Browsing by Author "Birungi, Josephine"
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Item ABC for people with HIV: responses to sexual behaviour recommendations among people receiving antiretroviral therapy in Jinja, Uganda(Taylor & Francis, 2011) Allen, Caroline; Mbonye, Martin; Seeley, Janet; Birungi, Josephine; Wolff, Brent; Coutinh, Alex; Jaffar, ShabbarPeople living with HIV who are taking antiretroviral therapy (ART) are increasingly involved in ‘positive prevention’ initiatives. These are generally oriented to promoting abstinence, ‘being faithful’ (partner reduction) and condom use (ABC). We conducted a longitudinal qualitative study with people living with HIV using ART, who were provided with adherence education and counselling support by a Ugandan non- governmental organisation, The AIDS Support Organisation (TASO). Forty people were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic- or home-based) and HIV progression stage (early or advanced) and interviewed at enrolment and at 3, 6, 18 and 30 months. At initiation of ART, participants agreed to follow TASO’s positive-living recommendations. Initially poor health prevented sexual activity. As health improved, participants prioritised resuming economic production and support for their children. With further improvements, sexual desire resurfaced and people in relationships cemented these via sex. The findings highlight the limitations of HIV prevention based on medical care/personal counselling. As ART leads to health improvements, social norms, economic needs and sexual desires increasingly influence sexual behaviour. Positive prevention interventions need to seek to modify normative and economiItem Adherence to Antiretroviral Therapy in Jinja, Uganda: A Six-Year Follow-Up Study(PLoS ONE, 2013) Mbonye, Martin; Seeley, Janet; Ssembajja, Fatuma; Birungi, Josephine; Jaffar, ShabbarIntroduction: We report on the adherence experience of a group of people living with HIV on ART over six years in Uganda. Methods: Between 2005 and 2009, we followed up 41 participants who were also part of a clinical trial comparing home and facility based delivery of ART in Jinja, eastern Uganda. We conducted qualitative in-depth interviews at enrolment, 3, 6, 18 and 30 months to capture experiences with adherence over time. In 2011 we returned to these participants to find out how they were fairing with long term adherence. We managed to retrace 24 participants and interviewed them about their experience. We thematically analysed the data and compared findings over time. Results: Initially there were few barriers to adherence and many followed the adherence guidance closely. By year six, relaxation of these rules was noticeable although self-reported adherence continued to be high. Alcohol consumption was more common than before. Some relatives of the participants who had died claimed that some deaths were a result of alcohol. While participants reported that ART had allowed them to reclaim independence and return to work the changes in work and social routines created new challenges for adherence. Side effects like lipodystrophy were not only causing some stigma but for some tested their faith in the drugs. Many participants reported resumption of sexual lives but apart from those who selected same status partners, disclosure to new partners was minimal. Conclusion: Good adherence practice to ART wanes over the long-term, and people who may have disclosed at initiation find it difficult to do so to new partners once they are healthy. Further adherence interventions and support with disclosure over the course of therapy may need to be considered. (Words: 283)Item Association of aging and survival in a large HIV-infected cohort on antiretroviral therapy(Aids, 2011) Bakanda, Celestin; Birungi, Josephine; Mwesigwa, Robert; Ford, Nathan; Cooper, Curtis L.; Au-Yeung, Christopher; Chan, Keith; Nachega, Jean B.; Woode, Evan; Hogg, Robert S.; Dybulg, Mark; Mills, Edward J.To examine if there is a significant difference in survival between elderly (>50 years) and nonelderly adult patients receiving combination antiretroviral therapy in Uganda between 2004 and 2010. Design: Prospective observational study. Methods: Patients 18–49 years of age (nonelderly) and 50 years of age and older enrolled in the AIDS Support Organization Uganda HIV/AIDS national programme were assessed for time to all-cause mortality. We applied a Weibull multivariable regression. Results: Among the 22 087 patients eligible for analyses, 19 657 (89.0%) were aged between 18 and 49 years and 2430 (11.0%) were aged 50 years or older. These populations differed in terms of the distributions of sex, baseline CD4 cell count and death. The age group 40–44 displayed the lowest crude mortality rate [31.4 deaths per 1000 person-years; 95% confidence interval (CI) 28.1, 34.7) and the age group 60–64 displayed the highest crude mortality rate (58.9 deaths per 1000 person-years; 95% CI 42.2, 75.5).Kaplan–Meier survival estimates indicated that nonelderly patients had better survival than elderly patients (P<0.001). AdjustedWeibull analysis indicated that elderly age status was importantly associated (adjusted hazard ratio 1.23, 95% CI 1.08–1.42) with mortality, when controlling for sex, baseline CD4 cell count and year of therapy initiation. Conclusion: As antiretroviral treatment cohorts mature, the proportion of patients who are elderly will inevitably increase. Elderly patients may require focused clinical care that extends beyond HIV treatment.Item Can we increase male involvement in AIDS treatment?