawula
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abraham J. Kandathil
- grid.21107.350000 0001 2171 9311John Hopkins University School of Medicine Division of Infectious Diseases, Baltimore, MD USA
| | - Alphonsus Matovu
- grid.461234.60000 0004 1779 8469Mubende Regional Referral Hospital, Mubende, Uganda
| | - Gilbert Aniku
- grid.461304.40000 0004 0532 790XArua Regional Referral Hospital, Arua, Uganda
| | - Yukari C. Manabe
- grid.21107.350000 0001 2171 9311John Hopkins University School of Medicine Division of Infectious Diseases, Baltimore, MD USA
| | - Mohammed Lamorde
- grid.11194.3c0000 0004 0620 0548Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Asiimwe IG, Blockman M, Cohen K, Cupido C, Hutchinson C, Jacobson B, Lamorde M, Morgan J, Mouton JP, Nakagaayi D, Okello E, Schapkaitz E, Sekaggya-Wiltshire C, Semakula JR, Waitt C, Zhang EJ, Jorgensen AL, Pirmohamed M. A genome-wide association study of plasma concentrations of warfarin enantiomers and metabolites in sub-Saharan black-African patients. Front Pharmacol 2022; 13:967082. [PMID: 36210801 PMCID: PMC9537548 DOI: 10.3389/fphar.2022.967082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/12/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022] Open
Abstract
Diversity in pharmacogenomic studies is poor, especially in relation to the inclusion of black African patients. Lack of funding and difficulties in recruitment, together with the requirement for large sample sizes because of the extensive genetic diversity in Africa, are amongst the factors which have hampered pharmacogenomic studies in Africa. Warfarin is widely used in sub-Saharan Africa, but as in other populations, dosing is highly variable due to genetic and non-genetic factors. In order to identify genetic factors determining warfarin response variability, we have conducted a genome-wide association study (GWAS) of plasma concentrations of warfarin enantiomers/metabolites in sub-Saharan black-Africans. This overcomes the issue of non-adherence and may have greater sensitivity at genome-wide level, to identify pharmacokinetic gene variants than focusing on mean weekly dose, the usual end-point used in previous studies. Participants recruited at 12 outpatient sites in Uganda and South Africa on stable warfarin dose were genotyped using the Illumina Infinium H3Africa Consortium Array v2. Imputation was conducted using the 1,000 Genomes Project phase III reference panel. Warfarin/metabolite plasma concentrations were determined by high-performance liquid chromatography with tandem mass spectrometry. Multivariable linear regression was undertaken, with adjustment made for five non-genetic covariates and ten principal components of genetic ancestry. After quality control procedures, 548 participants and 17,268,054 SNPs were retained. CYP2C9*8, CYP2C9*9, CYP2C9*11, and the CYP2C cluster SNP rs12777823 passed the Bonferroni-adjusted replication significance threshold (p < 3.21E-04) for warfarin/metabolite ratios. In an exploratory GWAS analysis, 373 unique SNPs in 13 genes, including CYP2C9*8, passed the Bonferroni-adjusted genome-wide significance threshold (p < 3.846E-9), with 325 (87%, all located on chromosome 10) SNPs being associated with the S-warfarin/R-warfarin outcome (top SNP rs11188082, CYP2C19 intron variant, p = 1.55E-17). Approximately 69% of these SNPs were in linkage disequilibrium (r2 > 0.8) with CYP2C9*8 (n = 216) and rs12777823 (n = 8). Using a pharmacokinetic approach, we have shown that variants other than CYP2C9*2 and CYP2C9*3 are more important in sub-Saharan black-Africans, mainly due to the allele frequencies. In exploratory work, we conducted the first warfarin pharmacokinetics-related GWAS in sub-Saharan Africans and identified novel SNPs that will require external replication and functional characterization before they can be considered for inclusion in warfarin dosing algorithms.
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Affiliation(s)
- Innocent G. Asiimwe
- The Wolfson Centre for Personalized Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- *Correspondence: Innocent G. Asiimwe, ; Munir Pirmohamed,
| | - Marc Blockman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Clint Cupido
- Victoria Hospital Internal Medicine Research Initiative, Victoria Hospital Wynberg and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Claire Hutchinson
- The Wolfson Centre for Personalized Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Barry Jacobson
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jennie Morgan
- Metro District Health Services, Western Cape Department of Health, Cape Town, South Africa
| | - Johannes P. Mouton
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Elise Schapkaitz
- Department of Molecular Medicine and Hematology, Charlotte Maxeke Johannesburg Academic Hospital National Health Laboratory System Complex and University of Witwatersrand, Johannesburg, South Africa
| | | | - Jerome R. Semakula
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Catriona Waitt
- The Wolfson Centre for Personalized Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Eunice J. Zhang
- The Wolfson Centre for Personalized Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Andrea L. Jorgensen
- Department of Health Data Science, Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- *Correspondence: Innocent G. Asiimwe, ; Munir Pirmohamed,
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28
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Nakalema S, Chappell CA, Pham M, Byakika-Kibwika P, Kaboggoza J, Walimbwa SI, Musaazi J, Nakijoba R, Mbabazi L, Kyohairwe I, Nassiwa S, Jeppson J, Winchester L, Siccardi M, Fletcher CV, Scarsi KK, Lamorde M. Pharmacokinetics of levonorgestrel and etonogestrel contraceptive implants over 48 weeks with rilpivirine- or darunavir-based antiretroviral therapy. J Antimicrob Chemother 2022; 77:3144-3152. [PMID: 36059130 DOI: 10.1093/jac/dkac296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/04/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pharmacokinetic data are lacking for progestin-releasing subdermal contraceptive implants when used with either rilpivirine- or darunavir/ritonavir-based ART. OBJECTIVES To characterize the pharmacokinetics of etonogestrel or levonorgestrel implants when administered with these ART regimens over 48 weeks. PATIENTS AND METHODS Two separate, parallel, three-group, non-randomized, pharmacokinetic studies evaluated either etonogestrel or levonorgestrel in women receiving rilpivirine- or darunavir-based ART compared with women without HIV (control group). Participants on ART were switched to rilpivirine-based ART with a run-in period of 6 weeks or darunavir-based ART with a run-in of 2 weeks prior to implant insertion. Plasma was collected on Day 0, and 1, 4, 12, 24, 36 and 48 weeks post-insertion. Plasma progestin concentrations were compared between ART and control groups by geometric mean ratio (GMR) and 90% CI. RESULTS At the primary endpoint of Week 24, progestin concentrations were similar between the rilpivirine and control groups [etonogestrel: 1.18 (0.99-1.37); levonorgestrel: 1.16 (0.97-1.33)]. At Week 24, progestin exposure was higher in the darunavir groups compared with the control group [etonogestrel: 2.56 (1.69-3.28); levonorgestrel: 1.89 (1.38-2.29)]. Results remained consistent through to Week 48. No differences in etonogestrel-related adverse events were observed, but both ART groups experienced more menstrual abnormalities versus the control group with levonorgestrel. CONCLUSIONS Etonogestrel and levonorgestrel concentrations were not altered by rilpivirine-based ART. Although progestin concentrations were higher in the ART groups containing ritonavir-boosted darunavir, no implant-related serious adverse events were observed. Both progestin-releasing implants are an appropriate contraceptive option with either rilpivirine- or darunavir/ritonavir-based ART.
