Browsing by Author "Ggita, Joseph"
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Item Assessing a norming intervention to promote acceptance of HIV testing and reduce stigma during household tuberculosis contact investigation: protocol for a cluster-randomised trial(BMJ Open, 2022) Armstrong-Hough, Mari; Ggita, Joseph; Gupta, Amanda J.; Shelby, Tyler; Nangendo, Joanita; Okello Ayen, Daniel; Davis, J. L.; Katamba, AchillesHIV status awareness is important for household contacts of patients with tuberculosis (TB). Home HIV testing during TB contact investigation increases HIV status awareness. Social interactions during home visits may influence perceived stigma and uptake of HIV testing. We designed an intervention to normalise and facilitate uptake of home HIV testing with five components: guided selection of first tester; prosocial invitation scripts; opt-out framing; optional sharing of decisions to test; and masking of decisions not to test. Methods and analysis We will evaluate the intervention effect in a household-randomised controlled trial. The primary aim is to assess whether contacts offered HIV testing using the norming strategy will accept HIV testing more often than those offered testing using standard strategies. Approximately 198 households will be enrolled through three public health facilities in Kampala, Uganda. Households will be randomised to receive the norming or standard strategy and visited by a community health worker (CHW) assigned to that strategy. Eligible contacts ≥15 years will be offered optional, free, home HIV testing. The primary outcome, proportion of contacts accepting HIV testing, will be assessed by CHWs and analysed using an intention-to- treat approach. Secondary outcomes will be changes in perceived HIV stigma, changes in perceived TB stigma, effects of perceived HIV stigma on HIV test uptake, effects of perceived TB stigma on HIV test uptake and proportions of first-invited contacts who accept HIV testing. Results will inform new, scalable strategies for delivering HIV testing. Ethics and dissemination This study was approved by the Yale Human Investigation Committee (2000024852), Makerere University School of Public Health Institutional Review Board (661) and Uganda National Council on Science and Technology (HS2567). All participants, including patients and their household contacts, will provide verbal informed consent. Results will be submitted to a peer-reviewed journal and disseminated to national stakeholders, including policy-makers and representatives of affected communities.Item Digital adherence technology for tuberculosis treatment supervision: a stepped-wedge cluster randomized trial(PLoS medicine, 2021) Cattamanchi, Adithya; Crowder, Rebecca; Kityamuwesi, Alex; Kiwanuka, Noah; Lamunu, Maureen; Namale, Catherine; Kunihira Tinka, Lynn; Sanyu Nakate, Agnes; Ggita, Joseph; Turimumahoro, Patricia; Babirye2, Diana; Oyuku, Denis; Berger, Christopher; Tucker, Austin; Patel, Devika; Sammann, Amanda; Stavia, Turyahabwe; Dowdy, David; Katamba, AchillesAdherence to and completion of tuberculosis (TB) treatment remain problematic in many high-burden countries. 99DOTS is a low-cost digital adherence technology that could increase TB treatment completion. Methods and findings We conducted a pragmatic stepped-wedge cluster-randomized trial including all adults treated for drug-susceptible pulmonary TB at 18 health facilities across Uganda over 8 months (1 December 2018–31 July 2019). Facilities were randomized to switch from routine (control period) to 99DOTS-based (intervention period) TB treatment supervision in consecutive months. Patients were allocated to the control or intervention period based on which facility they attended and their treatment start date. AU : IchangedPatientswereallocatedtothecontrolorinterventionperiodbasedontheirtreatmentstartdatetoPatientswereallocatedtothecontroloHealth facility staff and patients were not blinded to the intervention. The primary outcome was TB treatment completion. Due to the pragmatic nature of the trial, the primary analysis was done according to intention-to-treat (ITT) and per protocol (PP) principles. This trial is registered with the Pan African Clinical Trials Registry (PACTR201808609844917). Of 1,913 eligible patients at the 18 health facilities (1,022 and 891 during the control and intervention periods, respectively), 38.0% were women, mean (SD) age was 39.4 (14.4) years, 46.8% were HIV-infected, and most (91.4%) had newly diagnosed TB. In total, 463 (52.0%) patients were enrolled on 99DOTS during the intervention period. In the ITT analysis, the odds of treatment success were similar in the intervention and control periods (adjusted odds ratio [aOR] 1.04, 95% CI 0.68–1.58, p = 0.87). The odds of treatment success did not increase in the intervention period for either men (aOR 1.24, 95% CI 0.73–2.10) or women (aOR 0.67, 95% CI 0.35–1.29), or for either patients with HIV infection (aOR 1.51, 95% CI 0.81–2.85) or without HIV infection (aOR 0.78, 95% CI 0.46–1.32). In the PP analysis, the 99DOTS-based intervention increased the odds of treatment success (aOR 2.89, 95% CI 1.57–5.33, p = 0.001). The odds of completing the intensive phase of treatment and the odds of not being lost to follow-up were similarly improved in PP but not ITT analyses. Study limitations include the likelihood of selection bias in the PP analysis, inability to verify medication dosing in either arm, and incomplete implementation of some components of the intervention. Conclusions 99DOTS-based treatment supervision did not improve treatment outcomes in the overall study population. However, similar treatment outcomes were achieved during the control and intervention periods, and those patients enrolled on 99DOTS achieved high treatment completion. 