Browsing by Author "Crowell, Trevor A."
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Item Factors associated with sexually transmitted infections among care-seeking adults in the African Cohort Study(BMC public health, 2021) Semwogerere, Michael; Dear, Nicole; Tunnage, Joshua; Reed, Domonique; Kibuuka, Hannah; Kiweewa, Francis; Iroezindu, Michael; Bahemana, Emmanuel; Maswai, Jonah; Owuoth, John; Crowell, Trevor A.; Ake, Julie A.; Polyak, Christina S.; Esber, AllahnaSexually transmitted infections (STIs) are a major cause of morbidity. Understanding drivers of transmission can inform effective prevention programs. We describe STI prevalence and identify factors associated with STIs in four African countries. Methods: The African Cohort Study is an ongoing, prospective cohort in Kenya, Nigeria, Tanzania and Uganda. At enrollment, a physical exam was conducted and STI diagnosis made by a clinician using a syndromic management approach. Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for factors associated with an STI diagnosis. Results: As of June 2020, 3544 participants were enrolled. STI prevalence was 7.7% and did not differ by HIV status (p = 0.30). Prevalence differed by syndrome (3.5% vaginal discharge, 1.5% genital ulcer, 2.1% lower abdominal pain, 0.2% inguinal bubo). The odds of having an STI were higher at all sites compared to Kisumu West, Kenya, and among those with a primary level education or below compared to those with secondary or higher (aOR: 1.77; 95% CI: 1.32–2.38). The odds of an STI diagnosis was higher among participants 18–29 years (aOR: 2.29; 95% CI: 1.35– 3.87), females (aOR: 2.64; 95% CI: 1.94–3.59), and those with depression (aOR: 1.78; 95% CI: 1.32–2.38). Among PLWH, similar factors were independently associated with an STI diagnosis. Viral suppression was protective against STIs (aOR: 2.05; 95% CI: 1.32–3.20). Conclusions: Prevalence of STIs varied by site with young people and females most at risk for STIs. Mental health is a potential target area for intervention.Item Perceived satisfaction with HIV care and its association with adherence to antiretroviral therapy and viral suppression in the African Cohort Study(AIDS research and therapy, 2021) Somi, Nancy; Dear, Nicole; Reed, Domonique; Parikh, Ajay; Lwilla, Anange; Bahemana, Emmanuel; Khamadi, Samoel; Iroezindu, Michael; Kibuuka, Hannah; Maswai, Jonah; Crowell, Trevor A.; Owuoth, John; Maganga, Lucas; Polyak, Christina; Ake, Julie; Esber, AllahnaIncreased availability of HIV care over the past decade has dramatically reduced morbidity and mortality among people living with HIV (PLWH) in sub-Saharan Africa. However, perceived and experienced barriers to care, including dissatisfaction with services, may impact adherence and viral suppression. We examined the associations between satisfaction with HIV care and antiretroviral therapy (ART) adherence and viral load suppression. Methods: The African Cohort Study (AFRICOS) is a prospective observational study conducted at PEPFAR-supported clinics in four African countries. At enrollment and twice-yearly study visits, participants received a clinical assessment and a socio-behavioral questionnaire was administered. Participants were classified as dissatisfied with care if they reported dissatisfaction with any of the following: waiting time, health care worker skills, health care worker attitudes, quality of clinic building, or overall quality of care received. Robust Poisson regression was used to estimate prevalence ratios and 95% confidence intervals (CIs) for associations between satisfaction with care and ART adherence and between satisfaction with care and viral suppression (viral load < 1000 copies/mL). Results: As of 1 March 2020, 2928 PLWH were enrolled and 2311 had a year of follow-up visits. At the first annual follow-up visit, 2309 participants responded to questions regarding satisfaction with quality of care, and 2069 (89.6%) reported satisfaction with care. Dissatisfaction with waiting time was reported by 177 (7.6%), building quality by 59 (2.6%), overall quality of care by 18 (0.8%), health care worker attitudes by 16 (0.7%), and health care worker skills by 15 (0.7%). After adjusting for age and site, there was no significant difference in viral suppression between those who were satisfied with care and those who were dissatisfied (aPR: 1.03, 95% CI 0.97–1.09). Satisfaction with HIV care was moderately associated with ART adherence among AFRICOS participants (aPR: 1.09; 95% CI 1.00–1.16). Conclusions: While patient satisfaction in