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Affiliation(s)
- Shadia Nakalema
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michelle Pham
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Julian Kaboggoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joseph Musaazi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ritah Nakijoba
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Leah Mbabazi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Sylvia Nassiwa
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jeffrey Jeppson
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Lee Winchester
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marco Siccardi
- Department of Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Manabe YC, Betz J, Jackson O, Asoala V, Bazan I, Blair PW, Chang A, Chusri S, Crump JA, Edgel KA, Faix DJ, Fernandez S, Fox AT, Garcia JA, Grogl M, Hansen EA, Heang V, House SL, Jongsakul K, Kaburise MB, Klungthong C, Lamorde M, Letizia AG, Lorenzana I, Luy M, Maro VP, Mores CN, Myers CA, Oduro AR, Parham L, Porzucek AJ, Prouty M, Rabiger DS, Rubach MP, Siles C, Silva M, Ukachu C, Waitumbi JN, Phillips CL, Jones BW. Clinical evaluation of the BioFire Global Fever Panel for the identification of malaria, leptospirosis, chikungunya, and dengue from whole blood: a prospective, multicentre, cross-sectional diagnostic accuracy study. Lancet Infect Dis 2022; 22:1356-1364. [PMID: 35716700 PMCID: PMC9420791 DOI: 10.1016/s1473-3099(22)00290-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/27/2022] [Accepted: 04/12/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute febrile illness is a common presentation for patients at hospitals globally. Assays that can diagnose a variety of common pathogens in blood could help to establish a diagnosis for targeted disease management. We aimed to evaluate the performance of the BioFire Global Fever Panel (GF Panel), a multiplex nucleic acid amplification test performed on whole blood specimens run on the BioFire FilmArray System, in the diagnosis of several pathogens that cause acute febrile illness. METHODS We did a prospective, multicentre, cross-sectional diagnostic accuracy study to evaluate the GF Panel. Consenting adults and children older than 6 months presenting with fever in the previous 2 days were enrolled consecutively in sub-Saharan Africa (Ghana, Kenya, Tanzania, Uganda), southeast Asia (Cambodia, Thailand), central and South America (Honduras, Peru), and the USA (Washington, DC; St Louis, MO). We assessed the performance of six analytes (chikungunya virus, dengue virus [serotypes 1-4], Leptospira spp, Plasmodium spp, Plasmodium falciparum, and Plasmodium vivax or Plasmodium ovale) on the GF Panel. The performance of the GF Panel was assessed using comparator PCR assays with different primers followed by bidirectional sequencing on nucleic acid extracts from the same specimen. We calculated the positive percent agreement and negative percent agreement of the GF Panel with respect to the comparator assays. This study is registered with ClinicalTrials.gov, NCT02968355. FINDINGS From March 26, 2018, to Sept 30, 2019, 1965 participants were enrolled at ten sites worldwide. Of the 1875 participants with analysable results, 980 (52·3%) were female and the median age was 22 years (range 0-100). At least one analyte was detected in 657 (35·0%) of 1875 specimens. The GF Panel had a positive percent agreement for the six analytes evaluated as follows: chikungunya virus 100% (95% CI 86·3-100), dengue virus 94·0% (90·6-96·5), Leptospira spp 93·8% (69·8-99·8), Plasmodium spp 98·3% (96·3-99·4), P falciparum 92·7% (88·8-95·6), and P vivax or P ovale 92·7% (86·7-96·6). The GF Panel had a negative percent agreement equal to or greater than 99·2% (98·6-99·6) for all analytes. INTERPRETATION This 1 h sample-to-answer, molecular device can detect common causative agents of acute febrile illness with excellent positive percent agreement and negative percent agreement directly in whole blood. The targets of the assay are prevalent in tropical and subtropical regions globally, and the assay could help to provide both public health surveillance and individual diagnoses. FUNDING BioFire Defense, Joint Project Manager for Medical Countermeasure Systems and US Army Medical Materiel Development Activity, and National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Joshua Betz
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Victor Asoala
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Isabel Bazan
- Virology and Emerging Infections Department, US Naval Medical Research Unit Six, Lima, Peru
| | - Paul W Blair
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aileen Chang
- Department of Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Sarunyou Chusri
- Faculty of Medicine, Prince of Songkhla University, Songkhla, Thailand
| | - John A Crump
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University, Durham, NC, USA; Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | - Dennis J Faix
- US Naval Medical Research Unit Two, Phnom Penh, Cambodia
| | - Stefan Fernandez
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Anne T Fox
- US Naval Medical Research Unit Three, Ghana Detachment, Accra, Ghana
| | - Jose A Garcia
- US Naval Medical Research Unit Two, Phnom Penh, Cambodia
| | - Max Grogl
- Virology and Emerging Infections Department, US Naval Medical Research Unit Six, Lima, Peru
| | - Erin A Hansen
- Operational Infectious Diseases, Naval Health Research Center, San Diego, CA, USA
| | - Vireak Heang
- US Naval Medical Research Unit Two, Phnom Penh, Cambodia
| | - Stacey L House
- Washington University School of Medicine, Department of Emergency Medicine, St Louis, MO, USA
| | - Krisada Jongsakul
- Department of Bacterial and Parasitic Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Chonticha Klungthong
- Department of Virology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew G Letizia
- US Naval Medical Research Unit Three, Ghana Detachment, Accra, Ghana
| | - Ivette Lorenzana
- Universidad Nacional Autónoma de Honduras, Centro de Investigaciones Geneticas, Instituto de Investigacion en Microdbiologia, Tegucigalpa, Honduras
| | - Malen Luy
- US Naval Medical Research Unit Two, Phnom Penh, Cambodia
| | - Vanance P Maro
- Department of Medicine, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Christopher N Mores
- Virology and Emerging Infections Department, US Naval Medical Research Unit Six, Lima, Peru; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Christopher A Myers
- Operational Infectious Diseases, Naval Health Research Center, San Diego, CA, USA
| | - Abraham R Oduro
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Leda Parham
- Universidad Nacional Autónoma de Honduras, Centro de Investigaciones Geneticas, Instituto de Investigacion en Microdbiologia, Tegucigalpa, Honduras
| | - Abigail J Porzucek
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Michael Prouty
- Virology and Emerging Infections Department, US Naval Medical Research Unit Six, Lima, Peru
| | | | - Matthew P Rubach
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University, Durham, NC, USA
| | - Crystyan Siles
- Virology and Emerging Infections Department, US Naval Medical Research Unit Six, Lima, Peru
| | - Maria Silva
- Virology and Emerging Infections Department, US Naval Medical Research Unit Six, Lima, Peru
| | - Chinaka Ukachu
- Operational Infectious Diseases, Naval Health Research Center, San Diego, CA, USA
| | - John N Waitumbi
- US Army Medical Research Directorate-Africa, Kenya Medical Research Institute, Nairobi, Kenya
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Lamorde M, Ayebare R, Bulwadda D, Nanyondo J, Nakiire L, Walwema R, Otita M, Mukiibi P, Nabukenya I, Kakooza F, Kambugu A. Support for the response to COVID-19 in Uganda: contribution of the global health security program at Makerere University's Infectious Diseases Institute. Afr Health Sci 2022; 22:80-84. [PMID: 36321120 PMCID: PMC9590337 DOI: 10.4314/ahs.v22i2.13s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Outbreaks are occurring at increasing frequency and they require multisectoral and multi-stakeholder involvement for optimal response. The Global Health Security Agenda is a framework that governments and other stakeholders can use to strengthen countries' capacities to prevent, detect and respond to outbreaks but there are few examples of academic programs using this approach. Methods This is a narrative review of contributions of Makerere University through the Global Health Security Program at the Infectious Diseases Institute (IDI). Information was sourced from peer-reviewed publications and grey literature highlighting work done between 2017 – 2021. Results Aligned to GHSA, IDI made contributions to strengthen national and subnational capacities for biosafety and biosecurity, sample collection and transportation, electronic disease surveillance, infection prevention and control, case management prior to COVID-19 that were subsequently used to support response efforts for COVID-19 in Uganda. Conclusion The IDI Global Health Security program provides a model that can be used by institutions to deliberately develop capacities relevant to outbreak preparedness and response.
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Malaba TR, Nakatudde I, Kintu K, Colbers A, Chen T, Reynolds H, Read L, Read J, Stemmet LA, Mrubata M, Byrne K, Seden K, Twimukye A, Theunissen H, Hodel EM, Chiong J, Hu NC, Burger D, Wang D, Byamugisha J, Alhassan Y, Bokako S, Waitt C, Taegtmeyer M, Orrell C, Lamorde M, Myer L, Khoo S. 72 weeks post-partum follow-up of dolutegravir versus efavirenz initiated in late pregnancy (DolPHIN-2): an open-label, randomised controlled study. Lancet HIV 2022; 9:e534-e543. [PMID: 35905752 DOI: 10.1016/s2352-3018(22)00173-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/12/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Late initiation of antiretrovirals in pregnancy is associated with increased risk of perinatal transmission and higher infant mortality. We report the final 72-week postpartum results for efficacy and safety of dolutegravir-based compared with efavirenz-based regimens in mothers and infants. METHODS DolPHIN-2 was a randomised, open-label trial. Pregnant women in South Africa and Uganda aged at least 18 years, with untreated but confirmed HIV infection and an estimated gestation of at least 28 weeks, initiating antiretroviral therapy in third trimester were eligible for inclusion. Eligible women were randomly assigned (1:1) to receive either dolutegravir-based (50 mg dolutegravir, 300 mg tenofovir disoproxil fumarate, and either 200 mg emtricitabine in South Africa or 300 mg lamivudine in Uganda) or efavirenz-based (fixed dose combination 600 mg tenofovir disoproxil fumarate plus either emtricitabine in South Africa or lamivudine in Uganda) therapy. The primary efficacy outcome was the time to a viral load of less than 50 copies per mL measured at 6, 12, 24, 48, and 72 weeks postpartum with a Cox model adjusting for viral load and CD4 cell count. Safety endpoints were summarised by the number of women and infants with events. This trial is registered with ClinicalTrials.gov, NCT03249181. FINDINGS Between Jan 23 and Aug 15, 2018, 280 women were screened for inclusion, of whom 268 (96%) women were randomly assigned: 133 (50%) to the efavirenz group and 135 (50%) to the dolutegravir group. 250 (93%; 125 [50%] in the efavirenz group and 125 [50%] in the dolutegravir group) women were included in the intention-to-treat analysis of efficacy. Median time to viral load of less than 50 copies per mL was 4·1 weeks (IQR 4·0-5·1) in the dolutegravir group compared with 12·1 weeks (10·7-13·3) in the efavirenz group (adjusted hazard ratio [HR] 1·93 [95% CI 1·5-2·5]). At 72 weeks postpartum, 116 (93%) mothers in the dolutegravir group and 114 (91%) in the efavirenz group had a viral load of less than 50 copies per mL. Of 57 (21%) mothers with a severe adverse event, three (2%) in the dolutegravir group and five (4%) in the efavirenz group were related to the drug (dolutegravir drug-related events were one woman each with suicidal ideation, suicide attempt, herpes zoster meningitis; efavirenz drug-related events were one woman each with suicide attempt and liver cirrhosis, and three people with drug-induced liver injury). Of 136 (56%) infants in whom severe adverse events were recorded, none were related to the study drugs. In addition to the three infant HIV infections detected at birth in the dolutegravir group that have been previously reported, an additional transmission in the efavirenz group occurred during breastfeeding despite optimal maternal viral suppression and serial negative infant tests in the first year of life. INTERPRETATION Dolutegravir was safe and well tolerated, supporting updated WHO treatment recommendations in pregnant and breastfeeding women. Infant HIV transmissions can occur during breastfeeding despite persistently undetectable maternal viral load highlighting the need for continued infant testing. FUNDING Unitaid.
