Browsing by Author "Alamo, Stella"

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    Client and Provider Perspectives of the Efficiency and Quality of Care in the Context of Rapid Scale-Up of Antiretroviral Therapy
    (AIDS patient care and STDs, 2010) Amanyire, Gideon; Wanyenze, Rhoda K.; Alamo, Stella; Kwarisiima, Dalsone; Sunday, Pamela; Sebikaari, Gloria; Kamya, Moses; Wabwire-Mangen, Fred; Wagner, Glenn
    Global scale-up of antiretroviral therapy (ART) has focused on clinical outcomes with little attention on its impact on existing health systems. In June–August 2008, we conducted a formative evaluation on ART scale-up and clinic operations at three clinics in Uganda to generate lessons for informing policy and larger public health care systems. Site visits and semistructured interviews with 10 ART clients and 6 providers at each clinic were used to examine efficiency of clinic operations (patient flow, staff allocation to appropriate duties, scheduling of clinic visits, record management) and quality of care (attending to both client and provider needs, and providing support for treatment adherence and retention). Clients reported long waiting times but otherwise general satisfaction with the quality of care. Providers reported good patient adherence and retention, and support mechanisms for clients. Like clients, providers mentioned long waiting times and high workload as major challenges to clinic expansion. Providers called for more human resources and stress-release mechanisms to prevent staff burnout. Both providers and clients perceive these clinics to be delivering good quality care, despite the recognition of congested clinics and long waiting times. These findings highlight the need to address clinic efficiency as well as support for providers in the context of rapid scale-up.
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    Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda
    (Clinical Infectious Diseases, 2021) Loevinsohn, Gideon; Kigozi, Godfrey; Kagaayi, Joseph; Wawer, Maria J.; Nalugoda, Fred; Chang, Larry W.; Quinn, Thomas C.; Serwadda, David; Reynolds, Steven J.; Nelson, Lisa; Mills, Lisa; Alamo, Stella; Nakigozi, Gertrude; Kabuye, Geoffrey; Ssekubugu, Robert; Tobian, Aaron A. R.; Gray, Ronald H.; Grabowski, M. Kathryn
    The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men.
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    HIV epidemiologic trends among occupational groups in Rakai, Uganda: A population-based longitudinal study, 1999–2016
    (Public Library of Science, 2024-02-20) Popoola, Victor O; Kagaayi, Joseph; Ssekasanvu, Joseph; Ssekubugu, Robert; Kigozi, Grace; Ndyanabo, Anthony; Nalugoda, Fred; Chang, Larry W; Lutalo, Tom; Tobian, Aaron A. R; Kabatesi, Donna; Alamo, Stella; Mills, Lisa A; Kigozi, Godfrey; Wawer, Maria J; Santelli, John; Gray, Ronald H; Reynolds, Steven J; Serwadda, David; Lessler, Justin; Grabowski, M. Kate
    Certain occupations have been associated with heightened risk of HIV acquisition and spread in sub-Saharan Africa, including female bar and restaurant work and male transportation work. However, data on changes in population prevalence of HIV infection and HIV incidence within occupations following mass scale-up of African HIV treatment and prevention programs is very limited. We evaluated prospective data collected between 1999 and 2016 from the Rakai Community Cohort Study, a longitudinal population-based study of 15- to 49-year-old persons in Uganda. Adjusted prevalence risk ratios for overall, treated, and untreated, prevalent HIV infection, and incidence rate ratios for HIV incidence with 95% confidence intervals were estimated using Poisson regression to assess changes in HIV outcomes by occupation. Analyses were stratified by gender. There were 33,866 participants, including 19,113 (56%) women. Overall, HIV seroprevalence declined in most occupational subgroups among men, but increased or remained mostly stable among women. In contrast, prevalence of untreated HIV substantially declined between 1999 and 2016 in most occupations, irrespective of gender, including by 70% among men (12.3 to 4.2%; adjPRR = 0.30; 95%CI:0.23–0.41) and by 78% among women (14.7 to 4.0%; adjPRR = 0.22; 95%CI:0.18–0.27) working in agriculture, the most common self-reported primary occupation. Exceptions included men working in transportation. HIV incidence similarly declined in most occupations, but there were no reductions in incidence among female bar and restaurant workers, women working in local crafts, or men working in transportation. In summary, untreated HIV infection and HIV incidence have declined within most occupational groups in Uganda. However, women working in bars/restaurants and local crafts and men working in transportation continue to have a relatively high burden of untreated HIV and HIV incidence, and as such, should be considered priority populations for HIV programming.
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    HIV Incidence by Male Circumcision Status From the Population-Based HIV Impact Assessment Surveys—Eight Sub-Saharan African Countries, 2015–2017
    (JAIDS Journal of Acquired Immune Deficiency Syndromes, 2021) Hines, Jonas Z.; Sachathep, Karampreet; Pals, Sherri; Davis, Stephanie M.; Toledo, Carlos; Bronson, Megan; Parekh, Bharat; Carrasco, Maria; Xaba, Sinokuthemba; Mandisarisa, John; Kamobyi, Royd; Chituwo, Omega; Kirungi, Wilford L.; Alamo, Stella; Kabuye, Geoffrey; Awor, Anna Colletar; Mmbando, Susan; Simbeye, Daimon; Aupokolo, Mekondjo A.; Zemburuka, Brigitte; Nyirenda, Rose; Msungama, Wezi; Tarumbiswa, Tapiwa; Manda, Robert; Biribonwoha, Harriet Nuwagaba; Kiggundu, Valerian; Thomas, Anne G.; Voetsch, Andrew C.; Williams, Dan B.
