Infectious Diseases Institute (IDI)

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    The academic alliance for AIDS care and prevention in Africa
    (The Johns Hopkins University AIDS Service, 2001-11) Quinn, Thomas C.
    In the continent of Africa, AIDS is the leading cause of death, responsible for over 20% of all fatalities. To date, over 16 million people in Africa have died from AIDS, and approximately 26 million or 70% of the world’s total of HIV infected people reside in sub-Saharan Africa. Howe ve r, little or no treatment, either for HIV infection itself or for its complications, is available to HIV infected Africans. This inequity in care between Africa and western countries has been attributed to lack of infrastructure, poverty, lack of financial support from developed countries, insufficient health care delivery systems, lack of knowledge by African physicians on the use of these drugs, insufficient laboratory support,political inaction, and many other factors. Although increasing attention has been focused on the problem, particularly in the lay press, and although pharmaceutical companies have reduced the cost of their drugs, most Africans still cannot afford these medicines, and little has been done to bring good clinical care to the millions of HIV infected Africans. To address this problem, a new organization was formed in June 2001 called "The Academic Alliance for AIDS Care and Prevention in Africa," led by a group of Ugandan physicians from Makerere University and the Infectious Diseases Society of America with HIV/AIDS care experts from North America.
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    Access to HIV/AIDS care for mothers and children in sub-Saharan Africa: adherence to the postnatal PMTCT program
    (Taylor & Francis (Routledge), 2009-09) Nassali, Mercy ; Nakanjako, Damalie ; Kyabayinze, Daniel ; Beyeza, Jolly ; Okoth, Anthony ; Mutyaba, Twaha
    Despite scale up of perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions,postnatal continuity of comprehensive HIV/AIDS care, for both the mother and baby, remains a challenge in developing countries. We determined adherence to the postnatal PMTCT program (PN-PMTCT) and the associated factors among mothers at a public urban hospital in Uganda. We interviewed HIV-positive postnatal mothers on discharge and we determined adherence to PN-PMTCT by the proportion of mothers that honored their return appointments by the end of eight weeks postpartum. We had focus group discussions to assess factors that influence adherence to PN-PMTCT. Of 289 mothers, only 110 (38%) adhered to PN-PMTCT. Previous attendance of a routine postnatal review and having access to a phone were significantly associated with adherence to PMTCT among mothers older than 25 years (odds ratio (OR) 3.6 (95% confidence interval (CI); 1.2 10.4)) and (OR 3.1 (95% CI; 1.3 7.1)), respectively. On the other hand, Christianity (OR 3.2 (95% CI; 1.1 9.0)) was significantly associated with adherence to PN-PMTCT among mothers below 25 years of age. Mothers’ perceived benefits of the PN-PMTCT program, easy access to the program, and presence of social support from a spouse were important motivators for mothers to adhere to PN-PMTCT. Even with improved antenatal and intra-partum PMTCT services, only a third of the HIV-infected mothers adhered to the PNPMTCT program. Mothers who previously attended a routine postnatal care were 3.6 fold more likely to adhere to PN-PMTCT. We recommend strategies to increase mothers’ adherence to PN-PMTCT interventions in order to increase access to HIV/AIDS care for mothers and children in sub-Saharan Africa.
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    Adherence of health workers to guidelines for screening and management of cryptococcal meningitis in Uganda
    (PLOS, 2023) Namuju, Olivie C. ; Namuwenge, Proscovia M. ; Kwizera, Richard ; Obuya, Emmanuel ; Kirumira, Paul ; Naluyima, Rose ; Ahimbisibwe, Cynthia ; Ndyetukira, Jane Francis ; Nakato, Hawa ; Kirungi, Robert ; Gakuru, Jane ; Junju, Samuel ; Nuwagira, Edwin ; Rutakagirwa, Morris ; Nsibirwa, Sara ; Nabitaka, Vennie ; Nalintya, Elizabeth ; Mpoza, Edward ; Muzoora, Conrad K. ; Musubire, Abdu K. ; Boulware, David R. ; Meya, David B.