(2010) Birungi, Josephine; Mills, Edward J.In Uganda, men and boys are diffi cult to enrol in testing and treatment, and have increased mortality compared with women and girls. 5 Ad hoc HIV- positive men’s groups reach out to other men to increase testing and acceptance of results. However, in our experience, funders are unsupportive or unwilling to provide assistance to male-targeted interventions. Thus, male groups lack the sophistication of the female- focused eff orts and are unsustainable. Men, whether we blame them for their behaviours or not, represent a necessary population to engage with.Item Changes in sexual desires and behaviours of people living with HIV after initiation of ART: Implications for HIV prevention and health promotion(BMC Public Health, 2011) Wamoyi, Joyce; Mbonye, Martin; Seeley, Janet; Birungi, Josephine; Jaffar, ShabbarAbstract Background: As immune compromised HIV sero-positive people regain health after initiating antiretroviral treatment (ART), they may seek a return to an active ‘normal’ life, including sexual activity. The aim of the paper is to explore the changing sexual desires and behaviour of people on ART in Uganda over a 30 month period. Methods: This study employed longitudinal qualitative interviews with forty people starting ART. The participants received their ART, adherence education and counselling support from The AIDS Support Organisation (TASO). The participants were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic or home- based) and HIV progression stage (early or advanced) and interviewed at enrolment, 3, 6, 18 and 30 months of their ART use. Results: Sexual desire changed over time with many reporting diminished desire at 3 and 6 months on ART compared to 18 and 30 months of use. The reasons for remaining abstinent included fear of superinfection or infecting others, fear that engaging in sex would awaken the virus and weaken them and a desire to adhere to the counsellors’ health advice to remain abstinent. The motivations for resumption of sexual activity were: for companionship, to obtain material support, social norms around marriage, desire to bear children as well as to satisfy sexual desires. The challenges for most of the participants were using condoms consistently and finding a suitable sexual partner (preferably someone with a similar HIV serostatus) who could agree to have a sexual relationship with them and provide for their material needs. Conclusions: These findings point to the importance of tailoring counselling messages to the changing realities of the ART users’ cultural expectations around child bearing, marriage and sexual desire. People taking ART require support so they feel comfortable to disclose their HIV status to sexual partners.Item A Cluster-Randomised Trial to Compare Home-Based with Health Facility- Based Antiretroviral Treatment in Uganda: Study Design and Baseline Findings(Bentham Science Publishers Ltd., 2007) Amuron, Barbara; Coutinho, Alex; Grosskurth, Heiner; Nabiryo, Christine; Birungi, Josephine; Namara, Geoffrey; Levin, Jonathan; Smith, Peter G.; Jaffar, ShabbarThe scale-up of antiretroviral therapy is progressing rapidly in Africa but with a limited evidence-base. We re- port the baseline results from a large pragmatic cluster-randomised trial comparing different strategies of ART delivery. The trial is integrated in normal health service delivery. 1453 subjects were recruited into the study. Significantly more women (71%) than men (29%) were recruited. The WHO HIV clinical stage at presentation did not differ significantly between men and women: 58% and 53% respectively were at WHO stage III or IV (p=0.9). Median CD4 counts (IQR) x 10 6 cells/l were 98 (28, 160) among men and 111 (36, 166) among women. Sixty-four percent of women and 61% men had plasma viral load 100,000 copies. Baseline characteris- tics did not change over time. Considerably fewer men than women presented for treatment.Item Cohort Profile: The TASO-CAN Cohort Collaboration(International journal of epidemiology, 2012) Bakanda, Celestin; Birungi, Josephine; Nkoyooyo, Abdallah; Featherstone, Amber; Cooper, Curtis L.; Hogg, Robert S.; Mills, Edward J.Sub-Saharan Africa has scaled-up access to combination anti-retroviral therapy (cART) at unprecedented rates, yet data