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Affiliation(s)
- Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Irene Nakatudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kenneth Kintu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tao Chen
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Reynolds
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Lucy Read
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jim Read
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Lee-Ann Stemmet
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly Byrne
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kay Seden
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Helene Theunissen
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Eva Maria Hodel
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Justin Chiong
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Nai-Chung Hu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - David Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Duolao Wang
- Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Josaphat Byamugisha
- Department of Gynaecology and Obstetrics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sharon Bokako
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK; Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Catherine Orrell
- Desmond Tutu Health Foundation, Department of Medicine, Institute of Infectious Diseases & Molecular Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Centre for Infectious Diseases Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Saye Khoo
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK; Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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Alhassan Y, Twimukye A, Malaba T, Myer L, Waitt C, Lamorde M, Colbers A, Reynolds H, Khoo S, Taegtmeyer M. 'I fear my partner will abandon me': the intersection of late initiation of antenatal care in pregnancy and poor ART adherence among women living with HIV in South Africa and Uganda. BMC Pregnancy Childbirth 2022; 22:566. [PMID: 35840939 PMCID: PMC9284724 DOI: 10.1186/s12884-022-04896-5] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/29/2022] [Indexed: 11/29/2022] Open
Abstract
Background Many women in sub-Saharan Africa initiate antenatal care (ANC) late in pregnancy, undermining optimal prevention of mother-to-child-transmission (PMTCT) of HIV. Questions remain about whether and how late initiation of ANC in pregnancy is related to adherence to antiretroviral therapy (ART) in the era of national dolutegravir roll-out. Methods This study employed a qualitative design involving individual interviews and focus group discussions conducted between August 2018 and March 2019. We interviewed 37 pregnant and lactating women living with HIV selected purposively for early or late presentation to ANC from poor urban communities in South Africa and Uganda. Additionally, we carried out seven focused group discussions involving 67 participants in both countries. Data were analysed thematically in NVivo12. Results Women described common underlying factors influencing both late ANC initiation and poor ART adherence in South Africa and Uganda. These included poverty and time constraints; inadequate health knowledge; perceived low health risk; stigma of HIV in pregnancy; lack of disclosure; and negative provider attitudes. Most late ANC presenters reported relationship problems, lack of autonomy and the limited ability to dialogue with their partners to influence household decisions on health and resource allocation. Perception of poor privacy and confidentiality in maternity clinics was rife among women in both study settings and compounded risks associated with early disclosure of pregnancy and HIV. Women who initiated ANC late and were then diagnosed with HIV appeared to be more susceptible to poor ART adherence. They were often reprimanded by health workers for presenting late which hampered their participation in treatment counselling and festered provider mistrust and subsequent disengagement in care. Positive HIV diagnosis in late pregnancy complicated women’s ability to disclose their status to significant others which deprived them of essential social support for treatment adherence. Further, it appeared to adversely affect women’s mental health and treatment knowledge and self-efficacy. Conclusions We found clear links between late initiation of ANC and the potential for poor adherence to ART based on common structural barriers shaping both health seeking behaviours, and the adverse impact of late HIV diagnosis on women’s mental health and treatment knowledge and efficacy. Women who present late are a potential target group for better access to antiretrovirals that are easy to take and decrease viral load rapidly, and counselling support with adherence and partner disclosure. A combination of strengthened health literacy, economic empowerment, improved privacy and patient-provider relationships as well as community interventions that tackle inimical cultural practices on pregnancy and unfair gender norms may be required. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04896-5.
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Affiliation(s)
- Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, UK.
| | | | - Thokozile Malaba
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Angela Colbers
- Radboud University Nijmegen Medical Centre, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Helen Reynolds
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Miriam Taegtmeyer
- Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Musaazi J, Namageyo-Funa A, Carter VM, Carter RJ, Lamorde M, Apondi R, Bakyaita T, Boore AL, Brown VR, Homsy J, Kigozi J, Koyuncu A, Nabaggala MS, Nakate V, Nkurunziza E, Stowell DF, Walwema R, Olowo A, Jalloh MF. Evaluation of Community Perceptions and Prevention Practices Related to Ebola Virus as Part of Outbreak Preparedness in Uganda, 2020. Glob Health Sci Pract 2022; 10:GHSP-D-21-00661. [PMCID: PMC9242603 DOI: 10.9745/ghsp-d-21-00661] [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] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 03/29/2022] [Indexed: 11/15/2022]
Abstract
Targeted risk communication and community engagement strategies to raise Ebola virus disease awareness and knowledge, particularly in setting where risk of infection is perceived to be low, may not be sufficient to motivate people to adopt protective behaviors and prevention practices. Introduction: During the 2018–2020 Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo, risk communication and community engagement (RCCE) were prioritized in geographic areas in Uganda considered at high risk of introduction of EVD. To inform EVD preparedness in Uganda, we evaluated community perceptions and prevention practices related to EVD in 6 districts in Uganda. Methods: In March 2020, we conducted a population-based survey in 6 purposively selected districts in Uganda using multistage cluster sampling. We examined differences between districts classified as high- versus low risk for EVD in terms of their message exposure from RCCE; risk perception; and EVD knowledge, attitudes, and prevention practices. Results: A total of 3,485 respondents were interviewed (91% response rate). EVD message exposure was more common in the high- versus low-risk districts. EVD risk perceptions were low overall but greater in the high- versus low-risk districts. Comprehensive knowledge was significantly greater in the high- versus low-risk districts (adjusted prevalence ratio [aPR] 1.61, 95% confidence interval [CI]=1.35, 1.93). Respondents' engagement in all 3 EVD prevention practices (frequent handwashing with soap, avoiding physical contact with suspected Ebola patients, and avoiding burials involving contact with a corpse) was very low (4%). However, respondents with comprehensive knowledge were more likely to engage in all 3 EVD prevention practices compared to respondents without comprehensive knowledge (aPR 1.87, 95% CI=1.08, 3.25). Conclusion: Our findings suggest that while RCCE efforts as part of EVD outbreak preparedness may have contributed to higher EVD knowledge in the targeted high-risk districts, uptake of prevention behaviors was similarly low across districts. In a non-outbreak setting, implementing targeted RCCE strategies may not be sufficient to motivate people to adopt protective behaviors in the absence of a high threshold of perceived threat such as in an active outbreak.
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Affiliation(s)
- Joseph Musaazi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Correspondence to Joseph Musaazi ()
| | - Apophia Namageyo-Funa
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Victoria M. Carter
- National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rosalind J. Carter
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rose Apondi
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Amy L. Boore
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Vance R. Brown
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jaco Homsy
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Institute for Global Health Sciences, University of California San Francisco, California, USA
| | - Joanita Kigozi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Aybüke Koyuncu
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Maria Sarah Nabaggala
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Vivian Nakate
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Nkurunziza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Daniel F. Stowell
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Richard Walwema
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Apollo Olowo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mohamed F. Jalloh
- Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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Alhassan Y, Twimukye A, Malaba T, Myer L, Waitt C, Lamorde M, Colbers A, Reynolds H, Khoo S, Taegtmeyer M. "It's only fatness, it doesn't kill": a qualitative study on perceptions of weight gain from use of dolutegravir-based regimens in women living with HIV in Uganda. BMC Womens Health 2022; 22:246. [PMID: 35729541 PMCID: PMC9210809 DOI: 10.1186/s12905-022-01814-x] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background Dolutegravir (DTG)-based regimens have been recommended by the WHO as the preferred first-line and second-line HIV treatment in all populations. Evidence suggests an association with weight gain, particularly among black women. Our study investigated perceptions of weight gain from DTG-based regimen use on body image and adherence of antiretroviral therapy in women living with HIV (WLHIV) in Uganda. Methods Between April and June 2021, we conducted semi-structured interviews involving 25 WLHIV (adolescents, women of reproductive potential and post-menopausal women) and 19 healthcare professionals (clinicians, nurses, ART managers and counsellors) purposively selected from HIV clinics in Kampala. The interviews explored perceptions of body weight and image; experiences and management of weight related side effects associated with DTG; and knowledge and communication of DTG-related risks. Data was analysed thematically in NVivo 12 software. Results Our findings indicate WLHIV in Uganda commonly disliked thin body size and aspired to gain moderate to high level body weight to improve their body image, social standing and hide their sero-positive status. Both WLHIV and healthcare professionals widely associated weight gain with DTG use, although it was rarely perceived as an adverse event and was unlikely to be reported or to alter medication adherence. Clinical management and pharmacovigilance of DTG-related weight gain were hampered by the limited knowledge of WLHIV of the health risks of being over-weight and obesity; lack of diagnostic equipment and resources; and limited clinical guidance for managing weight gain and associated cardiovascular and metabolic comorbidities. Conclusions The study highlights the significance of large body-size in promoting psychosocial wellbeing in WLHIV in Uganda. Although weight gain is recognized as a side effect of DTG, it may be welcomed by some WLHIV. Healthcare professionals should actively talk about and monitor for weight gain and occurrence of associated comorbidities to facilitate timely interventions. Improved supply of diagnostic equipment and support with sufficient guidance for managing weight gain for healthcare professionals in Uganda are recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01814-x.