    Introduction: Health workers' failure to adhere to guidelines for screening, diagnosis and management of HIV-associated cryptococcal meningitis (CM) remains a significant public health concern. We aimed to assess adherence to the standards of care and management of HIV patients at risk of CM per the MoH guidelines and assess stock management of CM supplies in the period of January to June 2021 at selected public health facilities (HFs) in Uganda. Methods: The study employed an observational cross-sectional design to assess the level of adherence of health workers to standards of clinical care and management of HIV positive patients at risk of CM as per the clinical guidelines for Uganda, and stock management of CM supplies in the period of January to June 2021in selected public health facilities. The study team used a survey guide designed by MoH to assess and score the screening, diagnosis and management practices of Health Facilities towards CM. Scoring was categorized as red (< 80%), light green (80%-95%), and dark green (˃95%) in the order from worst to best adherence. The data was transcribed into a spread sheet and analysed using STATA-v15. Results: The study team visited a total of 15 public health facilities including 5 general hospitals, 9 regional referral hospitals (RRHs) and 1 National Referral hospital (NRH). The mean score for adherence to screening and management of CM for all the combined facilities was 15 (64.7%) classified as red. 10 (66.7%) HFs had not performed a baseline CD4 test for eligible patients within 2 weeks of ART initiation. With regards to treatment, 9 (60%) of the HFs were scored as light green on knowledge of the procedure for reconstituting intravenous Liposomal Amphotericin B. None of the HFs visited had potassium chloride tablets in stock. Conclusion: Major MoH guidelines are generally not being adhered to by health workers while managing cryptococcal meningitis. It is vital that government and implementing partners regularly support HFs with training, mentorship, and support supervision on CM management to improve adherence to CM screening and treatment guidelines.
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    Adherence to anti-retroviral ttherapy among HIV infected mothers on option B plus aattending the Upper Mulago post natal clinic
    (Makerere University, 2014-06) Naiwumbwe, Halima K
    Background: Over 90% of the children living with HIV in Sub-Saharan Africa acquire the infection through mother-to-child transmission (MTCT). Elimination of MTCT (eMTCT) of HIV could be realized by country wide rollout of Option B+ because of further simplification of the ART regimen, harmonization of PMTCT and HIV treatment programmes as well as reduction in transmission to serodiscordant partners. Studies have shown good adherence among people taking ART for their own health. However, in Option B+ where mothers are started on lifelong ART even when healthy for the sake of eMTCT, adherence remains questionable. Adherence to ART by mothers on Option B+ is very critical for eMTCT and long term maternal health benefits with improved infant survival by delaying emergence of resistant strains of the virus and ensuring durability of the present regimens. The study aim was to determine the level of and factors associated with adherence to ART by mothers on Option B+ attending the post natal clinic of Mulago hospital and the infant HIV prevalence at six weeks. Methods: HIV infected post natal mothers on option B+ attending the Upper Mulago post natal clinic with their infants were consecutively enrolled between August 2014 and January 2015. Questionnaires were administered to these mothers to gather information on adherence through the self-report and visual analogue scale (VAS) methods. The infants’ HIV DNA PCR test results routinely done by Baylor-Uganda (a pediatric HIV care center) were retrieved and recorded in the respective questionnaires. The mean adherence by self report over a three day and seven day recall periods as well as VAS were calculated separately. The three day self report adherence and that of VAS were used to assess for factors associated with optimal adherence. Multivariate logistic regression analysis was done to determine factors independently associated with adherence to ART. Results: A total of 228 postnatal women and their infants were enrolled. Their mean age was 26.5years (SD 5.2) and mean duration on ART was 5.8 months (SD 5.8). Their infants were seen at a mean age of 7.5weeks (SD 2.1). The mean adherence level by self report for the three day and one week recall period was 92.3% and 93.8% respectively. Mean adherence level by VAS was 84.6%. The proportion of mothers with optimal adherence by self report was 196/228 [86.0%, 95% CI 81.9% - 90.9%] and 181/228 [79.4%, 95% CI 74.1% - 84.7%] using three day and one week recall period respectively. Only 69/228 [30.3%, 95% CI 24.3% - 36.3%] of the mothers had optimal adherence to option B+ ART by the VAS. The factors that were independently associated with optimal adherence to ART by SR and VAS respectively included; duration on ART of at least six months [AOR=3.6, 95% CI 1.1- 11.6], not requiring food before taking ART [AOR= 2.9, 95% CI 1.2- 6.9] and being on an alternative ART regimen other than TDF/3TC/EFV [AOR= 2.1, 95% CI 1.1- 3.9]. The barriers to optimal adherence were; stigma within and outside the home (22.4% and 15.4%) respectively, lack of support from the partner (20.4%) and forgetfulness (11.9%). Eight of the 228 infants (3.5%) had a positive HIV DNA PCR result. Conclusion: The level of adherence to option B+ ART among the HIV-positive post natal mothers in Mulago Hospital was reasonably good with majority (84.6% by SR) having optimal adherence. The factors independently associated with adherence to ART in mothers on Option B+ were; duration on ART of at least six months, not requiring food before taking ART and being on an ART drug combination other than TDF/3TC/EFV. However, barriers to optimal adherence reported among the mothers were stigma within and outside the home, lack of support from the male partners and forgetfulness. The prevalence of HIV at six weeks among infants born to mothers on Option B+ at Mulago hospital was low at 3.5%.