on patient-related outcomes remain sparse. Representative databases that facilitate highquality collection, harmonization and analysis of HIV-related information from clinical and researchrelated sites are needed. The large sample sizes that nationally representative databases permit facilitate identification of rare outcomes and emerging problems and the elucidation of more complex relationships involving the use of cART. These efforts also allow meaningful comparisons between regional treatment programmes that differ in their operational procedures and serve diverse communities in different settings. Unique features of individual sites exist, such as language used and cultural norms, research and care capacity, infrastructure development, personnel training and experience, and collection of data elements that differ in type, number, definition or method of laboratory. Furthermore, the use of innovative databases and informatics approaches can provide a principled approach to pool national data, and improve uniformity and consistency in data management in such heterogeneous settings.Item Community‑based ART distribution system can effectively facilitate long‑term program retention and low‑rates of death and virologic failure in rural Uganda(AIDS research and therapy, 2015) Okoboi, Stephen; Ding, Erin; Persuad, Steven; Wangisi, Jonathan; Birungi, Josephine; Shurgold, Susan; Kato, Darius; Nyonyintono, Maureen; Egessa, Aggrey; Bakanda, Celestin; Munderi, Paula; Kaleebu, Pontiano; Moore, David M.Community-drug distribution point is a care model for stable patients in the community designed to make ART delivery more efficient for the health system and provide appropriate support to encourage long-term retention of patients. We examined program retention among ART program participants in rural Uganda, which has used a community-based distribution model of ART delivery since 2004. Methods: We analyzed data of all patients >18 years who initiated ART in Jinja, Ugandan site of The AIDS Support Organization between January 1, 2004 and July 31, 2009. Participants attended clinic or outreach visits every 2–3 months and had CD4 cell counts measured every 6 months. Retention to care was defined as any patient with at least one visit in the 6 months before June 1, 2013. We then identified participants with at least one visit in the 6 months before June 1, 2013 and examined associations with mortality and lost-to-follow-up (LTFU). Participants with >4 years of follow up during August, 2012 to May, 2013 had viral load conducted, since no routine viral load testing was available. Results: A total of 3345 participants began ART during 2004–2009. The median time on ART in June 2013 was 5.69 years. A total of 1335 (40 %) were residents of Jinja district and 2005 (60 %) resided in outlying districts. Of these, 2322 (69 %) were retained in care, 577 (17 %) died, 161 (5 %) transferred out and 285 (9 %) were LTFU. Factors associated with mortality or LTFU included male gender, [Adjusted Hazard Ratio (AHR) = 1.56; 95 % CI 1.28–1.9], CD4 cell count <50 cells/μL (AHR = 4.09; 95 % CI 3.13–5.36) or 50–199 cells/μL (AHR = 1.86; 95 % CI 1.46–2.37); ART initiation and WHO stages 3 (AHR = 1.35; 95 % CI 1.1–1.66) or 4 (AHR = 1.74; 95 % CI 1.23–2.45). Residence outside of Jinja district was not associated with mortality/LTFU (p value = 0.562). Of 870 participants who had VL tests, 756 (87 %) had VLs <50 copies/mL. Conclusion: Community-based ART distribution systems can effectively mitigate the barriers to program retention and result in good rates of virologic suppression.Item Density of Healthcare Providers and Patient Outcomes: Evidence from a Nationally Representative Multi-Site HIV Treatment Program in Uganda(PLoS ONE, 2011) Bakanda, Celestin; Birungi, Josephine; Mwesigwa, Robert; Zhang, Wendy; Hagopian, Amy; Ford, Nathan; Mills, Edward J.We examined the association between density of healthcare providers and patient outcomes using a large nationally representative cohort of patients receiving combination antiretroviral therapy (cART) in Uganda. Design: We obtained data from The AIDS Support Organization (TASO) in Uganda. Patients 18 years of age and older who initiated cART at TASO between 2004 and 2008 contributed to this analysis. The number of healthcare providers per 100 patients, the number of patients lost to follow-up per 100 person years and number of deaths per 100 person years were calculated. Spearman correlation was used to identify associations between patient loss to follow-up and mortality with the healthcare provider-patient ratios. Results: We found no significant associations between the number of patients lost to follow-up and physicians (p = 0.45), nurses (p = 0.93), clinical officers (p = 0.80), field officers (p = 0.56), and healthcare providers overall (p = 0.83). Similarly, no significant associations were observed between mortality and physicians (p = 0.65), nurses (p = 