99DOTS-based treatment supervision could be a viable alternative to directly observed therapy for a substantial proportion of patients with TB.Item Drop-out from the tuberculosis contact investigation cascade in a routine public health setting in urban Uganda: A prospective, multi-center study(PLoS ONE, 2017) Armstrong-Hough, Mari; Turimumahoro, Patricia; Meyer, Amanda J.; Ochom, Emmanuel; Babirye, Diana; Ayakaka, Irene; Mark, David; Ggita, Joseph; Cattamanchi, Adithya; Dowdy, David; Mugabe, Frank; Fair, Elizabeth; Haberer, Jessica E.; Katamba, Achilles; Davis, J. LucianSeven public tuberculosis (TB) units in Kampala, Uganda, where Uganda's national TB program recently introduced household contact investigation, as recommended by 2012 guidelines from WHO. Objective To apply a cascade analysis to implementation of household contact investigation in a programmatic setting. Design Prospective, multi-center observational study. Methods We constructed a cascade for household contact investigation to describe the proportions of: 1) index patient households recruited; 2) index patient households visited; 3) contacts screened for TB; and 4) contacts completing evaluation for, and diagnosed with, active TB. Results 338 (33%) of 1022 consecutive index TB patients were eligible for contact investigation. Lay health workers scheduled home visits for 207 (61%) index patients and completed 104 (50%). Among 287 eligible contacts, they screened 256 (89%) for symptoms or risk factors for TB. 131 (51%) had an indication for further TB evaluation. These included 59 (45%) with symptoms alone, 58 (44%) children <5, and 14 (11%) with HIV. Among 131 contacts found to be symptomatic or at risk, 26 (20%) contacts completed evaluation, including five (19%) diagnosed with and treated for active TB, for an overall yield of 1.7%. The cumulative conditional probability of completing the entire cascade was 5%. Conclusion Major opportunities exist for improving the effectiveness and yield of TB contact investigation by increasing the proportion of index households completing screening visits by lay health workers and the proportion of at-risk contacts completing TB evaluation.Item “Give Me Some Time”: Facilitators of and Barriers to Uptake of Home-based HIV Testing During Household Contact Investigation for Tuberculosis in Kampala, Uganda(Journal of acquired immune deficiency syndromes, 2018) Armstrong-Hough, Mari; Ggita, Joseph; Ayakaka, Irene; Dowdy, David; Cattamanchi, Adithya; Haberer, Jessica E.; Katamba, Achilles; Davis, J. LucianIntegrating home-based HIV counseling and testing (HCT) with tuberculosis (TB) evaluation could improve uptake of HIV testing among household contacts of patients with active TB. We sought to identify the facilitators of and barriers to HCT during household contact investigation for TB in Kampala, Uganda. Methods—We nested semi-structured interviews with 28 household contacts who were offered home-based HCT in a household-randomized trial of home-based strategies for TB contact investigation. Respondents reflected on their experiences of the home visit, the social context of the household, and their decision to accept or decline HIV testing. We used content analysis to identify and evaluate facilitators and barriers to testing, then categorized the emergent themes using the Capability, Opportunity, Motivation, and Behavior (COM-B) model. Results—Facilitators included a pre-existing desire to confirm HIV status or to show support for the index TB patient; a perception that home-based services are convenient; and positive perceptions of lay health workers. Key barriers included fear of results and feeling psychologically unprepared to receive results. The social influence of other household members operated as both a facilitator and a barrier. Conclusions—Pre-existing motivation, psychological readiness to test, and the social context of the household are major contributors to the decision to test for HIV at home. Uptake might be improved by providing normalizing information about HCT prior to the visit, by offering a second HCT opportunity, by offering self-tests with follow-up counseling, or by introducing HCT using “opt-out” language.Item Implementation, feasibility, and acceptability of 99DOTS-based supervision of treatment for drug- 2 susceptible TB in Uganda(medRxiv, 2022) Kiwanuka, Noah; Kityamuwesi, Alex; Crowder, Rebecca; Guzman, Kevin; Berger, Christopher A.; Lamunu, Maureen; Namale, Catherine; Kunihira Tinka, Lynn; Sanyu Nakate, Agnes; Ggita, Joseph; Turimumahoro, Patricia; Babirye, Diana; Oyuku, Denis; Patel, Devika; Sammann, Amanda; Stavia, Turyahabwe; Dowdy, David; Katamba, Achilles; Cattamanchi, Adithya99DOTS is a low-cost digital adherence technology that allows people with tuberculosis (TB) to self-report treatment adherence. There are limited data on its implementation, feasibility, and acceptability from sub-Saharan Africa. We conducted a longitudinal analysis and cross-sectional surveys nested within a stepped-wedge randomized trial at 18 health facilities in Uganda between December 2018 and January 2020. The longitudinal analysis assessed implementation of key components of a 99DOTS-based intervention, including self-reporting of TB medication adherence via toll-free phone calls, automated text message reminders and support actions by health workers monitoring