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    Adherence to antiretroviral therapy in HIV-positive adolescents in Uganda assessed by multiple methods a prospective cohort study
    (Adis, 2012-10) Wiens, Matthew O. ; MacLeod, Stuart ; Musiime, Victor ; Ssenyonga, Mark ; Kizza, Ruth ; Bakeera-Kitaka, Sabrina ; Odoi-Adome, Richard ; Ssali, Francis
    Background: The effectiveness of traditional adherence measurements used in adolescent populations isdifficult to assess. Antiretroviral (ARV) adherence research among adolescents living with HIV in resourceconstrained countries is particularly challenging and little evidence is available. Objectives: The primary objective of this study was to determine the feasibility of a large-scale, long-term study using electronic adherence monitoring in Uganda. The secondary objective was to compare accuracy of pill count (PC) and self-report (SR) adherence with electronic medication vials (eCAPs ). Methods: Adolescents receiving ARV therapy at the Joint Clinical Research Centre in Kampala, Uganda, were recruited. ARVs were dispensed in eCAPs for 1 year. Person-pill-days (PPDs) [1 day where adherence was measured for one medication in one patient] were calculated and a weighted paired t-test was used to compare the levels of adherence among subjects for three different adherence measurement methods. Results: Fifteen patients were included: 40% were female, mean age was 14 years, mean baseline CD4+ cell count was 244 cells/mL, and average treatment duration was 9 months at study entry. Overall, 4721 PPDs were observed. Some eCAPs required replacement during the study resulting in some data loss. Consent rate was high (94%) but was slow due to age limit cut-points. Overall adherence for SR was 99%, PC was 97% and eCAP was 88% (p < 0.05 for all comparisons). 93%, 67% and 23% of patients had an adherence of greater than 95% as measured by SR, PC and eCAP methods, respectively. Conclusions: A large-scale adherence study in Uganda would be feasible using a more robust electronic monitoring system. Adherence measurements produced by PCs and self-reporting methods appear to overestimate adherence measured electronically.
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    Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART
    (Wiley Online Library, 2018) Nuwagaba-Biribonwoha, Harriet ; Kiragga, Agnes N ; Yiannoutsos, Constantin T. ; Musick, Beverly S.  ; Wools-Kaloustian, Kara K. ; Ayaya, Samuel ; Wolf, Hilary ; Lugina, Emmanuel ; Ssali, John ; Abrams, Elaine J. ; Elul, Batya
    Introduction: Adolescence and pregnancy are potential risk factors for loss to follow-up (LTFU) while on antiretroviral therapy (ART). We compared adolescent and adult LTFU after ART initiation to quantify the impact of age, pregnancy, and site-level factors on LTFU. Methods: We used routine clinical data for patients initiating ART as young adolescents (YA; 10 to 14 years), older adolescents (OA; 15 to 19 years) and adults (≥20 years) from 2000 to 2014 at 52 health facilities affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) East Africa collaboration. We estimated cumulative incidence (95% confidence interval, CI) of LTFU (no clinic visit for ≥6 months after ART initiation) and identified patient and site-level correlates of LTFU, using multivariable Cox proportional hazards models for all patients as well as individual age groups. Results: A total of 138,387 patients initiated ART, including 2496 YA, 2955 OA and 132,936 adults. Of these, 55%, 78% and 66%, respectively, were female and 0.7% of YA, 22.3% of OA and 8.3% of adults were pregnant at ART initiation. Cumulative incidence of LTFU at five years was 26.6% (24.6 to 28.6) among YA, 44.1% (41.8 to 46.3) among OA and 29.3% (29.1 to 29.6) among adults. Overall, compared to adults, the adjusted hazard ratio, aHR, (95% CI) of LTFU for OA was 1.54 (1.41 to 1.68) and 0.77 (0.69 to 0.86) for YA. Compared to males, pregnant females had higher hazard of LTFU, aHR 1.20 (1.14 to 1.27), and nonpregnant women had lower hazard aHR 0.90 (0.88 to 0.93). LTFU hazard among the OA was primarily driven by both pregnant and nonpregnant females, aHR 2.42 (1.98 to 2.95) and 1.51 (1.27 to 1.80), respectively, compared to men. The LTFU hazard ratio varied by IeDEA program. Site-level factors associated with overall lower LTFU hazard included receiving care in tertiary versus primary-care clinics aHR 0.61 (0.56 to 0.67), integrated adult and adolescent services and food ration provision aHR 0.93 (0.89 to 0.97) versus nonintegrated clinics with food ration provision, having patient support groups aHR 0.77 (0.66 to 0.90) and group adherence counselling aHR 0.61 (0.57 to 0.67). Conclusions: Older adolescents experienced higher risk of LTFU compared to YA and adults. Interventions to prevent LTFU among older adolescents are critically needed, particularly for female and/or pregnant adolescents. Keywords: antiretroviral therapy (ART); pregnancy; adolescents; Africa; ART retention; HIV outcomes
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    Antiretroviral therapy in developing countries: pharmacologic considerations
    (Lippincott Williams & Wilkins, 2008) Lamorde, Mohammed ; Byakika-Kibwika, Pauline ; Merry, Concepta
    Purpose of review This article reviews recent studies in the field of clinical pharmacology of antiretroviral drugs and highlights the relevance of the findings to clinical practice in developing countries. Recent findings Differences in antiretroviral pharmacokinetics are associated with polymorphisms of genes encoding drug metabolizing enzymes. Inadequate concentrations of antiretrovirals in children are common. A study in African children found subtherapeutic concentrations in 40% of patients receiving efavirenz at recommended doses. Summary Recent findings on the pharmacokinetics of antiretroviral agents relevant to clinical practice in developing countries are reviewed. Widespread poverty impacts negatively on HIV/AIDS treatment and prevention efforts. Improved access to treatment, social and economic support and pharmacology research in target populations are needed.