0.49), clinical officers (p = 0.73), field officers (p = 0.78), and healthcare providers overall (p = 0.73). Conclusions: Patient outcomes, as measured by loss to follow-up and mortality, were not significantly associated with the number of doctors, nurses, clinical officers, field officers, or healthcare providers overall. This may suggest that that other factors, such as the presence of volunteer patient supporters or broader political or socioeconomic influences, may be more closely associated with outcomes of care among patients on cART in Uganda.Item Durability Of Non-Nucleotide Reverse Transcriptase Inhibitor-Based First-Line ART Regimens After 7 Years Of Treatment In Rural Uganda(Medicine, 2021) Nanfuka, Mastula; Forrest, Jamie I.; Zhang, Wendy; Okoboi, Stephen; Birungi, Josephine; Kaleebu, Pontiano; Zhu, Julia; Tibenganas, Samuel; Moore, David M.Most antiretroviral therapy (ART) programs in resource-limited settings have historically used non-nucleotide reverse transcriptase inhibitor (NNRTI)-based regimens with limited access to routine viral load (VL) testing. We examined the long-term success of these regimens in rural Uganda among participants with 1 measured suppressed VL. We conducted a prospective cohort study of participants who had been on NNRTI-based first-line regimens for ≥4years and had a VL <1000copies/mL at enrollment in Jinja, Uganda. We collected clinical and behavioral data every 6 months and measured VL again after 3 years. We quantified factors associated with virologic failure (VF) (VL≥1000copies/mL) using Wilcoxon Rank Sum, chisquare, and Fisher’s Exact Tests. We enrolled 503 participants; 75.9% were female, the median age was 45years, and the median duration of time on ART was 6.8 years (IQR=6.0–7.6 years). Sixty-nine percent of participants were receiving nevirapine, lamivudine, and zidovudine regimens; 22.5% were receiving efavirenz, lamivudine, and zidovudine; and 8.6% were receiving other regimens. Of the 479 with complete follow-up data, 12 (2.5%) had VL≥1000copies/mL. VF was inversely associated with reporting never missing pills (41.7% of VFs vs 72.8% non-VFs, P=.034). There were differences in distribution of the previous ART regimens (P=.005), but no clear associations with specific regimens. There was no association between having a VL of 50 to 999copies/mL at enrollment and later VF (P=.160). Incidence of VF among individuals receiving ART for nearly 7 years was very low in the subsequent 3 years. NNRTI-based regimens appear to be very durable among those with good initial adherence.Item Factors associated with long-term antiretroviral therapy attrition among adolescents in rural Uganda: a retrospective study(Journal of the International AIDS Society, 2016) Okoboi, Stephen; Ssali, Livingstone; Yansaneh, Aisha I.; Bakanda, Celestin; Birungi, Josephine; Nantume, Sophie; Lyavala Okullu, Joanne; Sharp, Alana R.; Moore, David M.; Kalibala, SamuelAs access to antiretroviral therapy (ART) increases, the success of treatment programmes depends on ensuring high patient retention in HIV care. We examined retention and attrition among adolescents in ART programmes across clinics operated by The AIDS Support Organization (TASO) in Uganda, which has operated both facility- and community-based distribution models of ART delivery since 2004. Methods: Using a retrospective cohort analysis of patient-level clinical data, we examined attrition and retention in HIV care and factors associated with attrition among HIV-positive adolescents aged 10 19 years who initiated ART at 10 TASO clinics between January 2006 and December 2011. Retention in care was defined as the proportion of adolescents who had had at least one facility visit within the six months prior to 1 June 2013, and attrition was defined as the proportion of adolescents who died, were lost to follow-up, or stopped treatment. Descriptive statistics and Cox proportional hazards regression models were used to determine the levels of retention in HIV care and the factors associated with attrition following ART initiation. Results: A total of 1228 adolescents began ART between 2006 and 2011, of whom 57% were female. The median duration in HIV care was four years (IQR 3 6 years). A total of 792 (65%) adolescents were retained in care over the five-year period; 36 (3%) had died or transferred out and 400 (32%) were classified as loss to follow-up. Factors associated with attrition included being older (adjusted hazard ratio (AHR) 1.38, 95% confidence interval (CI) 1.02 1.86), having a higher CD4 count (250 cells/mm3) at treatment initiation (AHR 0.49, 95% CI 0.34 0.69) and HIV care site with a higher risk of attrition among adolescents in Gulu (AHR 2.26; 95% CI 1.27 4.02) and Masindi (AHR 3.30, 95% CI 1.87 5.84) and a lower risk of attrition in Jinja (AHR 0.24, 95% CI 0.08 0.70). Having an advanced WHO clinical stage at initiation was not associated with attrition. Conclusions: We found an