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Affiliation(s)
- Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | | | - Thokozile Malaba
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Angela Colbers
- Radboud University Nijmegen Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Helen Reynolds
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.,Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
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Berendes D, Martinsen A, Lozier M, Rajasingham A, Medley A, Osborne T, Trinies V, Schweitzer R, Prentice-Mott G, Pratt C, Murphy J, Craig C, Lamorde M, Kesande M, Tusabe F, Mwaki A, Eleveld A, Odhiambo A, Ngere I, Kariuki Njenga M, Cordon-Rosales C, Contreras APG, Call D, Ramay BM, Ramm RES, Paulino CJT, Schnorr CD, Aubin MD, Dumas D, Murray KO, Bivens N, Ly A, Hawes E, Maliga A, Morazan GH, Manzanero R, Morey F, Maes P, Diallo Y, Ilboudo M, Richemond D, Hattab OE, Oger PY, Matsuhashi A, Nsambi G, Antoine J, Ayebare R, Nakubulwa T, Vosburgh W, Boore A, Herman-Roloff A, Zielinski-Gutierrez E, Handzel T. Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19. PLOS Water 2022; 1:e0000027. [PMID: 38410139 PMCID: PMC10896259 DOI: 10.1371/journal.pwat.0000027] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices-for example, hand hygiene-are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.
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Affiliation(s)
- David Berendes
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andrea Martinsen
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Matt Lozier
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anu Rajasingham
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alexandra Medley
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Taylor Osborne
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Victoria Trinies
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- CDC Foundation, Atlanta, Georgia, USA
| | - Ryan Schweitzer
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Graeme Prentice-Mott
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Caroline Pratt
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention
| | - Jennifer Murphy
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christina Craig
- Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Maureen Kesande
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Fred Tusabe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Alex Mwaki
- Safe Water and AIDS Project, Kisumu, Kenya
| | | | | | | | | | | | | | - Douglas Call
- Washington State University, Pullman, Washington, USA
| | | | | | | | | | - Michael De Aubin
- Brigham and Women's Hospital, Harvard University, Boston, MA, USA
| | - Devan Dumas
- Brigham and Women's Hospital, Harvard University, Boston, MA, USA
| | - Kristy O Murray
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Nicholas Bivens
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Anh Ly
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Ella Hawes
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Adrianna Maliga
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Gerhaldine H Morazan
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Belize Ministry of Health and Wellness, Belmopan, Belize
| | | | - Francis Morey
- Belize Ministry of Health and Wellness, Belmopan, Belize
| | - Peter Maes
- UNICEF, Kinshasa, Democratic Republic of Congo
| | | | | | | | | | | | | | - Gertrude Nsambi
- Department of Hygiene and Public Health, Ministry of Health, Kinshasa, Democratic Republic of Congo
| | | | | | | | - Waverly Vosburgh
- Division of Global Health Protection, Centers for Disease Control and Prevention, Kampala, Uganda
| | - Amy Boore
- Division of Global Health Protection, Centers for Disease Control and Prevention, Kampala, Uganda
| | - Amy Herman-Roloff
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Emily Zielinski-Gutierrez
- Division of Global Health Protection, Centers for Disease Control and Prevention, Guatemala City, Guatemala
| | - Tom Handzel
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Ochanda PN, Lamorde M, Kintu K, Wang D, Chen T, Malaba T, Myer L, Waitt C, Reynolds H, Khoo S. A randomized comparison of health-related quality of life outcomes of dolutegravir versus efavirenz-based antiretroviral treatment initiated in the third trimester of pregnancy. AIDS Res Ther 2022; 19:24. [PMID: 35672853 PMCID: PMC9172107 DOI: 10.1186/s12981-022-00446-3] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/04/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Evidence on health-related quality of life (HRQoL) outcomes is limited for new antiretroviral therapies (ART). Dolutegravir-based treatment is being rolled out as the preferred first-line treatment for HIV in many low- and middle-income countries. We compared HRQoL between treatment-naïve pregnant women randomized to dolutegravir- or efavirenz-based ART in a clinical trial in Uganda and South Africa. Methods We gathered HRQoL data from 203 pregnant women of mean age 28 years, randomized to either dolutegravir- or efavirenz-based ART. We used the medical outcomes study-HIV health survey at baseline, 24 and 48 weeks between years 2018 and 2019. Physical health summary (PHS) and mental health summary (MHS) scores were the primary study outcomes, while the 11 MOS-HIV subscales were secondary outcomes. We applied mixed model analysis to estimate differences within and between-treatment groups. Multivariate regression analysis was included to identify associations between primary outcomes and selected variables. Results At 24 weeks postpartum, HRQoL scores increased from baseline in both treatment arms: PHS (10.40, 95% CI 9.24, 11.55) and MHS (9.23, 95% CI 7.35, 11.10) for dolutegravir-based ART; PHS (10.24, 95% CI 9.10, 11.38) and MHS (7.54, 95% CI 5.66, 9.42) for efavirenz-based ART. Increased scores for all secondary outcomes were significant at p < 0.0001. At 48 weeks, improvements remained significant for primary outcomes within group comparison. Estimated difference in PHS were higher in the dolutegravir-based arm, while increases in MHS were more for women in the efavirenz-based armat 24 and 48 weeks. No significant differences were noted for corresponding PHS scores at these time points compared between groups. Differences between arms were observed in two secondary outcomes: role function (1.11, 95% CI 0.08, 2.13), p = 0.034 and physical function outcomes (2.97, 95% CI 1.20, 4.73), p = 0.001. In the multivariate analysis, internet access was associated with higher PHS scores while owning a bank account, using the internet and longer treatment duration were associated with an increase in MHS scores. Conclusion We found no important differences in HRQoL outcomes among HIV-positive women started on dolutegravir relative to efavirenz in late pregnancy. Increases in HRQoL in the first year after delivery provide additional support for the initiation of ART in HIV-positive women presenting late in pregnancy. Trial Registration Clinical Trial Number: NCT03249181
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Affiliation(s)
- Perez Nicholas Ochanda
- Research Department, Infectious Diseases Institute, Makerere University, Hall Lane, P.O Box 22418, Kampala, Uganda.
| | - Mohammed Lamorde
- Research Department, Infectious Diseases Institute, Makerere University, Hall Lane, P.O Box 22418, Kampala, Uganda
| | - Kenneth Kintu
- Research Department, Infectious Diseases Institute, Makerere University, Hall Lane, P.O Box 22418, Kampala, Uganda
| | - Duolao Wang
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tao Chen
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thokozile Malaba
- School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Helen Reynolds
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Cresswell FV, Lamorde M. Implementation of long-acting antiretroviral therapy in low-income and middle-income countries. Curr Opin HIV AIDS 2022; 17:127-134. [PMID: 35439787 DOI: 10.1097/coh.0000000000000732] [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] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW With oral antiretroviral therapy, HIV has become a manageable chronic illness. However, UNAIDS targets for virologic suppression have not yet been attained in many low-income and middle-income countries (LMICs). Long-acting drug formulations hold promise to improve treatment outcomes. In this rapidly evolving area of research, we aim to review recent literature on the treatment of HIV with long-acting agents and identify implementation considerations for LMICs. RECENT FINDINGS Randomized controlled trials have shown that monthly long-acting injectable cabotegravir (CAB) and rilpivirine (RPV) is noninferior to oral ART, and 2-monthly CAB/RPV is noninferior to monthly injections. However, few people from LMICs were included. A modelling study predicts that in sub-Saharan Africa, injectable CAB/RPV is best targeted to those with poor adherence (HIV viral load >1000 copies/ml) in whom cost-effectiveness is greatest and risk of contributing to further resistance is no greater than continuation of oral ART. Other promising agents, such as lenacapavir are under investigation and may prove particularly useful in heavily treatment-experienced adults. SUMMARY Long-acting regimens are a promising advance in HIV treatment. By extending the dosing interval, increasing convenience and being discreet these regimens may reduce HIV treatment challenges. However, there are multiple implementation considerations in LMICs including the need for exclusion of hepatitis B, cold chain, oral bridging in case of missed dosing and switching during tuberculosis therapy. Efficacy and safety data are also awaited for settings without routine access to baseline resistance testing or regular viral load monitoring and for special populations, such as pregnancy, children and the elderly.
