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ItemOptimizing HIV virologic outcomes for pregnant and breastfeeding women and infant testing coverage in South Western Uganda(Makerere University, 2026)Background: Achieving viral suppression among pregnant and breastfeeding women is critical for eliminating vertical transmission of HIV in Sub-Saharan Africa. Adherence to antiretroviral therapy (ART) and disclosure of HIV status are key determinants of viral suppression and play a crucial role in preventing perinatal HIV transmission. However, multiple barriers—including stigma, limited knowledge, and restricted healthcare access—impede these efforts. Peer-led counseling interventions offer a promising approach to improving maternal ART adherence, promoting HIV status disclosure, and enhancing early infant diagnosis by equipping mothers with the knowledge and skills necessary to prevent perinatal HIV transmission. Understanding maternal perceptions of viral suppression is essential for implementing effective strategies to eliminate Vertical transmission of HIV. Objective: To evaluate the effect of the Enhanced Viral Load Counseling and Standardized Peer-Mother Support (ENHANCED-SPS) intervention on viral suppression among pregnant and breastfeeding women living with HIV in rural Uganda, and assess whether peer-led support enhances completion of infant HIV testing. Methods: This was an Implementation Science Research study that utilized a before-and-after cluster randomized trial design conducted in two phases. In phase one, we determined the prevalence of viral suppression and identified motivators and barriers to viral suppression among pregnant and postpartum women using retrospective data from the SEARCH trial. Additionally, we examined facility- and community-level barriers and facilitators of viral suppression among women of reproductive age in southwestern Uganda. Based on these findings, we employed the PRECEDE model of health promotion to design the ENHANCED-SPS intervention, which included enhanced viral load counseling and standardized peer-mother support to address structural barriers and specific needs of the target population. In phase two, we evaluated the ENHANCED-SPS intervention’s impact on viral suppression (primary outcome) and secondary outcomes, including ART adherence, HIV status disclosure, and infant HIV testing. A cluster-randomized trial (NCT04122144) was conducted from September 2019 to October 2021 in 14 high-HIV-prevalence public facilities in rural southwestern Uganda, randomized 1:1 to intervention or standard care. Guided by the PRECEDE model, the intervention included: (1) provider training on viral load counseling (predisposing), (2) standardized peer-mother support with bi-weekly phone counseling (enabling), and (3) point-of-care viral load monitoring with provider-peer feedback (reinforcing). Participants received adherence assessments and tailored plans to address ART and infant testing barriers. Outcomes were analyzed using TMLE to account for missing data, repeated measures, and clustering. Secondary outcomes included ART adherence (≤1 missed dose/month), HIV disclosure, and infant HIV testing (via medical record review). A qualitative sub-study explored women's perceptions of viral suppression using transcribed, coded interviews in Dedoose. Results: In phase one of the study, among enumerated participants at baseline, HIV testing among 15–45-year-old women was high at 92% and 93% with similar HIV prevalence of 12.6% and 12.3%, in intervention and control communities, retrospectively. Among women living with HIV, with a history of pregnancy/live birth, viral suppression was 42% and 44% at baseline, and 81% and 76% (p=0.002) at year 3, respectively. Overall, by year 3, the intervention communities achieved significantly higher viral suppression (77%) compared to controls (68%, p<0.001) among all 15-45-year-old women living with HIV. Pregnancy/live birth was a predictor of year-3 VS in control (p=0.016) but not intervention (p=0.43). Younger age was a risk factor for non-suppression in both arms. In Phase two of the study, a total of 505 pregnant and postpartum women were enrolled between September 2019 and October 2020. The median age was 28 years; 96% were pregnant, 69% had been previously diagnosed with HIV, and 70.0% (95% CI: 65.9–74.1%) were virally suppressed at baseline. After 12 months, viral suppression increased to 94.9% (95% CI: 92.5–97.4%), representing an absolute increase of 24.9% (95% CI: 21.6–28.2%; p < 0.001). The intervention yielded significant improvements in viral suppression across all age groups, among both pregnant and postpartum women, and within strata defined by care status and duration of ART use. Despite a 58.9% (95%CI: 27.4-90.3%) improvement from baseline, viral suppression among post-partum women at 12 months was only 75.7%. ART adherence improved from 68% (95% CI: 62–74%) at baseline to 93% (95% CI: 81–100%) at 12 months, a 25% increase (95% CI: 9–40%; p = 0.009), with the largest gains seen in participants aged 15–24 years, those breastfeeding, or those not virally suppressed at enrollment. HIV status disclosure increased from 80% (95% CI: 69–90%) at baseline to 94% (95% CI: 89–99%) after 12 months, a 14% improvement (95% CI: 8–21%; p = 0.003); similar trends were observed for disclosure to a spouse or partner. Among 464 children (234 in the intervention and 230 in the control arm) born to study participants, final HIV testing (antibody rapid test at 18 months) was completed in 94.5% (95% CI: 91.6–97.5%) of cases in the intervention group versus 83.3% (95% CI: 78.4–88.3%) in the control group, yielding an 11.2% difference (95% CI: 5.4–17.0%; p < 0.001). While there were no significant differences in the proportions completing the 1st (4–6 weeks) or 2nd (9 months) tests, the 3rd test (6 weeks post-breastfeeding cessation) was completed at a rate 14.8% (95% CI: 7.9–21.8%; p < 0.001) higher in the intervention arm. In a qualitative sub-study, women living with HIV described viral suppression in the context of achieving good health and ensuring HIV-free infants. They emphasized that adherence to ART was key to attaining viral suppression and noted that engagement with healthcare providers was crucial, despite experiencing barriers such as anticipated stigma, challenges with HIV status disclosure, pregnancy-related distress, and long distances to health facilities. Conclusion: The multi-component, peer-led ENHANCED-SPS intervention significantly improved viral suppression, ART adherence, and HIV status disclosure among pregnant and postpartum women. The intervention also increased infant HIV testing completion rates, facilitating early diagnosis and timely linkage to care. Despite these successes, viral suppression among breastfeeding women remained suboptimal (75.7%), underscoring the need for additional postpartum interventions. The findings emphasize the importance of culturally sensitive viral suppression education, adherence support, and non-judgmental healthcare environments to enhance maternal and infant health outcomes in HIV care programs.