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    Are the best antiretrovirals being used in Africa?
    (Mediscript Limited, 2006) John, Laurence ; Kambugu, Andrew ; Songa, Patricia ; castelnouvo, Barbara ; Colebunders, Robert ; Kamya, Moses
    No Abstract
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    Artemether-Lumefantrine combination therapy for treatment of uncomplicated malaria: The potential for complex interactions with antiretroviral drugs in HIV-infected individuals
    (Malaria Research and Treatment, 2011-02-14) Byakika-Kibwika, Pauline ; Lamorde, Mohammed ; Mayanja-Kizza, Harriet ; Khoo, Saye ; Merry, Concepta ; Van geertruyden, Jean-Pierre
    Treatment of malaria in HIV-infected individuals receiving antiretroviral therapy (ART) poses significant challenges. Artemether-lumefantrine (AL) is one of the artemisisnin-based combination therapies recommended for treatment of malaria. The drug combination is highly efficacious against sensitive and multidrug resistant falciparum malaria. Both artemether and lumefantrine are metabolized by hepatic cytochrome P450 (CYP450) enzymes which metabolize the protease inhibitors (PIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs) used for HIV treatment. Coadministration of NNRTIs and PIs with AL could potentially cause complex pharmacokinetic drug interactions. NNRTI by inducing CYP450 3A4 enzyme and PIs by inhibiting CYP450 3A4 enzymes could influence both artemether and lumefantrine concentrations and their active metabolites dihydroartemisinin and desbutyl-lumefantrine, predisposing patients to poor treatment response, toxicity, and risk for development of resistance. There are scanty data on these interactions and their consequences. Pharmacokinetic studies to evaluate these interactions in the target populations are urgently needed.
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    Assessment of the patient flow at the infectious diseases institute out-patient clinic, Kampala, Uganda
    (Taylor & Francis (Routledge), 2007) Colebunders, Robert ; Bukenya, T. ; Pakker, N. ; Smith, O. ; Boeynaems, V. ; Waldron, J. ; Muganga, Muganzi A. ; Twijukye, Coleb ; Mcadam, Keith ; Katabira, Elly
    In order to cope with the increasing patient load, a study was performed to identify bottlenecks in patient flow at the Infectious Diseases out-patient clinic in Kampala, Uganda on 10 January 2005. On a standardised questionnaire we recorded for all patients: the time they presented at reception, waiting times for different services and in- and out times for nursing, counselling and doctor visits. 250 patients visited the clinic the study day: 36 (20 per cent) were asymptomatic; 133 (75 per cent) symptomatic but not critically ill and 8 (4.5 per cent) severely ill; 63 (37.5 per cent) were on antiretroviral treatment. The median time spend at the clinic was 157 minutes (range 22-426). The median time from reception to the triage/vital-signs measuring unit was 34 minutes (range 3-92), from triage nurse to doctor 51 minutes (range 1-205), from doctor to pharmacy 24 minutes (range 5-292). The median waiting time at the pharmacy was 30 minutes (range 10-175). Based on these results, organisational changes were proposed. A similar methodology could be used to evaluate and compare health service delivery systems for persons with HIV infection in Africa in order to identify the most efficient models of care.
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    Assessment of parasite clearance following treatment of severe malaria with intravenous artesunate in Ugandan children enrolled in a randomized controlled clinical trial
    (BMC, 2018) Byakika‑Kibwika, Pauline ; Nyakato, Patience ; Lamorde, Mohammed ; Kiragga, Agnes N.