    Conducting HIV surveys in resource-limited settings is challenging because of logistics, limited availability of trained personnel, and complexity of testing. We described the procedures and systems deemed critical to ensure high-quality laboratory data in the population-based HIV impact assessments and large-scale household surveys.Laboratory professionals were engaged in every stage of the surveys, including protocol development, site assessments, procurement, training, quality assurance, monitoring, analysis, and reporting writing. A tiered network of household, satellite laboratories, and central laboratories, accompanied with trainings, optimized process for blood specimen collection, storage, transport, and real-time monitoring of specimen quality, and test results at each level proved critical in maintaining specimen integrity and high-quality testing. A plausibility review of aggregate merged data was conducted to confirm associations between key variables as a final quality check for quality of laboratory results.Overall, we conducted a hands-on training for 3355 survey staff across 13 surveys, with 160–387 personnel trained per survey on biomarker processes. Extensive training and monitoring demonstrated that overall, 99% of specimens had adequate volume and 99.8% had no hemolysis, indicating high quality. We implemented quality control and proficiency testing for testing, resolved discrepancies, verified >300 Pima CD4 instruments, and monitored user errors. Aggregate data review for plausibility further confirmed the high quality of testing.Ongoing engagement of laboratory personnel to oversee processes at all levels of the surveys is critical for successful national surveys. High-quality population-based HIV impact assessments laboratory data ensured reliable results and demonstrated the impact of HIV programs in 13 countries.
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    Impact of combination HIV interventions on HIV incidence in hyperendemic fishing communities in Uganda: a prospective cohort study
    (The lancet HIV,, 2019) Kagaayi, Joseph; Chang, Larry W.; Ssempijja, Victor; Grabowski, M. Kate; Ssekubugu, Robert; Nakigozi, Gertrude; Kigozi, Godfrey; Serwadda, David M.; Gray, Ronald H.; Nalugoda, Fred; Sewankambo, Nelson K; Nelson, Lisa; Mills, Lisa A.; Kabatesi, Donna; Alamo, Stella; Kennedy, Caitlin E.; Tobian, Aaron A. R.; Santelli, John S.; Mia Ekström, Anna; Nordenstedt, Helena; Quinn, Thomas C.; Wawer, Maria J.; Reynolds, Steven J.
    Targeting combination HIV interventions to locations and populations with high HIV burden is a global priority, but the impact of these strategies on HIV incidence is unclear. We assessed the impact of combination HIV interventions on HIV incidence in four HIV-hyperendemic communities in Uganda. Methods We did an open population-based cohort study of people aged 15–49 years residing in four fishing communities on Lake Victoria. The communities were surveyed five times to collect self-reported demographic, behavioural, and service-uptake data. Free HIV testing was provided at each interview, with referral to combination HIV intervention services as appropriate. From November, 2011, combination HIV intervention services were rapidly expanded in these geographical areas. We evaluated trends in HIV testing coverage among all participants, circumcision coverage among male participants, antiretroviral therapy (ART) coverage and HIV viral load among HIV-positive participants, and sexual behaviours and HIV incidence among HIV-negative participants. Findings From Nov 4, 2011, to Aug 16, 2017, data were collected from five surveys. Overall, 8942 participants contributed 20 721 person-visits; 4619 (52%) of 8942 participants were male. HIV prevalence was 41% (1598 of 3870) in the 2011–12 baseline survey and declined to 37% (1740 of 4738) at the final survey (p<0·0001). 3222 participants who were HIV-negative at baseline, and who had at least one repeat visit, contributed 9477 person-years of follow-up, and 230 incident HIV infections occurred. From the first survey in 2011–12 to the last survey in 2016–17, HIV testing coverage increased from 68% (2613 of 3870) to 96% (4526 of 4738; p<0·0001); male circumcision coverage increased from 35% (698 of 2011) to 65% (1630 of 2525; p<0·0001); ART coverage increased from 16% (254 of 1598) to 82% (1420 of 1740; p<0·0001); and population HIV viral load suppression in all HIV-positive participants increased from 34% (546 of 1596) to 80% (1383 of 1734; p<0·0001). Risky sexual behaviours did not decrease over this period. HIV incidence decreased from 3·43 per 100 person-years (95% CI 2·45–4·67) in 2011–12 to 1·59 per 100 person-years (95% CI 1·19–2·07) in 2016–17; adjusted incidence rate ratio (IRR) 0·52 (95% CI 0·34–0·79). Declines in HIV incidence were similar among men (adjusted IRR 0·53, 95% CI 0·30–0·93) and women (0·51, 0·27–0·96). The risk of incident HIV infection was lower in circumcised men than in uncircumcised men (0·46, 0·32–0·67). Interpretation Rapid expansion of combination HIV interventions in HIV-hyperendemic fishing communities is feasible and could have a substantial impact on HIV incidence. However, incidence remains higher than HIV epidemic control targets, and additional efforts will be needed to achieve this global health priority. Funding The National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, the National Cancer Institute, the National Institute for Allergy and Infectious Diseases Division of Intramural Research, Centers for Disease Control and Prevention Uganda, Karolinska Institutet, and the Johns Hopkins University Center for AIDS Research.