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ItemElectronic logistics management information system and supply chain performance in public health facilities in Greater Kampala Metropolitan Area(Makerere University, 2026)Introduction: Efficient and transparent supply chain systems are essential for sustained access to medicines and health commodities. Uganda's Ministry of Health introduced the Electronic Logistics Management Information System (eLMIS) to strengthen inventory control, reporting, and logistics decision-making; however, evidence on the extent of its adoption, depth of utilization, and measurable effect on supply chain performance at facility level remains limited. Objective: To assess the adoption and utilization of eLMIS and their effect on supply chain performance in public health facilities in the Greater Kampala Metropolitan Area (GKMA). Methods: A cross-sectional descriptive–analytical study was conducted in 60 public health facilities across Kampala, Wakiso, Mukono, and Mpigi districts, with one purposively selected respondent responsible for medicines management per facility. Data were collected through structured facility assessments, staff interviews, and document review of tracer-commodity records. Analysis in IBM SPSS Statistics version 28 employed descriptive statistics, chi-square and independent-samples t-tests, Pearson correlation, and multiple linear regression with facility level as a control variable. Results: Overall, 55.0% (33/60; 95% CI: 41.6–67.9%) of facilities had adopted eLMIS, with adoption increasing by level of care: 45.5% of Health Centre IIIs, 72.7% of Health Centre IVs, and 100% of hospitals. Among adopters, the system was used predominantly for reporting (90.9%) and inventory management (81.8%), and facilities with trained staff recorded higher utilization than those without (mean 4.0 vs 3.2). Compared with non-adopters, eLMIS facilities had fewer stock-outs of tracer medicines (21% vs 52%; χ² = 6.13, p = 0.013), fewer expired batches (mean 3.1 vs 7.4; p = 0.005), and shorter order lead times (3.2 vs 4.6 weeks; p = 0.033). eLMIS utilization independently predicted supply chain performance after adjusting for facility level (β = 0.61, p < 0.001), with the model explaining 44% of performance variance (R² = 0.44). Conclusion: eLMIS adoption and, more decisively, the intensity of its utilization were associated with superior supply chain performance. Scaling these benefits equitably requires targeted investment in infrastructure, staff training, and supportive supervision, particularly at Health Centre III level, alongside routine monitoring of objective supply chain indicators. Keywords: electronic Logistics Management Information System; eLMIS; supply chain performance; adoption; utilization; public health facilities; Greater Kampala Metropolitan Area; Uganda
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ItemIntention to vaccinate against COVID-19 and adherence to non-pharmaceutical interventions against COVID-19 prior to the second wave of the pandemic in Uganda: a cross-sectional study(BMJ, 2022)Objectives The resurgence in cases and deaths due to COVID-19 in many countries suggests complacency in adhering to COVID-19 preventive guidelines. Vaccination, therefore, remains a key intervention in mitigating the impact of the COVID-19 pandemic. This study investigated the level of adherence to COVID-19 preventive measures and intention to receive the COVID-19 vaccine among Ugandans. Design, setting and participants A nationwide crosssectional survey of 1053 Ugandan adults was conducted in March 2021 using telephone interviews. Main outcome measures Participants reported on adherence to COVID-19 preventive measures and intention to be vaccinated with COVID-19 vaccines. Results Overall, 10.2% of the respondents adhered to the COVID-19 preventive guidelines and 57.8% stated definite intention to receive a SARS-CoV-2 vaccine. Compared with women, men were less likely to adhere to COVID-19 guidelines (Odds Ratio (OR)=0.64, 95% CI 0.41 to 0.99). Participants from the northern (4.0%, OR=0.28, 95% CI 0.12 to 0.92), western (5.1%, OR=0.30, 95% CI 0.14 to 0.65) and eastern regions (6.5%, OR=0.47, 95% CI 0.24 to 0.92), respectively, had lower odds of adhering to the COVID-19 guidelines than those from the central region (14.7%). A higher monthly income of ≥US$137 (OR=2.31, 95% CI 1.14 to 4.58) and a history of chronic disease (OR=1.81, 95% CI 1.14 to 2.86) were predictors of adherence. Concerns about the chances of getting COVID-19 in the future (Prevalence Ratio (PR)=1.26, 95% CI 1.06 to 1.48) and fear of severe COVID-19 infection (PR=1.20, 95% CI 1.04 to 1.38) were the strongest predictors for a definite intention, while concerns for side effects were negatively associated with vaccination intent (PR=0.75, 95% CI 0.68 to 0.83). Conclusion Behaviour change programmes need to be strengthened to promote adherence to COVID-19 preventive guidelines as vaccination is rolled out as another preventive measure. Dissemination of accurate, safe and efficacious information about the vaccines is necessary to enhance vaccine uptake.