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Affiliation(s)
- Fiona V Cresswell
- Infectious Diseases Institute, Kampala
- MRC-UVRI-LSHTM Uganda research unit, Entebbe, Uganda
- Department of Global Health and Infection, Brighton and Sussex University Hospital, Brighton, United Kingdom
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Yang F, Katumba KR, Roudijk B, Yang Z, Revill P, Griffin S, Ochanda PN, Lamorde M, Greco G, Seeley J, Sculpher M. Developing the EQ-5D-5L Value Set for Uganda Using the 'Lite' Protocol. Pharmacoeconomics 2022; 40:309-321. [PMID: 34841471 PMCID: PMC8627844 DOI: 10.1007/s40273-021-01101-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE A 'lite' version of the EQ-5D-5L valuation protocol, which requires a smaller sample by collecting more data from each participant, was proposed and used to develop an EQ-5D-5L value set for Uganda. METHODS Adult respondents from the general Ugandan population were quota sampled based on age and sex. Eligible participants were asked to complete 20 composite time trade-off tasks in the tablet-assisted personal interviews using the offline EuroQol Portable Valuation Technology software under routine quality control. No discrete choice experiment task was administered. The composite time trade-off data were modelled using four additive and two multiplicative regression models. Model performance was evaluated based on face validity, prediction accuracy in cross-validation and in predicting mild health states. The final value set was generated using the best-performing model. RESULTS A representative sample (N = 545) participated in this study. Responses to composite time trade-off tasks from 492 participants were included in the primary analysis. All models showed face validity and generated comparable prediction accuracy. The Tobit model with constrained intercepts and corrected for heteroscedasticity was considered the preferred model for the value set on the basis of better performance. The value set ranges from - 1.116 (state 55555) to 1 (state 11111) with 'pain/discomfort' as the most important dimension. CONCLUSIONS This is the first EQ-5D-5L valuation study using a 'lite' protocol involving composite time trade-off data only. Our results suggest its feasibility in resource-constrained settings. The established EQ-5D-5L value set for Uganda is expected to be used for economic evaluations and decision making in Uganda and the East Africa region.
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Affiliation(s)
- Fan Yang
- Centre for Health Economics, University of York, York, UK.
| | | | - Bram Roudijk
- EuroQol Research Foundation, Rotterdam, The Netherlands
| | - Zhihao Yang
- Health Services Management Department, Guizhou Medical University, Guiyang, China
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, York, UK
| | - Perez N Ochanda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Giulia Greco
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
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Naggirinya AB, Kyomugisha EL, Nabaggala MS, Nasasira B, Akirana J, Oseku E, Kiragga A, Castelnuovo B, King RL, Katabira E, Byonanebye DM, Lamorde M, Parkes-Ratanshi R. Willingness to pay for an mHealth anti-retroviral therapy adherence and information tool: Transitioning to sustainability, Call for life randomised study experience in Uganda. BMC Med Inform Decis Mak 2022; 22:52. [PMID: 35219309 PMCID: PMC8882291 DOI: 10.1186/s12911-022-01782-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 02/15/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Evidence shows benefit of digital technology for people living with human immunodeficiency virus on antiretroviral therapy adherence and retention in care, however, scalability and sustainability have scarcely been evaluated. We assessed participants’ willingness to pay a fee for mHealth “Call for life Uganda” support, a mobile-phone based tool with the objective to assess sustainability and scalability. Methods “Call for Life study”, approved by Makerere University, School of Public Health research & ethics committee, at 2 sites in Uganda, evaluated a MoTech based software “CONNECT FOR LIFE™” mHealth tool termed “Call for life Uganda”. It provides short messages service or Interactive Voice Response functionalities, with a web-based interface, allows a computer to interact with humans through use of voice and tones input via keypad. Participants were randomized at 1:1 ratio to Standard of Care or standard of care plus Call for life Uganda. This sends pill reminders, visit reminders, voice messages and self-reported symptom support. At study visits 18 and 24 months, through mixed method approach we assessed mHealth sustainability and scalability. Participants were interviewed on desire to have or continue adherence support and willingness to pay a nominal fee for tool. We computed proportions willing to pay (± 95% confidence interval), stratified by study arm and predictors of willingness to continue and to pay using multivariate logistic regression model backed up by themes from qualitative interviews. Results 95% of participants were willing to continue using C4LU with 77.8% willing to pay for the service. Persons receiving care at the peri-urban clinic (OR 3.12, 95% CI 1.43–9.11.86) and those with exposure to the C4LU intervention (OR 4.2, 95% CI 1.55–11.84) were more likely to continue and pay for the service. Qualitative interviews revealed mixed feelings regarding amounts to pay, those willing to pay, argued that since they have been paying for personal phone calls/messages, they should not fail to pay for Call for life.
Conclusions Payment for the service offers opportunities to scale up and sustain mHealth interventions which may not be priorities for government funding. A co-pay model could be acceptable to PLHIV to access mHealth services in low resource settings.
Clinical Trial Number NCT 02953080. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01782-0.
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Odongpiny ELA, Cresswell F, Arinaitwe A, Nakate V, Kyenkya J, Lamorde M, Waitt C, Meya D, Kiragga A. High willingness to use injectable antiretroviral therapy among women who have been lost to follow-up from HIV programmes: A nested cross-sectional study. HIV Med 2022; 23:319-323. [PMID: 35199432 DOI: 10.1111/hiv.13260] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Efforts to achieve zero transmission of HIV to infants born to women living with HIV in sub-Saharan African are undermined by high rates of loss to follow-up in prevention of vertical transmission (PVT) programmes. The fear of HIV status disclosure through the discovery of pill bottles at home is a major contributor. Injectable antiretroviral therapy (ART) has proved to be efficacious in clinical trials and is discreet, offering a potential solution. We investigated the knowledge and willingness to use injectable ART among women who were lost to follow-up from the PVT programme in Uganda. METHODS Women were traced by nurse counsellors and knowledge and opinions relating to injectable ART, including willingness to use it when it becomes available, were collected. Generalized linear models were used to determine predictors of willingness to use injectable ART. CONCLUSIONS Among 1023 women registered between 2017 and 2019 under the PVT programmes in Kampala and Wakiso districts, Uganda, 385 (38%) were lost to follow-up from care and 22% of these (83/385) were successfully traced and interviewed. Only 25% (21/83) had heard of injectable ART. Over half (55%, 46/83) were very willing to use injectable ART, 40% (33/83) were somewhat willing and four (5%) were not willing. Those who associated ART tablets with disclosure risk were more willing to consider injectable ART (adjusted odds ratio = 4.21; 95% confidence interval: 1.45-12.19; p = 0.008). We report high willingness to use injectable ART associated with fears that ART tablets were a potential source of HIV status disclosure. Injectable ART could be a solution for women who have challenges with disclosure.
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Affiliation(s)
- Eva Laker Agnes Odongpiny
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Postgraduate School of Medicine, University of St Andrews, St Andrews, UK
| | - Fiona Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.,MRC-UVRI London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Arnold Arinaitwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Vivian Nakate
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joshua Kyenkya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Catriona Waitt
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - David Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Agnes Kiragga
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Asiimwe IG, Blockman M, Cohen K, Cupido C, Hutchinson C, Jacobson B, Lamorde M, Morgan J, Mouton JP, Nakagaayi D, Okello E, Schapkaitz E, Sekaggya-Wiltshire C, Semakula JR, Waitt C, Zhang EJ, Jorgensen AL, Pirmohamed M. Stable warfarin dose prediction in sub-Saharan African patients: A machine-learning approach and external validation of a clinical dose-initiation algorithm. CPT Pharmacometrics Syst Pharmacol 2022; 11:20-29. [PMID: 34889080 PMCID: PMC8752108 DOI: 10.1002/psp4.12740] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/24/2021] [Accepted: 10/27/2021] [Indexed: 12/11/2022] Open
Abstract
Warfarin remains the most widely prescribed oral anticoagulant in sub‐Saharan Africa. However, because of its narrow therapeutic index, dosing can be challenging. We have therefore (a) evaluated and compared the performance of 21 machine‐learning techniques in predicting stable warfarin dose in sub‐Saharan Black‐African patients and (b) externally validated a previously developed Warfarin Anticoagulation in Patients in Sub‐Saharan Africa (War‐PATH) clinical dose–initiation algorithm. The development cohort included 364 patients recruited from eight outpatient clinics and hospital departments in Uganda and South Africa (June 2018–July 2019). Validation was conducted using an external validation cohort (270 patients recruited from August 2019 to March 2020 in 12 outpatient clinics and hospital departments). Based on the mean absolute error (MAE; mean of absolute differences between the actual and predicted doses), random forest regression (12.07 mg/week; 95% confidence interval [CI], 10.39–13.76) was the best performing machine‐learning technique in the external validation cohort, whereas the worst performing technique was model trees (17.59 mg/week; 95% CI, 15.75–19.43). By comparison, the simple, commonly used regression technique (ordinary least squares) performed similarly to more complex supervised machine‐learning techniques and achieved an MAE of 13.01 mg/week (95% CI, 11.45–14.58). In summary, we have demonstrated that simpler regression techniques perform similarly to more complex supervised machine‐learning techniques. We have also externally validated our previously developed clinical dose–initiation algorithm, which is being prospectively tested for clinical utility.