overall retention rate of 65%, which is comparable to rates achieved by TASO’s adult patients and adolescents in other studies in Africa. Variations in the risk of attrition by TASO treatment site and by clinical and demographic characteristics suggest the need for early diagnosis of HIV infection, use of innovative approaches to reach and retain adolescents living with HIV in treatment and identifying specific groups, such as older adolescents, that are at high risk of dropping out of treatment for targeted care and support.Item He said, she said’: assessing dyadic agreement of reported sexual behaviour and decision-making among an HIV sero-discordant couples cohort in Uganda(BMJ, 2016) Birungi, Josephine; Maldoon, Cathrine; Kanters, Steve; King, Racheal; Nyonyintono, Moreen; Khanakwa, Sarah; Moore, David. M.Background The intimate nature of sexuality makes it challenging to accurately measure sexual behaviour. To assess response reliability, we examined agreement between couples in heterosexual HIV sero-discordant partnership on survey questions regarding condom use and sexual decision-making. Methods Data for this analysis come from baseline data from a cohort study of HIV sero- discordant couples in Jinja, Uganda. We examined the degree of agreement between male and female partners on standard measures of sexual behaviour using the kappa (κ) statistic and 95% confidence intervals (95% CIs). Results Among 409 couples, the median age for the male partner was 41 [interquartile range (IQR) 35–48] years and the female partner was 35 (IQR 30–40) years. Among 58.2% of the couples, the male was the HIV-positive partner. Questions with high or substantial couple agreement included condom use at last sex (κ=0.635, 95% CI 0.551–0.718) and frequency of condom use (κ=0.625, 95% CI 0.551–0.698). Questions with low or fair couple agreement included decision-making regarding condom use (κ=0.385, 95% CI 0.319–0.451), wanting more biological children (κ=0.375, 95% CI 0.301– 0.449) and deciding when to have sex (κ=0.236, 95% CI 0.167–0.306). Conclusions Survey questions assessing condom use had the highest level of couple agreement and questions regarding sexual decision-making and fertility desire had low couple agreement. Questions with high agreement have increased reliability and reduced measurement bias; however, questions with low agreement between couples identify important areas for further investigation, particularly perceived relationship control and gender differences.Item Incarceration and exposure to internally displaced persons camps associated with reproductive rights abuses among sex workers in northern Uganda(BMJ, 2017) Birungi, Josephine; Erickson, Margaret; Goldenberg, Shira M.; Akello, Monica; Shannon, Kate; Nguyen, Paul; Muzaaya, GodfreyWhile female sex workers (FSWs) face a high burden of violence and criminalisation, coupled with low access to safe, non-coercive care, little is known about such experiences among FSWs in conflict-affected settings, particularly as they relate to sexual and reproductive health (SRH) and rights. We explored factors associated with lifetime abortions among FSWs in northern Uganda; and separately modelled the independent effect of lifetime exposures to incarceration and living in internally displaced persons (IDP) camps on coerced and unsafe abortions. Methods Analyses are based on a community- based cross-sectional research project in Gulu District, northern Uganda (2011–2012) with The AIDS Support Organization (TASO) Gulu, FSWs, and other community organisations. We conducted questionnaires, sex worker/ community-led outreach to sex work venues, and voluntary HIV testing by TASO. Results Of 400 FSWs, 62 had ever accessed an abortion. In a multivariable model, gendered violence, both childhood mistreatment/or abuse at home [adjusted odds ratio (AOR) 1.96; 95% confidence interval (95% CI) 0.99–3.90] and workplace violence by clients (AOR 3.57; 95% CI 1.31–9.72) were linked to increased experiences of abortion. Lifetime exposure to incarceration retained an independent effect on increased odds of coerced abortion (AOR 5.16; 95% CI 1.39–19.11), and living in IDP camps was positively associated with unsafe abortion (AOR 4.71; 95% CI 1.42–15.61). Discussion and conclusions These results suggest a critical need for removal of legal and social barriers to realising the SRH rights of all women, and ensuring safe, voluntary access to reproductive choice for marginalised and criminalised populations of FSWs.Item Lessons learned from a mobile technology-based intervention informed by behavioral economics to improve ART adherence among youth in Uganda. AIDS Care.