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ItemUnintended socio-economic and health consequences of COVID-19 among slum dwellers in Kampala, Uganda(BMC Public Health, 2022)Abstract Background: To reduce the spread of COVID-19, several countries in Africa instituted countrywide lockdowns and other public health measures. Whereas lockdowns contributed to the control of the pandemic, there were concerns about the unintended consequences of these measures especially in the most vulnerable populations. We assessed unintended socio-economic and health consequences due to the COVID-19 pandemic and the mitigation measures among slum dwellers in Kampala to inform the on-going and future pandemic response strategies. Methods: This was a mixed methods cross-sectional study conducted in Bwaise I and Bwaise III slums of Kawempe division, Kampala Uganda from October to December 2020. We used systematic sampling to randomly select 425 household heads for the face-to-face quantitative interviews. We also conducted six focus group discussions (FGDs) with slum dwellers and used photovoice among eight Community Health Workers (CHWs) to document unintended socio-economic and health consequences. Quantitative data were imported into STATA version 14.0 for analysis, while qualitative data were analysed thematically using NVivo version 12. Modified Poisson regression analysis was conducted to establish factors associated with impact on access to food. Results: Most respondents reported limited access to food (71.1%; 302/425); disruption in education (77.1%; 270/350); drop in daily income and wages (86.1%; 329/382) and loss of employment (63.1; 125/198). Twenty five percent of the respondents (25.4%; 86/338) reported domestic violence as one of the challenges. Seven themes emerged from the qualitative findings on the impact of COVID-19 including: limited access to food; negative impact on children’s rights (child labour and teenage pregnancies) and education; poor housing and lack of accommodation; negative social behaviours; negative impact on family and child care; reduced income and employment; and negative impact on health and access to health care services. Conclusion: The slum dwellers of Bwaise I and Bwaise III experienced several negative socio-economic and health consequences of COVID-19 and its prevention measures that severely affected their wellbeing. Children experienced severe consequences such as child labour and teenage pregnancies among the girls. Response activities should be contextualised to different settings and protocols to protect the vulnerable groups in the community such as children and women should be developed and mainstreamed in response activities.
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ItemToll-Like Receptor-Induced Immune Responses During Early Childhood and Their Associations With Clinical Outcomes Following Acute Illness Among Infants in Sub-Saharan Africa(Frontiers in Immunology, 2022)Severely ill children in low- and middle-income countries (LMICs) experience high rates of mortality from a broad range of infectious diseases, with the risk of infection-related death compounded by co-existing undernutrition. How undernutrition and acute illness impact immune responses in young children in LMICs remains understudied, and it is unclear what aspects of immunity are compromised in this highly vulnerable population. To address this knowledge gap, we profiled longitudinal whole blood cytokine responses to Toll-like receptor (TLR) ligands among severely ill children (n=63; 2-23 months old) with varied nutritional backgrounds, enrolled in the CHAIN Network cohort from Kampala, Uganda, and Kilifi, Kenya, and compared these responses to similar-aged well children in local communities (n=41). Cytokine responses to ligands for TLR-4 and TLR-7/8, as well as Staphylococcus enterotoxin B (SEB), demonstrated transient impairment in T cell function among acutely ill children, whereas innate cytokine responses were exaggerated during both acute illness and following clinical recovery. Nutritional status was associated with the magnitude of cytokine responses in all stimulated conditions. Among children who died following hospital discharge or required hospital re-admission, exaggerated production of interleukin-7 (IL-7) to all stimulation conditions, as well as leukopenia with reduced lymphocyte and monocyte counts, were observed. Overall, our findings demonstrate exaggerated innate immune responses to pathogen-associated molecules among acutely ill young children that persist during recovery. Heightened innate immune responses to TLR ligands may contribute to chronic systemic inflammation and dysregulated responses to subsequent infectious challenges. Further delineating mechanisms of innate immune dysregulation in this population should be prioritized to identify novel interventions that promote immune homeostasis and improve outcomes.