AFRICOS was high and the association between perceived quality of care and adherence to ART was marginal, we did identify potential target areas for HIV care improvement, including reducing clinic waiting times.Item Predictors of All-Cause Mortality Among People With Human Immunodeficiency Virus (HIV) in a Prospective Cohort Study in East Africa and Nigeria(Clinical Infectious Diseases, 2022) Kibuuka, Hannah; Musingye, Ezra; Mwesigwa, Betty; Semwogerere, Michael; Iroezindu, Michael; Bahemana, Emmanuel; Maswai, Jonah; Owuoth, John; Esber, Allahna; Dear, Nicole; Crowell, Trevor A.; Polyak, Christina S.; Ake, Julie A.Introduction of antiretroviral therapy (ART) has been associated with a decline in human immunodeficiency virus (HIV)-related mortality, although HIV remains a leading cause of death in sub-Saharan Africa. We describe all-cause mortality and its predictors in people living with HIV (PLWH) in the African Cohort Study (AFRICOS). Methods. AFRICOS enrolls participants with or without HIV at 12 sites in Kenya, Uganda, Tanzania, and Nigeria. Evaluations every 6 months include sociobehavioral questionnaires, medical history, physical examination, and laboratory tests. Mortality data are collected from medical records and survivor interviews. Multivariable Cox proportional hazards models were used to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for factors associated with mortality. Results. From 2013 through 2020, 2724 PLWH completed at least 1 follow-up visit or experienced death. Of these 58.4% were females, 25.8% were aged ≥ 50 years, and 98.3% were ART-experienced. We observed 11.42 deaths per 1000 person-years (95% CI: 9.53–13.68) with causes ascertained in 54% of participants. Deaths were caused by malignancy (28.1%), infections (29.7%), and other non-HIV related conditions. Predictors of mortality included CD4 ≤ 350 cells/μL (aHR 2.01 [95% CI: 1.31–3.08]), a log10copies/mL increase of viral load (aHR 1.36 [95% CI: 1.22–1.51]), recent fever (aHR 1.85[95% CI: 1.22–2.81]), body mass index < 18.5 kg/m2 (aHR 2.20 [95% CI: 1.44–3.38]), clinical depression (aHR 2.42 [95% CI: 1.40–4.18]), World Health Organization (WHO) stage III (aHR 2.18 [95% CI: 1.31–3.61]), a g/dL increase in hemoglobin (aHR 0.79 [95% CI: .72–.85]), and every year on ART (aHR 0.67 [95% CI: .56–.81]). Conclusions. The mortality rate was low in this cohort of mostly virally suppressed PLWH. Patterns of deaths and identified predictors suggest multiple targets for interventions to reduce mortality.Item The pregnancy factor: the prevalence of depression among women living with HIV enrolled in the African Cohort Study (AFRICOS) by pregnancy status(Archives of Women's Mental Health, 2021) Jones, Milissa U.; Esber, Allahna L.; Dear, Nicole; Bahemana, Emmanuel; Kibuuka, Hannah; Iroezindu, Michael; Maswai, Jonah; Owuoth, John; Polyak, Christina S.; Ake, Julie A.; Crowell, Trevor A.; Hickey, Patrick W.Among Sub-Saharan African women living with HIV (WLWH), pregnancy creates unique stressors that may cause depression. We describe the prevalence of depression among WLWHenrolled in the African Cohort Study (AFRICOS) by pregnancy status and describe factors associated with depression. WLWH < 45 years of age underwent six-monthly visits with depression diagnosed using the Center for Epidemiological Studies-Depression scale. Visits were categorized as “pregnant;” “postpartum” (the first visit made after the last pregnancy visit), and “non-pregnant.” The prevalence of depression was calculated for each visit type and compared using prevalence odds ratios (POR) with 95% confidence intervals (CI). Logistic regression with generalized estimating equations was used to evaluate sociodemographic factors associated with depression. From January 2013 toMarch 1, 2020, 1333 WLWH were enrolled, and 214 had pregnancies during follow-up. As compared to the prevalence of depression during “non-pregnant” visits (9.1%), depression was less common at “pregnant” (6.3%; POR = 0.68 [CI: 0.42, 1.09]) and “postpartum” (3.4%; POR = 0.36 [CI: 0.17, 0.76]) visits. When controlling for other factors, the visit category was not independently associated with depression. Visit number, study site, employment status, and food security were independently associated with decreased odds of depression. We observed a lower prevalence of depression during pregnancy and the postpartum period than has been previously described amongWLWH during similar time points.We observed protective factors against depression which highlight the impact that holistic and consistent