    Background Malaria control largely depends on availability of highly efficacious drugs, however, over the years, has been threatened by emergence of drug resistance. It is, therefore, important to monitor the impact of recurrent anti-malarial treatment on the long-term efficacy of anti-malarial regimens, especially in sub-Saharan African countries with high malaria transmission. Evaluation of parasite clearance following treatment of severe malaria with intravenous artesunate among patients in Eastern Uganda, was performed, as a contribution to monitoring anti-malarial effectiveness. Methods Parasite clearance data obtained from a clinical trial whose objective was to evaluate the 42-day parasitological treatment outcomes and safety following treatment of severe malaria with intravenous artesunate plus artemisinin-based combination therapy among patients attending Tororo District Hospital in Eastern Uganda, were analysed. Serial blood smears were performed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20, 24 h, followed by 6-hourly blood smears post start of treatment until 6 h post the first negative blood smear when parasite clearance was achieved. Study endpoints were; parasite clearance half-life (the time required for parasitaemia to decrease by 50% based on the linear portion of the parasite clearance slope) and parasite clearance time (time required for complete clearance of initial parasitaemia). Results One hundred and fifty participants with severe malaria were enrolled. All participants were treated with intravenous artesunate. All study participants tolerated artesunate well with rapid recovery from symptoms and ability to take oral mediation within 24 h. No immediate adverse events were recorded. The median (IQR) number of days to complete parasite clearance was of 2 (1–2). The median (IQR) time to clear 50% and 99% parasites was 4.8 (3.61–7.10) and 17.55 (14.66–20.66) h, respectively. The median estimated clearance rate constant per hour was 0.32. The median (IQR) slope half-life was 2.15 (1.64, 2.61) h. Conclusion Parasite clearance following treatment with intravenous artesunate was rapid and adequate. This finding provides supportive evidence that resistance to artemisinins is unlikely to have emerged in this study area. Continuous monitoring of artemisinin effectiveness for malaria treatment should be established in high malaria transmission areas in sub-Saharan Africa where spread of resistance would be disastrous.
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    An Autopsy Study Describing Causes of Death and Comparing Clinico-Pathological Findings among Hospitalized Patients in Kampala, Uganda
    (PLoS ONE, 2012-03-14) Cox, Janneke A. ; Lukande, Robert L. ; Nelson, Ann M. ; Mayanja-Kizza, Harriet ; Colebunders, Robert ; Van Marck, Eric ; Manabe, Yukari C.
    Background: Information on causes of death in HIV-infected patients in Sub-Saharan Africa is mainly derived from observational cohort and verbal autopsy studies. Autopsy is the gold standard to ascertain cause of death. We conducted an autopsy study to describe and compare the clinical and autopsy causes of death and contributory findings in hospitalized HIV-infected and HIV-uninfected patients in Uganda. Methods: Between May and September 2009 a complete autopsy was performed on patients that died on a combined infectious diseases gastroenterology ward in Mulago Hospital in Kampala, Uganda. Autopsy cause of death and contributing findings were based on the macro- and microscopic post-mortem findings combined with clinical information. Clinical diagnoses were reported by the ward doctor and classified as confirmed, highly suspected, considered or not considered, based on information derived from the medical chart. Results are reported according to HIV serostatus. Results: Fifty-three complete autopsies were performed in 66% HIV-positive, 21% HIV-negative and 13% patients with an unknown HIV serological status. Infectious diseases caused death in 83% of HIV-positive patients, with disseminated TB as the main diagnosis causing 37% of deaths. The spectrum of illness and causes of death were substantially different between HIV-positive and HIV-negative patients. In HIV-positive patients 12% of postmortem diagnoses were clinically confirmed, 27% highly suspected, 16% considered and 45% not considered. In HIV-negative patients 17% of postmortem diagnoses were clinically highly suspected, 42% considered and 42% not considered. Conclusion: Autopsy examination remains an important tool to ascertain causes of death particularly in settings with limited access to diagnostic testing during life. HIV-positive patients continue to die from treatable and clinically undiagnosed infectious diseases. Until rapid-point of care testing is available to confirm common infections, empiric treatment should be further investigated.