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Affiliation(s)
- Innocent G Asiimwe
- Department of Pharmacology and Therapeutics, The Wolfson Centre for Personalized Medicine, Medical Research Council Centre for Drug Safety Science, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Marc Blockman
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Clint Cupido
- Victoria Hospital Internal Medicine Research Initiative, Victoria Hospital Wynberg, Cape Town, South Africa.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Claire Hutchinson
- Department of Pharmacology and Therapeutics, The Wolfson Centre for Personalized Medicine, Medical Research Council Centre for Drug Safety Science, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Barry Jacobson
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jennie Morgan
- Metro District Health Services, Western Cape Department of Health, Cape Town, South Africa
| | - Johannes P Mouton
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Elise Schapkaitz
- Department of Molecular Medicine and Hematology, Charlotte Maxeke Johannesburg Academic Hospital National Health Laboratory System Complex and University of Witwatersrand, Johannesburg, South Africa
| | | | - Jerome R Semakula
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Catriona Waitt
- Department of Pharmacology and Therapeutics, The Wolfson Centre for Personalized Medicine, Medical Research Council Centre for Drug Safety Science, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Eunice J Zhang
- Department of Pharmacology and Therapeutics, The Wolfson Centre for Personalized Medicine, Medical Research Council Centre for Drug Safety Science, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Andrea L Jorgensen
- Department of Health Data Science, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, The Wolfson Centre for Personalized Medicine, Medical Research Council Centre for Drug Safety Science, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Blair PW, Lamorde M, Dumler JS. Rickettsioses and Q Fever in Tanzania: Estimating the Burden of Pervasive and Neglected Causes of Severe Febrile Illness in Sub-Saharan Africa. Am J Trop Med Hyg 2021; 106:371-372. [PMID: 34929671 PMCID: PMC8832924 DOI: 10.4269/ajtmh.21-0963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Paul W Blair
- Department of Pathology, Uniformed Services University, Bethesda, Maryland
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - J Stephen Dumler
- Department of Pathology, Uniformed Services University, Bethesda, Maryland.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Abongomera G, Koller M, Musaazi J, Lamorde M, Kaelin M, Tasimwa HB, Eberhard N, Hongler J, Haller S, Kambugu A, Castelnuovo B, Fehr J. Spectrum of antibiotic resistance in UTI caused by Escherichia coli among HIV-infected patients in Uganda: a cross-sectional study. BMC Infect Dis 2021; 21:1179. [PMID: 34814849 PMCID: PMC8609806 DOI: 10.1186/s12879-021-06865-3] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/12/2021] [Indexed: 11/28/2022] Open
Abstract
Background Antimicrobial drug resistance is one of the top ten threats to global health according to the World Health Organization. Urinary tract infections (UTIs) are among the most common bacterial infections and main reason for antibiotic prescription. The incidence of UTIs appears to be high among people living with HIV. We sought to determine the most common UTI pathogens among HIV infected patients and evaluate their susceptibility towards antibiotics. Methods We performed a cross-sectional study among HIV-infected patients aged ≥ 18 years presenting at an HIV care specialized clinic with symptoms suggestive of a urethritis. Urine cultures were subjected to antibiotic susceptibility testing according to Clinical Laboratory Standards Institute. The data was analyzed using STATA, we performed Pearson’s Chi-square and Fisher’s exact tests to compare differences between proportions. Results Out of the 200 patients, 123 (62%) were female. The median age was 41.9 years (IQR 34.7–49.3). Only 32 (16%) urine cultures showed bacterial growth. Escherichia coli was the most commonly isolated uropathogen (72%), followed by Klebsiella pneumoniae (9%). E. coli was completely resistant to cotrimoxazole and ampicillin; resistance to ciprofloxacin and ceftriaxone was 44% and 35% respectively; 9% to gentamicin; no resistance detected to nitrofurantoin and imipenem. Conclusions Our findings are congruent with the Uganda national clinical guidelines which recommends nitrofurantoin as the first line antibiotic for uncomplicated UTI. Significant ciprofloxacin and ceftriaxone resistance was detected. In the era of emerging antibiotic resistance, understanding the local susceptibilities among sub-populations such as HIV infected patients is crucial. Further investigation is needed to address reasons for the low bacterial growth rate observed in the urine cultures. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06865-3.
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Affiliation(s)
- George Abongomera
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH 8001, Zurich, Switzerland.
| | - Maurice Koller
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH 8001, Zurich, Switzerland
| | - Joseph Musaazi
- Makerere University Infectious Diseases Institute, Kampala, Uganda
| | - Mohammed Lamorde
- Makerere University Infectious Diseases Institute, Kampala, Uganda
| | - Marisa Kaelin
- University Hospital Zurich, Infectious Diseases and Hospital Epidemiology, Zürich, Switzerland
| | | | - Nadia Eberhard
- University Hospital Zurich, Infectious Diseases and Hospital Epidemiology, Zürich, Switzerland
| | - Jan Hongler
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH 8001, Zurich, Switzerland
| | - Sabine Haller
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH 8001, Zurich, Switzerland
| | - Andrew Kambugu
- Makerere University Infectious Diseases Institute, Kampala, Uganda
| | | | - Jan Fehr
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich and University Hospital Zurich, Infectious Diseases and Hospital Epidemiology, Zürich, Switzerland
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44
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Walimbwa SI, Kaboggoza JP, Waitt C, Byakika-Kibwika P, D'Avolio A, Lamorde M. An open-label, randomized, single intravenous dosing study to investigate the effect of fixed-dose combinations of tenofovir/lamivudine or atazanavir/ritonavir on the pharmacokinetics of remdesivir in Ugandan healthy volunteers (RemTLAR). Trials 2021; 22:831. [PMID: 34814933 PMCID: PMC8609173 DOI: 10.1186/s13063-021-05752-1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Remdesivir is a novel broad-spectrum antiviral therapeutic with activity against several viruses that cause emerging infectious diseases. The purpose of this study is to explore how commonly utilized antiretroviral therapy (tenofovir disoproxil fumarate/lamivudine [TDF/3TC] and atazanavir/ritonavir [ATV/r]) influence plasma and intracellular concentrations of remdesivir. METHODS This is an open-label, randomized, fixed sequence single intravenous dosing study to assess pharmacokinetic interactions between remdesivir and TDF/3TC (Study A, crossover design) or TDF/3TC plus ATV/r (Study B). Healthy volunteers satisfying study entry criteria will be enrolled in the study and randomized to either Study A; N=16 (Sequence 1 or Sequence 2) or Study B; N=8. Participants will receive standard adult doses of antiretroviral therapy for 7 days and a single 200mg remdesivir infusion administered over 60 min. Pharmacokinetic blood sampling will be performed relative to the start of remdesivir infusion; predose (before the start of remdesivir infusion) and 30 min after the start of remdesivir infusion. Additional blood samples will be taken at 2, 4, 6, 12, and 24 h after the end of remdesivir infusion. DISCUSSION This study will characterize the pharmacokinetics of remdesivir from a typical African population in whom clinical use is anticipated. Furthermore, this study will deliver pharmacokinetic datasets for remdesivir drug concentrations and demographic characteristics which could support pharmacometric approaches for simulation of remdesivir treatment regimens in patients concurrently using tenofovir/lamivudine and/or atazanavir/ritonavir. TRIAL REGISTRATION ClinicalTrials.gov NCT04385719 . Registered 13 May 2020.
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Affiliation(s)
- Stephen I Walimbwa
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Julian P Kaboggoza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Catriona Waitt
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Pauline Byakika-Kibwika
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Medicine, Makerere University, Kampala, Uganda
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, Turin, Italy.,CoQua Lab, Turin, Italy
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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45
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Twimukye A, Laker M, Odongpiny EAL, Ajok F, Onen H, Kalule I, Kajubi P, Seden K, Owarwo N, Kiragga A, Armstrong-Hough M, Katahoire A, Mujugira A, Lamorde M, Castelnuovo B. Patient experiences of switching from Efavirenz- to Dolutegravir-based antiretroviral therapy: a qualitative study in Uganda. BMC Infect Dis 2021; 21:1154. [PMID: 34774018 PMCID: PMC8590364 DOI: 10.1186/s12879-021-06851-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 05/10/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background In 2019, the World Health Organisation (WHO) recommended Dolutegravir (DTG) as the preferred first-line antiretroviral treatment (ART) for all persons with HIV. ART regimen switches may affect HIV treatment adherence. We sought to describe patient experiences switching from EFV to DTG-based ART in Kampala, Uganda. Methods Between July and September 2019, we purposively sampled adults living with HIV who had switched to DTG at the Infectious Diseases Institute HIV clinic. We conducted in-depth interviews with adults who switched to DTG, to explore their preparation to switch and experiences on DTG. Interviews were audio-recorded, transcribed and analysed thematically using Atlas ti version 8 software. Results We interviewed 25 adults: 18 (72%) were women, and the median age was 35 years (interquartile range [IQR] 30–40). Median length on ART before switching to DTG was 67 months (IQR 51–125). Duration on DTG after switching was 16 months (IQR 10–18). Participants reported accepting provider recommendations to switch to DTG mainly because they anticipated that swallowing a smaller pill once a day would be more convenient. While most participants initially felt uncertain about drug switching, their providers offer of frequent appointments and a toll-free number to call in the event of side effects allayed their anxiety. At the same time, participants said they felt rushed to switch to the new ART regimen considering that they had been on their previous regimen(s) for several years and the switch to DTG happened during a routine visit when they had expected their regular prescription. Some participants felt unprepared for new adverse events associated with DTG and for the abrupt change in treatment schedule. Most participants said they needed additional support from their health providers before and after switching to DTG. Conclusion and recommendations Adults living with HIV stable on an EFV-based regimen but were switched to DTG in a program-wide policy change found the duration between counselling and drug switching inadequate. DTG was nonetheless largely preferred because of the small pill size, once daily dosing, and absence of EFV-like side effects. Community-engaged research is needed to devise acceptable ways to prepare participants for switching ART at scale. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06851-9.