health care at HIV-centered clinics may have on the well-being ofWLWH in AFRICOS.Item Prevalence and predictors of food insecurity among people living with and without HIV in the African Cohort Study(Public Health Nutrition, 2022) Onyenakie, Cecilia C.; Nnakwe, Raphael U.; Dear, Nicole; Esber, Allahna; Bahemana, Emmanuel; Kibuuka, Hannah; Maswai, Jonah; Owuoth, John; Crowell, Trevor A.; Polyak, Christina S.; Ake, Julie A.; Iroezindu, MichaelWe determined the prevalence and identified predictors of food insecurity in four African countries. Design: Cross-sectional analyses at study enrolment. Setting: From January 2013 to March 2020, people living with HIV (PLWH) and without HIV were enrolled at twelve clinics in Kenya, Uganda, Tanzania and Nigeria. Participants: Participants reporting not having enough food to eat over the past 12 months or receiving <3 meals/d were defined as food insecure. Robust Poisson regression models were used to estimate unadjusted and adjusted prevalence ratios (aPR) and 95 % CI for predictors of food insecurity among all participants and separately among PLWH. Results: 1694/3496 participants (48·5 %) reported food insecurity at enrolment, with no difference by HIV status. Food insecurity was more common among older participants (50þ v. 18–24 years aPR 1·35, 95 % CI 1·15, 1·59). Having 2–5 (aPR 1·14, 95 % CI 1·01, 1·30) or >5 dependents (aPR 1·17, 95 % CI 1·02, 1·35), and residing in Kisumu West, Kenya (aPR 1·63, 95 % CI 1·42, 1·87) or Nigeria (aPR 1·20, 95 % CI 1·01, 1·41) was associated with food insecurity. Residing in Tanzania (aPR 0·65, 95 % CI 0·53, 0·80) and increasing education (secondary/above education v. none/ some primary education aPR 0·73, 95 % CI 0·66, 0·81) was protective against food insecurity. Antiretroviral therapy (ART)-experienced PLWH were more likely to be food secure irrespective of viral load. Conclusion: Food insecurity was highly prevalent in our cohort though not significantly associated with HIV. Policies aimed at promoting education, elderly care, ART access in PLWH and financial independence could potentially improve food security in Africa.Item Prevalence and risk factors associated with HIV and syphilis co‑infection in the African Cohort Study: a cross‑sectional study(BMC Infectious Diseases, 2021) Gilbert, Laura; Dear, Nicole; Esber, Allahna; Iroezindu, Michael; Bahemana, Emmanuel; Kibuuka, Hannah; Owuoth, John; Maswai, Jonah; Crowell, Trevor A.; Polyak, Christina S.; Ake, Julie A.Each year, 5.6 million new syphilis cases are diagnosed globally. Guidelines for people living with HIV (PLWH) in low-income countries (LIC) recommend STI testing for symptomatic persons and those newly diagnosed with HIV; routine STI testing is less clear. Here we provide updated syphilis prevalence and identify co-infection risk factors in PLWH in the African Cohort Study (AFRICOS) to understand these rates as they relate to syndromic treatment. Methods: AFRICOS is a study enrolling PLWH and HIV-uninfected individuals in four African countries. Participant study enrollment information was used to determine syphilis prevalence and co-infection risk factors. Inclusion criteria consisted of adults 18 years or older receiving care at a participating clinic as a long-term resident who consented to data and specimen collection. Exclusion criteria consisted of pregnancy and/or imprisonment. Screen-positive syphilis was defined as a reactive rapid plasma regain (RPR) upon study enrollment whereas confirmed syphilis included a reactive RPR followed by reactive treponemal test. Multivariate analyses was performed to determine HIV and syphilis co-infection risk factors. Results: Between 2013 and March 1, 2020, 2939 PLWH enrolled and 2818 were included for analysis. Screen-positive and confirmed syphilis prevalence were 5.3% (151/2818) and 3.1% (87/2818), respectively. When the analysis was restricted to PLWH with an RPR titer of greater than, or equal to, 1:8, 11/87 (12.6%) participants were included. No PLWH and confirmed syphilis had documented genital ulcers. In the multivariate model, participants with confirmed syphilis co-infection were more likely to have none or some primary education [aOR 3.29 (1.60, 6.74)] and consume alcohol [aOR 1.87 (1.16, 3.03)] compared to those without syphilis. Antiretroviral therapy (ART) with suppressed viral load (VL) was protective in the unadjusted model but not adjusted multivariate model. Conclusions: Our findings show that syphilis rates in sub-Saharan Africa remain elevated where diagnosis remains challenging, and