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    Awareness and acceptability of sickle cell screening among youth attending outpatient department, Soroti regional referral hospital, eastern Uganda
    (Makerere University, 2016-05) Okuuny, Vincent
    Background: The morbidity and mortality rate of SCD is of a global concern particularly in developing countries. Therefore screening for sickle cell and genetic counseling before child bearing may be helpful in the prevention of the condition. It provides genetic related reproductive risk information especially in resource limited countries where other available preventive methods may not be readily available or ethically/legally allowed. However, the awareness and acceptability of sickle cell screening among youth is not well documented in Uganda and Soroti district in particular. It is therefore important to determine awareness, acceptability as well as factors influencing sickle cell screening among youth. This is particularly so for the youth since they constitute the majority of intending couples hence those that will produce genes that will make up the gene pool for future generations. Objective: To assess the awareness and acceptability as well describe the factors influencing sickle cell screening among youth attending the OPD at SRRH in Eastern Uganda. Methods: This was a cross-sectional study carried out in SRRH. A sample size of 384 participants was estimated to be recruited into the study using the consecutive sampling method. Data was collected for a month using pre-tested questionnaires. Data was entered into EpiData3.1 computer software and exported to STATA 10.0 for analysis. Frequencies and percentages were determined, univariate, bivariate, multivariate and logistic regression was done. Results: A total of 378 respondents participated in the study. The awareness of sickle cell screening was low 151(43%) although awareness of sickle cell disease was high 348(92%) among the participants. The level of acceptability of sickle cell screening among the participants was high 338(97%). However the socio demographic factors did not have influence on awareness and acceptability of sickle cell screening except tribe that had an influence on awareness. Conclusion: There was a low level of awareness of sickle cell screening although the level of acceptability of sickle cell screening was high amongst youth. Generally socio demographic factors did not have influence on awareness and acceptability except the tribe. Recommendations: Routine sickle cell screening need to be introduced at all health care levels to enable youth make well informed decisions concerning genetic consequences of SCD before child bearing. CHAPTER ONE 1.0 Background SCD is an autosomal recessive genetically transmitted hemoglobinopathy. In Africa, three forms exist namely; sickle cell anemia (HbSS), sickle cell hemoglobin C (HbSC) and sickle cell thalassemia (HbSThal).Children born to two parents with the sickle cell trait(SCT) gene have a 25% chance of having SCD and a 50% chance of having the SCT(1) In African countries, the prevalence of sickle cell is variable with the highest prevalence of the SCT occurring between latitudes 15°north and 20°south. This is attributed to the selective advantage sickle cell trait carriers have due to their immunity to severe malaria (2) The main pathology in SCD is the trapping of sickle shaped red cells in small blood vessels that manifests as pain and is the most distressing symptoms which may often warrant hospitalization of the clients. Until recently, there has been no effective cure for SCD, increasing attention is being paid to stem cell and gene therapy intervention but it is unlikely that this will become standard management in resource limited countries like Uganda soon. Therefore the mainstay of management in the present situation is only supportive when in crisis(3). The morbidity and mortality rates of hemoglobin disorders especially SCD is of a global concern particularly in developing countries since hemoglobin disorders account for about 3.4% of deaths globally and 6.4% in Africa alone among children less than 5 years of age (4) It is estimated that approximately 7% of the world population are carriers of these disorders and 300,000–400,000 babies with severe forms of these disorders are born each year with 83% sickle cell disorders and 17% thalassemia(5) It is imperative to promote preventive efforts against SCD since it is a genetic disorder with no cure. Genetic counseling for couples intending to have children is a highly recommended approach. However, for this approach to succeed, the potential parents should be aware of the disease. A study done in West Africa reported low awareness on sickle cell and this might explain the continued propagation of the condition. This may as well be the reason why SCD prevention has remained a challenge even 100 years after it was first described in the western medical literature by James B. Herrick since over 9 million carriers continue to become pregnant annually (6) Other approaches like, post-natal diagnosis and selective abortion still remain a challenge. It is difficult to know who and what you are aborting, meaning that preconception genetic testing and strategic reproductive choices are basics that are more consistent with ethical principles and good conscience
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    Barriers and facilitators to chemotherapy initiation and adherence for patients with HIV-associated Kaposi’s sarcoma in Kenya: A qualitative study
    (BMC, 2022) McMahon, Devon E. ; Singh, Rhea ; Chemta, Linda ; Semeere, Aggrey ; Byakwaga, Helen ; Grant, Merridy ; Laker‑Oketta, Miriam ; Lagat, Celestine ; Collier, Sigrid ; Maurer, Toby ; Martin, Jeffrey ; Bassett, Ingrid V. ; Butler, Lisa ; Kiprono, Samson ; Busakhala, Naftali ; Freeman, Esther E.
    Background: Kaposi sarcoma is one of the most prevalent HIV‑associated malignancies in sub‑Saharan Africa and is often diagnosed at advanced stage of disease. Only 50% of KS patients who qualify for chemotherapy receive it and adherence is sub‑optimal. Methods: 57 patients > 18 years with newly diagnosed KS within the AMPATH clinic network in Western Kenya were purposively selected to participate in semi‑structured interviews stratified by whether they had completed, partially completed, or not completed chemotherapy for advanced stage KS. We based the interview guide and coding framework on the situated Information, Motivation, Behavioral Skills (sIMB) framework, in which the core patient centered IMB constructs are situated into the socioecological context of receiving care. Results: Of the 57 participants, the median age was 37 (IQR 32–41) and the majority were male (68%). Notable barriers to chemotherapy initiation and adherence included lack of financial means, difficulty with convenience of appointments such as distance to facility, appointment times, long lines, limited appointments, intrapersonal barriers such as fear or hopelessness, and lack of proper or sufficient information about chemotherapy. Factors that facilitated chemotherapy initiation and adherence included health literacy, motivation to treat symptoms, improvement on chemotherapy, prioritization of self‑care, resilience while experiencing side effects, ability to carry out behavioral skills, obtaining national health insurance, and free chemotherapy. Conclusion: Our findings about the barriers and facilitators to chemotherapy initiation and adherence for KS in Western Kenya support further work that promotes public health campaigns with reliable cancer and chemotherapy information, improves education about the chemotherapy process and side effects, increases oncology service ability, supports enrollment in national health insurance, and increases incorporation of chronic disease care into existing HIV treatment networks.