(Taylor & Francis, 2019) MacCarthy, Sarah; Mendoza-Graf, Alexandra; Samba, Clare; Saya, Uzaib; Birungi, Josephine; Okobo, StephenEvidence suggests that simple text messaging interventions may not suffice to improve ART adherence among youth in low-resource settings. To address this shortcoming, we developed an intervention that shared weekly real-time adherence feedback to youth in Uganda using short message services (SMS), based on information tracked by an electronic device (Wisepill). We present results from 7 formative and 6 exit focus groups (FGs) in Mulago and Entebbe, Uganda with youth ages 15–24, providers, and Community Advisory Board members. Participants consistently conveyed positive impressions of Wisepill, noting that it helped store their medications, facilitated travel, served as a reminder, and motivated adherence. Participants raised phone-related issues before the study; most were addressed but some remained (e.g., limited network access, electricity for powering phones). Further, they highlighted the importance of carefully crafting text messages (e.g., use slang rather than potentially stigmatizing words) and viewed personalizing messages favorably but were divided on the desirability of including their name in study-related texts. Exit FGs confirmed that sharing group adherence levels with participants tapped into the competitive spirit common among youth. Our results suggest future mobile technology-based interventions can be improved by providing messages that go beyond simple reminders to provide individual and group-level adherence feedback.Item Life Expectancy of Persons Receiving Combination Antiretroviral Therapy in Low-Income Countries: A Cohort Analysis From Uganda(Annals of internal medicine, 2011) Mills, Edward J.; Bakanda, Celestin; Birungi, Josephine; Chan, Keith; Ford, Nathan; Cooper, Curtis L.; Nachega, Jean B.; Dybul, Mark; Hogg, Robert S.Little is known about the effect of combination antiretroviral therapy (cART) on life expectancy in sub-Saharan Africa. Objective: To estimate life expectancy of patients once they initiate cART in Uganda. Design: Prospective cohort study. Setting: Public sector HIV and AIDS disease-management program in Uganda. Patients: 22 315 eligible patients initiated cART during the study period, of whom 1943 were considered to have died. Measurements: All-cause mortality rates were calculated and abridged life tables were constructed and stratified by sex and baseline CD4 cell count status to estimate life expectancies for patients receiving cART. The average number of years remaining to be lived by patients who received cART at varying age categories was estimated. Results: After adjustment for loss to follow-up, crude mortality rates (deaths per 1000 person-years) ranged from 26.9 (95% CI, 25.4 to 28.5) in women to 43.9 (CI, 40.7 to 47.0) in men. For patients with a baseline CD4 cell count less than 0.050 109 cells/L, the mortality rate was 67.3 (CI, 62.1 to 72.9) deaths per 1000 person-years, whereas among persons with a baseline CD4 cell count of 0.250 109 cells/L or more, the mortality rate was 19.1 (CI, 16.0 to 22.7) deaths per 1000 person-years. Life expectancy at age 20 years for the overall cohort was 26.7 (CI, 25.0 to 28.4) additional years and at age 35 years was 27.9 (CI, 26.7 to 29.1) additional years. Life expectancy increased substantially with increasing baseline CD4 cell count. Similar trends are observed for older age groups. Limitations: A small (6.4%) proportion of patients were lost to follow-up, and it was imputed that 30% of these patients had died. Few patients with a CD4 cell count greater than 0.250 109 cells/L initiated cART. Conclusion: Ugandan patients receiving cART can expect an almost normal life expectancy, although there is considerable variability among subgroups of patients.Item Male gender predicts mortality in a large cohort of patients receiving antiretroviral therapy in Uganda(Journal of the International AIDS Society, 2011) Mills, Edward J.; Bakanda, Celestin; Birungi, Josephine; Chan, Keith; Hogg, Robert S.; Ford, Nathan; Nachega, Jean B.; Cooper, Curtis L.Because men in Africa are less likely to access HIV/AIDS care than women, we aimed to determine if men have differing outcomes from women across a nationally representative sample of adult patients receiving combination antiretroviral therapy in Uganda. Methods: We estimated survival distributions for adult male and female patients using Kaplan-Meier, and constructed multivariable regressions to model associations of baseline variables with mortality. We assessed person-years of life lost up to age 55 by sex. To minimize the impact of patient attrition, we assumed a weighted 30% mortality rate among those lost to follow up. Results: We included data from 22,315 adults receiving antiretroviral therapy. At baseline, men tended to be older, had lower CD4 baseline values, more advanced disease, had pulmonary tuberculosis and had received less treatment follow up (all at p < 0.001). Loss to follow up differed between men and women (7.5 versus 5.9%, p < 0.001). Over the period of study, men had a significantly increased risk of death compared with female patients (adjusted hazard ratio 1.43, 95% CI 