that both lower education level and alcohol consumption are significantly associated with HIV/syphilis co-infection in AFRICOS. Based on our analysis, current STI guidelines targeting testing for African individuals with either new HIV diagnosis or syndromic symptoms may be inadequate, highlighting the need for increased testing and treatment strategies in resource-limited settings.Item Routine HIV clinic visit adherence in the African Cohort Study(AIDS research and therapy, 2022) Dear, Nicole; Esber, Allahna; Iroezindu, Michael; Bahemana, Emmanuel; Kibuuka, Hannah; Maswai, Jonah; Owuoth, John; Polyak, Christina S.; Ake, Julie A.; Crowell, Trevor A.Retention in clinical care is important for people living with HIV (PLWH). Evidence suggests that missed clinic visits are associated with interruptions in antiretroviral therapy (ART), lower CD4 counts, virologic failure, and overlooked coinfections. We identified factors associated with missed routine clinic visits in the African Cohort Study (AFRICOS). Methods: In 2013, AFRICOS began enrolling people with and without HIV in Uganda, Kenya, Tanzania, and Nigeria. At enrollment and every 6 months thereafter, sociodemographic questionnaires are administered and clinical outcomes assessed. Missed clinic visits were measured as the self-reported number of clinic visits missed in the past 6 months and dichotomized into none or one or more visits missed. Logistic regression with generalized estimating equations was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and missed visits. Results: Between January 2013 and March 2020, 2937 PLWH were enrolled, of whom 2807 (95.6%) had initiated ART and 2771 had complete data available for analyses. Compared to PLWH 50+, missed clinic visits were more common among those 18–29 years (aOR 2.33, 95% CI 1.65–3.29), 30–39 years (aOR 1.59, 95% CI 1.19–2.13), and 40–49 years (aOR 1.42, 95% CI 1.07–1.89). As compared to PLWH on ART for < 2 years, those on ART for 4+ years were less likely to have missed clinic visits (aOR 0.72, 95% CI 0.55–0.95). Missed clinic visits were associated with alcohol use (aOR 1.34, 95% CI 1.05–1.70), a history of incarceration (aOR 1.42, 95% CI 1.07–1.88), depression (aOR 1.47, 95% CI 1.13–1.91), and viral non-suppression (aOR 2.50, 95% CI 2.00–3.12). As compared to PLWH who did not miss any ART in the past month, missed clinic visits were more common among those who missed 1–2 days (aOR 2.09, 95% CI 1.65–2.64) and 3+ days of ART (aOR 7.06, 95% CI 5.43–9.19). Conclusions: Inconsistent clinic attendance is associated with worsened HIV-related outcomes. Strategies to improve visit adherence are especially needed for young PLWH and those with depression.Item Transient Reductions in Human Immunodeficiency Virus (HIV) Clinic Attendance and Food Security During the Coronavirus Disease 2019 (COVID-19) Pandemic for People Living With HIV in 4 African Countries(Clinical Infectious Diseases, 2021) Dear, Nicole; Duff, Emma; Esber, Allahna; Parikh, Ajay; Iroezindu, Michael; Bahemana, Emmanuel; Kibuuka, Hannah; Owuoth, John; Maswai, Jonah; Crowell, Trevor A.; Ake, Julie A.; Polyak, Christina S.The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented public health crisis. Governmental responses have varied in stringency and enforcement, sometimes including handwashing, physical distancing, face covering, lockdowns, curfews, and/or suspension of large gatherings and public transportation. In sub-Saharan Africa, policies must precariously balance public health and economic consequences in settings with a high reliance on informal economic activity [1], insufficient social safety net systems [2], and densely populated cities or cramped living conditions that impede physical distancing and hygiene [3]. Failure to contain the COVID-19 pandemic could overwhelm underresourced African healthcare systems [4] and obstruct healthcare access for other conditions due to interrupted supply chains, healthcare provider redeployment or illness, and disrupted transportation [5]. People living with human immunodeficiency virus (PLWH) could be particularly vulnerable to such disruptions [6], with the potential for lifelong consequences if they lead to viral failure and emergent drug resistance. Financial, food security, and social losses could contribute to emotional distress, reduced mental well-being, unhealthy coping strategies, and noncompliance with mitigation measures [7, 8]. We assessed human immunodeficiency virus (HIV) care and food security in the context of the COVID-19 pandemic in 4 African countries.