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    Belief in divine healing can be a barrier to antiretroviral therapy adherence in Uganda
    (Lippincott Williams & Wilkins., 2007) Wanyama, Jane ; Castelnuovo, Barbara ; Wandera, Bonnie ; Mwebaze, Patricia ; Kambugu, Andrew ; Bangsberg, David R. ; Kamya, Moses R.
    Although recent data suggest high levels of adherence to expanding antiretroviral therapy (ART) programmes in resource-limited settings, the culture- specific barriers to adherence are poorly understood. In a prospective observational study, we found that 1.2% of patients discontinued ART because of a belief in spiritual healing. Spiritual beliefs should be an important part of ART adherence counselling in resource-limited settings, requiring close collaboration between HIV care programmes and religious leaders to identify common goals and ensure successful treatment.
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    Bilateral pedal edema in an HIV patient: Lopinavir/Ritonavir-containing treatment regimen as a potential cause?
    (Open Learning on Enteric Pathogens, 2009-03) Shihab, Hasan M ; Lutwama, Fred ; Piloya, Theresa ; Castelnuovo, Barbara ; Kambugu, Andrew D. ; Colebunders, Robert
    A large number of patients are switched to second-line antiretroviral therapy, especially in resource limited settings. Lopinavir/Ritonavir is the main drug used in second-line treatment regimens. We describe a patient attending an HIV treatment centre in Kampala, Uganda, who presented with bilateral non-tender pitting inflammatory edema two weeks after switching to a Lopinavir/Ritonavir-containing second-line treatment regimen. The lack of an alternate explanation led us to suspect that Lopinavir/Ritonavir was potentially responsible for the edema
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    Biomarkers of HIV immune reconstitution inflammatory syndrome
    (Future Medicine, 2008) Bonham, Shuli ; Meya, David B ; Bohjanen, Paul R. ; Boulware, David R.
    Dysregulation of the immune system drives HIV pathogenesis. As we develop new ways to treat HIV and AIDS, we encounter new clinical ramifications of our treatment on regulatory components of the Immune system. HIV-associated Immune in reconstruction Inflammatory syndrome (IRIS) occurs after initiation of antiretroviral therapy with inappropriate and unbalanced restoration of the immune system, resulting in pathologic Inflammatory reactions with significant morbidity. IRIS is most commonly associated with latent, occur or past infectious, including tuberculosis, Cryptococcus neoformans and Mycobacterium avium complex. We discuss common clinical presentations, new diagnostic modalities, current hypotheses of IRIS pathogenesis and future directions of IRIS-related research, focusing on the identification biomarkers that can be used to predict and diagnose IRIS
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    Bronchoalveolar lavage enzyme-linked immunospot for diagnosis of smear-negative tuberculosis in HIV infected patients
    (Public Library of Science, 2012-06-26) Cattamanchi, Adithya ; Ssewenyana, Isaac ; Nabatanzi, Rose ; Den Boon, Saskia ; Andama, Alfred ; Worodria, William ; Cao, Huyen ; Huang, Laurence ; Davis, J. Lucian ; Miller, Cecily R.
    Background: Peripheral blood interferon-gamma release assays (IGRAs) have sub-optimal sensitivity and specificity for diagnosis of active pulmonary tuberculosis (TB). However, assessment of local immune responses has been reported to improve the accuracy of TB diagnosis. Methods: We enrolled HIV-infected adults with cough $2 weeks’ duration admitted to Mulago Hospital in Kampala, Uganda and referred for bronchoscopy following two negative sputum acid-fast bacillus smears. We performed an ELISPOT-based IGRA (T-SPOT.TBH, Oxford Immunotec, Oxford, UK) using peripheral blood and bronchoalveolar lavage (BAL) fluid mononuclear cells, and determined the accuracy of IGRAs using mycobacterial culture results as a reference standard. Results: 94 HIV-infected patients with paired peripheral blood and BAL IGRA results were included. The study population was young (median age 34 years [IQR 28–40 years]) and had advanced HIV/AIDS (median CD4+ T-lymphocyte count 60 cells/ml [IQR 22–200 cells/ml]). The proportion of indeterminate IGRA results was higher in BAL fluid than in peripheral blood specimens (34% vs. 14%, difference 20%, 95% CI 7–33%, p = 0.002). BAL IGRA had moderate sensitivity (73%, 95% CI 50– 89%) but poor specificity (48%, 95% CI 32–64%) for TB diagnosis. Sensitivity was similar (75%, 95% CI 57–89%) and specificity was higher (78%, 95% CI 63–88%) when IGRA was performed on peripheral blood. Conclusions: BAL IGRA performed poorly for the diagnosis of smear-negative TB in a high HIV/TB burden setting. Further studies are needed to examine reasons for the large proportion of indeterminate results and low specificity of BAL IGRA for active TB in high HIV/TB burden settings.