1.31-1.57, p < 0.001). The crude mortality rate for males differed importantly from females (43.9, 95% CI 40.7-47.0/1000 person-years versus 26.9, 95% CI 25.4-28.5/1000 person years, p < 0.001). The probability of survival was 91.2% among males and 94.1% among females at 12 months. Person-years of life lost was lower for females than males (689.7 versus 995.9 per 1000 person-years, respectively). Conclusions: In order to maximize the benefits of antiretroviral therapy, treatment programmes need to be gender sensitive to the specific needs of both women and men. Particular efforts are needed to enroll men earlier into care.Item Mortality by baseline CD4 cell count among HIV patients initiating antiretroviral therapy: evidence from a large cohort in Uganda(Aids, 2011) Mills, Edward J.; Bakanda, Celestin; Birungi, Josephine; Mwesigwa, Robert; Chan, Keith; Ford, Nathan; Hogg, Robert S.; Cooper, CurtisEvaluations of CD4 cell count and other prognostic factors on the survival of HIV patients in sub-Saharan Africa are extremely limited. Funders have been reticent to recommend earlier initiation of treatment. We aimed to examine the effect of baseline CD4 cell count on mortality using data from HIV patients receiving combination antiretroviral therapy (cART) in Uganda. Design: Observational study of patients aged at least 14 years enrolled in 10 clinics across Uganda for which The AIDS Support Organization (TASO) has data. Methods: CD4 cell count was stratified into categories (<50, 50–99, 100–149, 150– 199, 200–249, 250–299, 300 cells/ml) and Cox proportional hazards regression was used to model the associations between CD4 cell count and mortality. Results: A total of 22 315 patients were included. 1498 patients died during follow-up (6.7%) and 1433 (6.4%) of patients were lost to follow-up. Crude mortality rates (CMRs) ranged from 53.8 per 1000 patient-years [95% confidence interval (CI) 48.8–58.8] among those with CD4 cell counts of less than 50, to 15.7, (95% CI 12.1–19.3) among those with at least 300 cells/ml. Relative to a baseline CD4 cell count of less than 50 cells/ml, the risk of mortality was 0.75 (95% CI 0.65–0.88), 0.60 (95% CI 0.51–0.70), 0.43 (0.37–0.50), and 0.41 (0.33–0.51) for those with baseline CD4 cell counts of 50–99, 100–149, 150–249, and 250 cells/ml, respectively. Conclusion: Earlier initiation of cART is associated with increased survival benefits over deferred treatment.Item A new strategy and its effect on adherence to intermittent preventive treatment of malaria in pregnancy in Uganda(BioMed Central, 2013) Mbonye, Anthony K.; Yanow, Stephanie; Birungi, Josephine; Magnussen, PascalBackground: Few women in Uganda access intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP). Previous studies have shown that high costs, frequent stock-out of drugs, supplies and poor quality of care are the greatest hindrance for women to access health services. In order to increase adherence to IPTp, we conceptualised an intervention that offset delivery care costs through providing a mama kit, created awareness on health benefits of IPTp and built trust between the provider and the client. Methods: The new strategy was conceived along four constructs namely: 1) creating awareness by training midwives to explain the benefits of SP and the importance of adhering to the two doses of SP as IPTp to all pregnant women who attended ANC and consented to the study. Midwives were trained for two days in customer care and to provide a friendly environment. The pregnant women were also informed of the benefits of attending ANC and delivering at health facilities. 2) Each woman was promised a mama kit during ANC; 3) trust was built by showing the mama kit to each woman and branding it with her name; 4) keeping the promise by providing the mama kit when women came to deliver. The strategy to increase adherence to two doses of SP and encourage women to deliver at health facilities was implemented at two health facilities in Mukono district (Kawolo hospital and Mukono health centre IV). The inclusion criteria were women who: i) consented to the study and ii) were in the second trimester of pregnancy. All pregnant women in the second trimester (4-6 months gestation) who attended ANC and consented to participate in the study were informed of the benefits of SP, the importance of delivering at health facilities, were advised to attend the scheduled visits, promised a mama kit and ensured the kit was available at delivery. The primary outcome was the proportion of pregnant women adhering to a two dose SP regimen. Results: A total of 2,276 women received the first dose of SP and 1,656 (72.8%) came back for the second dose. 1,069 women were involved in the evaluation (384 had participated in the intervention while 685 had not). The main reasons that enabled those who participated in the intervention to adhere to the two doses of IPTp and deliver at the study facilities were: an explanation provided on the benefits of IPTp and delivering at health facilities (25.1%), availability of a mama kit at delivery (24.6%), kind midwives (19.8%) and fearing complications of pregnancy (8.5%). Overall, 78.0% of these women reported that they were influenced to adhere to IPTp by the intervention. In a multivariable regression, nearby facility, P = 0. 