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Affiliation(s)
- Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda.
| | - Miriam Laker
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Eva Agnes Laker Odongpiny
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | | | - Henry Onen
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Ivan Kalule
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Phoebe Kajubi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Kay Seden
- University of Liverpool, Liverpool, UK
| | - Noela Owarwo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Agnes Kiragga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Mari Armstrong-Hough
- School of Global Public Health, New York University, New York, NY, USA.,Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda.,Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
| | - Anne Katahoire
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda.,School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, Uganda
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Nabadda S, Kakooza F, Kiggundu R, Walwema R, Bazira J, Mayito J, Mugerwa I, Sekamatte M, Kambugu A, Lamorde M, Kajumbula H, Mwebasa H. Implementation of the World Health Organization Global Antimicrobial Resistance Surveillance System in Uganda, 2015-2020: Mixed-Methods Study Using National Surveillance Data. JMIR Public Health Surveill 2021; 7:e29954. [PMID: 34673531 PMCID: PMC8569544 DOI: 10.2196/29954] [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] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 12/17/2022] Open
Abstract
Background Antimicrobial resistance (AMR) is an emerging public health crisis in Uganda. The World Health Organization (WHO) Global Action Plan recommends that countries should develop and implement National Action Plans for AMR. We describe the establishment of the national AMR program in Uganda and present the early microbial sensitivity results from the program. Objective The aim of this study is to describe a national surveillance program that was developed to perform the systematic and continuous collection, analysis, and interpretation of AMR data. Methods A systematic qualitative description of the process and progress made in the establishment of the national AMR program is provided, detailing the progress made from 2015 to 2020. This is followed by a report of the findings of the isolates that were collected from AMR surveillance sites. Identification and antimicrobial susceptibility testing (AST) of the bacterial isolates were performed using standard methods at both the surveillance sites and the reference laboratory. Results Remarkable progress has been achieved in the establishment of the national AMR program, which is guided by the WHO Global Laboratory AMR Surveillance System (GLASS) in Uganda. A functional national coordinating center for AMR has been established with a supporting designated reference laboratory. WHONET software for AMR data management has been installed in the surveillance sites and laboratory staff trained on data quality assurance. Uganda has progressively submitted data to the WHO GLASS reporting system. Of the 19,216 isolates from WHO GLASS priority specimens collected from October 2015 to June 2020, 22.95% (n=4411) had community-acquired infections, 9.46% (n=1818) had hospital-acquired infections, and 68.57% (n=12,987) had infections of unknown origin. The highest proportion of the specimens was blood (12,398/19,216, 64.52%), followed by urine (5278/19,216, 27.47%) and stool (1266/19,216, 6.59%), whereas the lowest proportion was urogenital swabs (274/19,216, 1.4%). The mean age was 19.1 (SD 19.8 years), whereas the median age was 13 years (IQR 28). Approximately 49.13% (9440/19,216) of the participants were female and 50.51% (9706/19,216) were male. Participants with community-acquired infections were older (mean age 28, SD 18.6 years; median age 26, IQR 20.5 years) than those with hospital-acquired infections (mean age 17.3, SD 20.9 years; median age 8, IQR 26 years). All gram-negative (Escherichia coli, Klebsiella pneumoniae, and Neisseria gonorrhoeae) and gram-positive (Staphylococcus aureus and Enterococcus sp) bacteria with AST showed resistance to each of the tested antibiotics. Conclusions Uganda is the first African country to implement a structured national AMR surveillance program in alignment with the WHO GLASS. The reported AST data indicate very high resistance to the recommended and prescribed antibiotics for treatment of infections. More effort is required regarding quality assurance of laboratory testing methodologies to ensure optimal adherence to WHO GLASS–recommended pathogen-antimicrobial combinations. The current AMR data will inform the development of treatment algorithms and clinical guidelines.
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Affiliation(s)
- Susan Nabadda
- Laboratory and Diagnostics Services Department, Ministry of Health, Kampala, Uganda
| | - Francis Kakooza
- Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda.,Department of Immunology and Molecular Biology, Makerere University, Kampala, Uganda
| | - Reuben Kiggundu
- Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda.,United States Agency for International Development Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Kampala, Uganda
| | - Richard Walwema
- Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Joel Bazira
- Department of Medical Microbiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jonathan Mayito
- Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Ibrahimm Mugerwa
- Laboratory and Diagnostics Services Department, Ministry of Health, Kampala, Uganda.,Antimicrobial Resistance Sub-Committee, National One Health Platform, Kampala, Uganda
| | - Musa Sekamatte
- Antimicrobial Resistance Sub-Committee, National One Health Platform, Kampala, Uganda
| | - Andrew Kambugu
- Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Mohammed Lamorde
- Global Health Security Department, Infectious Diseases Institute, Kampala, Uganda
| | - Henry Kajumbula
- Antimicrobial Resistance Sub-Committee, National One Health Platform, Kampala, Uganda.,Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Henry Mwebasa
- Laboratory and Diagnostics Services Department, Ministry of Health, Kampala, Uganda.,Antimicrobial Resistance Sub-Committee, National One Health Platform, Kampala, Uganda
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47
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Roberts O, Kinvig H, Owen A, Lamorde M, Siccardi M, Scarsi KK. In vitro assessment of the potential for dolutegravir to affect hepatic clearance of levonorgestrel. HIV Med 2021; 22:898-906. [PMID: 34328253 PMCID: PMC9363158 DOI: 10.1111/hiv.13136] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 06/07/2021] [Indexed: 12/01/2022]
Abstract
Objectives: The World Health Organization recommends that all countries adopt dolutegravir-based antiretroviral therapy as the preferred regimen for all individuals living with HIV. Levonorgestrel is a commonly used hormonal contraceptive, which undergoes drug–drug interactions with some antiretrovirals, but the potential interaction between dolutegravir and levonorgestrel has not been examined. We aimed to evaluate cytochrome P450 (CYP)-mediated levonorgestrel metabolism and quantify the effects of dolutegravir on levonorgestrel apparent intrinsic clearance (CLint.app.) and CYP gene expression. Methods: In vitro CYP-mediated CLint.app. of levonorgestrel was quantified using a recombinant human CYP (rhCYP) enzyme system. A primary human hepatocyte model of drug metabolism was used to assess the effects of dolutegravir on (1) levonorgestrel CLint.app., using liquid chromatography-tandem mass spectrometry, and (2) the expression of specific CYP enzymes, using quantitative real-time polymerase chain reaction. Results: Levonorgestrel clearance was mediated by multiple rhCYPs, including rhCYP3A4. Under control conditions, levonorgestrel CLint.app. was 22.4 ± 5.0 μL/min/106 hepatocytes. Incubation with 43.1 nM of unbound dolutegravir elevated levonorgestrel CLint.app. to 31.4 ± 7.8 μL/min/106 hepatocytes (P = 0.168), while 142.23 nM increased levonorgestrel CLint.app. to 37.0 ± 2.9 μL/min/106 hepatocytes (P = 0.012). Unbound dolutegravir ≥ 431 nM induced expression of CYP3A4 (≥ two-fold) in a dose-dependent manner, while 1.44 μM of unbound dolutegravir induced CYP2B6 expression 2.2 ± 0.3-fold (P = 0.0004). Conclusions: In summary, this in vitro study suggests that dolutegravir has the potential to increase hepatic clearance of levonorgestrel by inducing both CYP3A and non-CYP3A enzymes. The observed in vitro dolutegravir–levonorgestrel drug–drug interaction should be further examined in clinical studies.