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    The burden of severe asthma in sub-Saharan Africa: Findings from the African Severe Asthma Project
    (Elsevier, 2024) Kirenga, Bruce J. ; Chakaya, Jeremiah ; Yimer, Getnet ; Nyale, George ; Haile, Tewodros ; Muttamba, Winters ; Mugenyi, Levicatus ; Katagira, Winceslaus ; Worodria, William ; Aanyu-Tukamuhebwa, Hellen ; Lugogo, Njira ; Joloba, Moses ; Mersha, Tesfaye B. ; Bekele, Amsalu ; Fred Makumbi, Fred ; Mekasha, Amha ; Green, Cynthia L. ; de Jong, Corina ; Kamya, Moses ; van der Molen, Thys
    Background: Severe asthma is associated with high morbidity, mortality, and health care utilization, but its burden in Africa is unknown. Objective: We sought to determine the burden (prevalence, mortality, and activity and work impairment) of severe asthma in 3 countries in East Africa: Uganda, Kenya, and Ethiopia. Methods: Using the American Thoracic Society/European Respiratory Society case definition of severe asthma, we analyzed for the prevalence of severe asthma (requiring Global Initiative for Asthma [GINA] steps 4-5 asthma medications for the previous year to achieve control) and severe refractory asthma (remains uncontrolled despite treatment with GINA steps 4-5 asthma medications) in a cohort of 1086 asthma patients who had been in care for 12 months and had received all GINA-recommended medications. Asthma control was assessed by the asthma control questionnaire (ACQ). Results: Overall, the prevalence of severe asthma and severe refractory asthma was 25.6% (95% confidence interval [CI], 23.1-28.3) and 4.6% (95% CI, 3.5-6.0), respectively. Patients with severe asthma were (nonsevere vs severe vs severe refractory) older (39, 42, 45 years, P = .011), had high skin prick test reactivity (67.1%, 76.0%, 76.0%, P = .004), had lower forced expiratory volume in 1 second percentage (81%, 61%, 55.5%, P < .001), had lower quality of life score (129, 127 vs 121, P < .001), and had higher activity impairment (10%, 30%, 50%, P < .001). Factors independently associated with severe asthma were hypertension comorbidity; adjusted odds ratio 2.21 (1.10-4.47), P = .027, high bronchial hyperresponsiveness questionnaire score; adjusted odds ratio 2.16 (1.01-4.61), P = .047 and higher ACQ score at baseline 2.80 (1.55-5.08), P = .001. Conclusion: The prevalence of severe asthma in Africa is high and is associated with high morbidity and poor quality of life.
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    Can response of a pruritic papular eruption to antiretroviral therapy be used as a clinical parameter to monitor virological outcome?
    (Lippincott Williams & Wilkins, 2008) Castelnuovo, Barbara ; Byakwaga, Hellen ; Menten, Joris ; Schaefer, Petra ; Kamya, Moses ; Colebunders, Robert
    Background: A pruritic papular eruption (PPE) is a common skin manifestation observed in 12–46% of persons with HIV infection living in tropical countries. Objective: To determine whether PPE responds to HAART and whether monitoring PPE severity could be used as a clinical marker to predict virological outcome in resource limited settings where viral load testing is not available. Methods: The study enrolled 53 patients with PPE for at least 1 month before starting a first-line HAART regimen as part of a prospective study. CD4 cell count and viral load were measured at enrolment and every 3 months. A scoring system was developed to evaluate the PPE severity by asking two questions. Over the last month how itchy has your skin been? Over the last month how has itching interfered with your sleep? Results: Median CD4 cell count was 15 cells/ml and median viral load 268 663 copies/ ml. All patients initiated a regimen containing a nonnucleoside reverse transcriptase inhibitor. Mean PPE score declined from 3.9 at enrolment to 0.1 at 24 months. In 37 (86%) of the 43 patients with at least 6 months of follow-up data, the PPE disappeared and never returned. Patients with viral load >400 copies/ml at months 9 and/or 12 had significantly higher PPE scores at months 9 to 12 than the patients with <400 copies/ml. Conclusions: In most patients, PPE disappears during HAART and PPE severity scores were higher in patients whose first-line HAART failed to control plasma viral load.