007, promising a mama kit, P = 0.002, kind midwives, P = 0.0001 and husbands’ encouragement, P = 0.0001 were the significant factors influencing adherence to IPTp with SP. Conclusion: The new strategy was a good incentive for women to attend scheduled ANC visits, adhere to IPTp and deliver at the study facilities. Policy implications include the urgent need for developing a motivation package based on the Health-Trust Model to increase access and adherence to IPTp.Item Predictive value of CD4 cell count nadir on long-term mortality in HIV-positive patients in Uganda(HIV/AIDS – Research and Palliative Care, 2012) Bray, Sarah; Gedeon, Jillian; Hadi, Ahsan ard J Mills; Kotb, Ahmed; Rahman, Tarun; Sarwar, Elaha; Savelyeva, Anna; Sévigny, Marika; Bakanda, Celestin; Birungi, Josephine; Chan, Keith; Yaya, Sanni; Deonandan, Raywat; Mills, Edward J.Although international guidelines recommend initiating antiretroviral therapy (ART) when a patient’s CD4 cell count is #350 cells/μL, most patients in resource-limited settings present with much lower CD4 cell counts. The lowest level that their CD4 cell count reaches, the nadir, may have long-term consequences in terms of mortality. We examined this health state in a large cohort of HIV+ patients in Uganda. Design: This was an observational study of HIV patients in Uganda aged 14 years or older, who were enrolled in 10 major clinics across Uganda. Methods: We assessed the CD4 nadir of patients, using their CD4 cell count at initiation of ART, stratified into categories (,50, 50–99, 100–149, 150–249, 250+ cells/μL). We constructed Kaplan–Meier curves to assess the differences in survivorship for patients left-censored at 1 year and 2 years after treatment initiation. We used Cox proportional hazards regression to model the associations between CD4 nadir and mortality. We adjusted mortality for loss-to-follow-up. Results: Of 22,315 patients, 20,129 patients had greater than 1 year of treatment follow-up. Among these patients, 327 (1.6%) died and 444 (2.2%) were lost to follow-up. After left-censoring at one year, relative to lowest CD4 strata, patients with higher CD4 counts had significantly lower rates of mortality (CD4 150–249, hazard ratio [HR] 0.60, 95% confidence interval [CI]: 0.45–0.82, P = 0.001; 250+, HR 0.66, 95% CI, 0.44–1.00, P = −0.05). Male sex, older age, and duration of time on ART were independently associated with mortality. When left-censoring at 2 years, CD4 nadir was no longer statistically significantly associated with mortality. Conclusion: After surviving for 1 year on ART, a CD4 nadir was strongly predictive of longer-term mortality among patients in Uganda. This should argue for efforts to increase engagement with patients to ensure a higher CD4 nadir at initiation of treatment.Item The prognostic value of baseline CD4R cell count beyond 6 months of antiretroviral therapy in HIV-positive patients in a resource-limited setting(Aids, 2012) Mills, Edward J.; Bakanda, Celestin; Birungi, Josephine; Yaya, Sanni; Ford, NathanThe risk of death is highest in the first few months after initiation of antiretroviral therapy (ART). We examined whether initial CD4þ cell count maintains a strong prognostic value among patients with at least 6 months follow-up after the initiation of ART. Design: Observational study of HIV patients in Uganda aged 14 years or older enrolled in 10 clinics across Uganda. Methods: Baseline CD4þ cell count of patients with more than 6 months of follow-up were stratified into categories (<50, 50–99, 100–149, 150–249, >250 cells/ml). A Kaplan–Meier survival analysis and Cox proportional hazards regression was used to model the associations between baseline CD4þ cell count and mortality. Results: Of 22 315 patients, 20 730 (92.8%) had more than 6 months of follow-up. Six hundred and eleven (2.9%) patients died during follow-up and 737 (3.6%) were lost to follow-up. Relative to a baseline CD4þ cell counts of less than 50 cells/ml, the adjusted hazard ratios for death were 0.83 [95% confidence interval (CI) 0.67–1.02], 0.71 (95% CI 0.57–0.88), 0.52 (95% CI 0.42–0.64), and 0.55 (95% CI 0.42–0.70) favouring those with baseline CD4þ cell counts of 50–99, 100–149, 150–249, and at least 250 cells/ml, respectively. Differing ages and male sex increased the likelihood of mortality. Conclusion: Among patients with more than 6 months of follow-up after initiation of ART, baseline CD4þ cell count at initiation still has important prognostic value. This suggests that active engagement and earlier treatment initiation is important for longterm survival.