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Affiliation(s)
- Owain Roberts
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Hannah Kinvig
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Andrew Owen
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, Materials Innovation Factory, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Marco Siccardi
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
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Griffiths GO, FitzGerald R, Jaki T, Corkhill A, Reynolds H, Ewings S, Condie S, Tilt E, Johnson L, Radford M, Simpson C, Saunders G, Yeats S, Mozgunov P, Tansley-Hancock O, Martin K, Downs N, Eberhart I, Martin JWB, Goncalves C, Song A, Fletcher T, Byrne K, Lalloo DG, Owen A, Jacobs M, Walker L, Lyon R, Woods C, Gibney J, Chiong J, Chandiwana N, Jacob S, Lamorde M, Orrell C, Pirmohamed M, Khoo S. AGILE: a seamless phase I/IIa platform for the rapid evaluation of candidates for COVID-19 treatment: an update to the structured summary of a study protocol for a randomised platform trial letter. Trials 2021; 22:487. [PMID: 34311777 PMCID: PMC8311065 DOI: 10.1186/s13063-021-05458-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/14/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There is an urgent unmet clinical need for the identification of novel therapeutics for the treatment of COVID-19. A number of COVID-19 late phase trial platforms have been developed to investigate (often repurposed) drugs both in the UK and globally (e.g. RECOVERY led by the University of Oxford and SOLIDARITY led by WHO). There is a pressing need to investigate novel candidates within early phase trial platforms, from which promising candidates can feed into established later phase platforms. AGILE grew from a UK-wide collaboration to undertake early stage clinical evaluation of candidates for SARS-CoV-2 infection to accelerate national and global healthcare interventions. METHODS/DESIGN AGILE is a seamless phase I/IIa platform study to establish the optimum dose, determine the activity and safety of each candidate and recommend whether it should be evaluated further. Each candidate is evaluated in its own trial, either as an open label single arm healthy volunteer study or in patients, randomising between candidate and control usually in a 2:1 allocation in favour of the candidate. Each dose is assessed sequentially for safety usually in cohorts of 6 patients. Once a phase II dose has been identified, efficacy is assessed by seamlessly expanding into a larger cohort. AGILE is completely flexible in that the core design in the master protocol can be adapted for each candidate based on prior knowledge of the candidate (i.e. population, primary endpoint and sample size can be amended). This information is detailed in each candidate specific trial protocol of the master protocol. DISCUSSION Few approved treatments for COVID-19 are available such as dexamethasone, remdesivir and tocilizumab in hospitalised patients. The AGILE platform aims to rapidly identify new efficacious and safe treatments to help end the current global COVID-19 pandemic. We currently have three candidate specific trials within this platform study that are open to recruitment. TRIAL REGISTRATION EudraCT Number: 2020-001860-27 14 March 2020 ClinicalTrials.gov Identifier: NCT04746183 19 February 2021 ISRCTN reference: 27106947.
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Affiliation(s)
- Gareth O. Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Richard FitzGerald
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Thomas Jaki
- Lancaster University, Lancaster UK and MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Andrea Corkhill
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | | | - Sean Ewings
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Susannah Condie
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Emma Tilt
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Lucy Johnson
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Mike Radford
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Catherine Simpson
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Geoffrey Saunders
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Sara Yeats
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Pavel Mozgunov
- Lancaster University, Lancaster UK and MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Olana Tansley-Hancock
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Karen Martin
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Nichola Downs
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Izabela Eberhart
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Jonathan W. B. Martin
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Cristiana Goncalves
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Anna Song
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
| | - Tom Fletcher
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kelly Byrne
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | | | - Lauren Walker
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Rebecca Lyon
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christie Woods
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Jennifer Gibney
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Justin Chiong
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Catherine Orrell
- Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Munir Pirmohamed
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Saye Khoo
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - on behalf of the AGILE investigators
- Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, UK
- NIHR Royal Liverpool and Broadgreen CRF, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Lancaster University, Lancaster UK and MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- University of Liverpool, Liverpool, UK
- Liverpool School of Tropical Medicine, Liverpool, UK
- Royal Free London NHS Foundation Trust, London, UK
- University of the Witwatersrand, Johannesburg, South Africa
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
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49
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Kawuma AN, Walimbwa SI, Pillai GC, Khoo S, Lamorde M, Wasmann RE, Denti P. Dolutegravir pharmacokinetics during co-administration with either artemether/lumefantrine or artesunate/amodiaquine. J Antimicrob Chemother 2021; 76:1269-1272. [PMID: 33550391 DOI: 10.1093/jac/dkab022] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/09/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, artemisinin-containing therapies for malaria treatment are regularly co-administered with ART. Currently, dolutegravir-based regimens are recommended as first-line therapy for HIV across most of Africa. OBJECTIVES To investigate the population pharmacokinetics of dolutegravir during co-administration with artemether/lumefantrine or artesunate/amodiaquine, two commonly used antimalarial therapies. METHODS We developed a population pharmacokinetic model of dolutegravir with data from 26 healthy volunteers in two Phase 2 studies with a total of 403 dolutegravir plasma concentrations at steady state. Volunteers received 50 mg of dolutegravir once daily alone or in combination with standard treatment doses of artemether/lumefantrine (80/480 mg) or artesunate/amodiaquine (200/540 mg). RESULTS A two-compartment model with first-order elimination and transit compartment absorption best described the concentration-time data of dolutegravir. Typical population estimates for clearance, absorption rate constant, central volume, peripheral volume and mean absorption transit time were 0.713 L/h, 1.68 h-1, 13.2 L, 5.73 L and 1.18 h, respectively. Co-administration of artemether/lumefantrine or artesunate/amodiaquine increased dolutegravir clearance by 10.6% (95% CI 4.09%-34.5%) and 26.4% (95% CI 14.3%-51.4%), respectively. Simulations showed that simulated trough concentrations of dolutegravir alone or in combination with artemether/lumefantrine or artesunate/amodiaquine are maintained above the dolutegravir protein-adjusted IC90 of 0.064 mg/L for more than 99% of the individuals. CONCLUSIONS Dolutegravir dose adjustments are not necessary for patients who are taking standard 3 day treatment doses of artemether/lumefantrine or artesunate/amodiaquine.
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Affiliation(s)
- Aida N Kawuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Goonaseelan Colin Pillai
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,CP+ Associates GmbH, Basel, Switzerland
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Twimukye A, Bwanika Naggirinya A, Parkes-Ratanshi R, Kasirye R, Kiragga A, Castelnuovo B, Wasswa J, Nabaggala MS, Katabira E, Lamorde M, King RL. Acceptability of a Mobile Phone Support Tool (Call for Life Uganda) for Promoting Adherence to Antiretroviral Therapy Among Young Adults in a Randomized Controlled Trial: Exploratory Qualitative Study. JMIR Mhealth Uhealth 2021; 9:e17418. [PMID: 34121665 PMCID: PMC8240800 DOI: 10.2196/17418] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 10/19/2020] [Accepted: 05/07/2021] [Indexed: 12/16/2022] Open
Abstract
Background Adherence to treatment is critical for successful treatment outcomes. Although factors influencing antiretroviral therapy (ART) adherence vary, young adults are less likely to adhere owing to psychosocial issues such as stigma, ART-related side effects, and a lack of access to treatment. The Call for Life Uganda (CFLU) mobile health (mHealth) tool is a mobile phone–based technology that provides text messages or interactive voice response functionalities through a web interface and offers 4 modules of support. Objective This study aims to describe the acceptability and feasibility of a mobile phone support tool to promote adherence to ART among young adults in a randomized controlled trial. Methods An exploratory qualitative design with a phenomenological approach at 2 study sites was used. A total of 17 purposively selected young adults with HIV infection who had used the mHealth tool CFLU from 2 clinics were included. In total, 11 in-depth interviews and 1 focus group discussion were conducted to examine the following topics: experience with the CFLU tool (benefits and challenges), components of the tool, the efficiency of the system (level of comfort, ease, or difficulty in using the system), how CFLU resolved adherence challenges, and suggestions to improve CFLU. Participants belonged to 4 categories of interest: young adults on ART for the prevention of mother-to-child transmission, young adults switching to or on the second-line ART, positive partners in an HIV-discordant relationship, and young adults initiating the first-line ART. All young adults had 12 months of daily experience using the tool. Data were analyzed using NVivo version 11 software (QSR International Limited) based on a thematic approach. Results The CFLU mHealth tool was perceived as an acceptable intervention; young adults reported improvement in medication adherence, strengthened clinician-patient relationships, and increased health knowledge from health tips. Appointment reminders and symptom reporting were singled out as beneficial and helped to address the problems of forgetfulness and stigma-related issues. HIV-related stigma was reported by a few young people. Participants requested extra support for scaling up CFLU to make it more youth friendly. Improving the tool to reduce technical issues, including network outages and a period of software failure, was suggested. They suggested that in addition to digital solutions, other support, including the promotion of peer support meetings and the establishment of a designated space and staff members for youth, was also important. Conclusions This mHealth tool was an acceptable and feasible strategy for improving ART adherence and retention among young adults in resource-limited settings. Trial Registration ClinicalTrials.gov NCT02953080; https://clinicaltrials.gov/ct2/show/NCT02953080
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Affiliation(s)
- Adelline Twimukye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Rosalind Parkes-Ratanshi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,Department of Public Health & Primary Care, Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
| | - Ronnie Kasirye
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Agnes Kiragga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jacob Wasswa
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Maria Sarah Nabaggala
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.,College of Health Sciences, School of Medicine, Makerere University, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rachel Lisa King
- Institute for Global Health Sciences, University of California, San Francisco, CA, United States
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