adherence data. Cross-sectional surveys administered to a subset of people with TB and health workers assessed 99DOTS feasibility and acceptability. Composite scores for capability, opportunity, and motivation to use 99DOTS were estimated as mean Likert scale responses. Among 462 people with pulmonary TB enrolled on 99DOTS, median adherence was 58.4% (inter-quartile range [IQR] 38.7-75.6) as confirmed by self-reporting dosing via phone calls and 99.4% (IQR 96.4-100) when also including doses confirmed by health workers. Phone call-confirmed adherence declined over the treatment period and was lower among people with HIV (median 50.6% vs. 63.7%, p<0.001). People with TB received SMS dosing reminders on 90.5% of treatment days. Health worker support actions were documented for 261/409 (63.8%) people with TB who missed >3 consecutive doses. Surveys were completed by 83 people with TB and 22 health workers. Composite scores for capability, opportunity, and motivation were high; among people with TB, composite scores did not differ by gender or HIV status. Barriers to using 99DOTS included technical issues (phone access, charging, and network connection) and concerns regarding disclosure. 99DOTS was feasible to implement and highly acceptable to people with TB and their health workers. National TB Programs should offer 99DOTS as an option for TB treatment supervision.Item Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruption(Global Public Health, 2021) Hennein, Rachel; Ggita, Joseph; Ssuna, Bashir; Shelley, Donna; Akiteng, Ann R.; Davis, J. Lucian; Katamba, Achilles; Armstrong-Hough, MariMany implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform re-implementation strategies. We sought to devise an approach for evaluating interruptions by exploring the sustainability of a programme that implemented diabetes mellitus (DM) screening within tuberculosis clinics in Uganda in 2017. In 2019, we conducted nine interviews with clinic staff and observed clinic visits to determine their views and practices on providing integrated care. We mapped themes to a social ecological model with three levels derived from the Consolidated Framework for Implementation Research (CFIR): outer setting (i.e. community), inner setting (i.e. clinic), and individuals (i.e. clinicians). Respondents explained that DM screening ceased due to disruptions in the national supply chain for glucose test strips, which had cascading effects on clinics and clinicians. Lack of screening supplies in clinics limited clinicians’ opportunities to perform DM screening, which contributed to diminished self-efficacy. However, culture, compatibility and clinicians’ beliefs about DM screening sustained throughout the interruption. We propose an approach for evaluating interruptions using the CFIR and social ecological model; other programmes can adapt this approach to identify cascading effects of interruptions and target them for re-implementation.Item Opportunities to improve digital adherence technologies and TB using human-centered design(The official journal of the International Union against Tuberculosis and Lung Disease, 2020) Berger, Christopher; Patel, Devika; Kityamuwesi, Alex; Ggita, Joseph; Kunihira Tinka, Lynn; Turimumahoro, Patricia; Neville, Katie; Chehab, Lara; Chen, Amy Z.; Gupta, Nakull; Turyahabwe, Stavia; Katamba, Achilles; Cattamanchi, Adithya; Sammann, AmandaDigital adherence technologies (DATs) have emerged as a promising solution for supporting and supervising patients being treated for tuberculosis (TB). Despite considerable enthusiasm and wide-scale implementation (1), few clinical trials and programmatic data have demonstrated improvement in treatment outcomes and shown variable uptake and engagement by patients and providers (2–6).Item Study protocol and implementation details for a pragmatic, stepped-wedge cluster randomised trial of a digital adherence technology to facilitate tuberculosis treatment completion(BMJ Open, 2020) Crowder, Rebecca; Kityamuwesi, Alex; Kiwanuka, Noah; Lamunu, Maureen; Namale, Catherine; Kunihira Tinka, Lynn; Sanyu Nakate, Agnes; Ggita, Joseph; Turimumahoro, Patricia; Babirye, Diana; Oyuku, Denis; Allen Berger, Christopher; Tucker, Austin; Patel, Devika; Sammann, Amanda; Dowdy, David; Turyahabwe, Stavia,; Cattamanchi, Adithya; Katamba, AchillesLow-cost digital adherence technologies (DATs) such as 99DOTS have emerged as an alternative to directly observed therapy (DOT), the current standard for tuberculosis (TB) treatment supervision. However, there are limited data to support DAT scale-up. The ‘DOT to DAT’ trial aims to evaluate the effectiveness and implementation of a 99DOTS-based TB treatment supervision strategy. Methods and analysis This is a pragmatic, stepped-wedge cluster randomised trial, with hybrid type 2 effectiveness-implementation design. The trial will include all adults (estimated N=1890) treated for drug-susceptible pulmonary TB over an 8-month period at 18 TB treatment units in Uganda. Three sites per month will switch from routine care (DOT) to the intervention (99DOTS-based treatment supervision) beginning in month 2, with the order determined randomly. 99DOTS enables patients to be monitored while self-administering TB medicines. Patients receive daily automated short message service (SMS) dosing reminders and confirm dosing by calling toll-free numbers. The primary effectiveness outcome is the proportion of patients completing TB treatment. With 18 clusters randomised into six steps and an average cluster size of 15 patients per month, the study will have 89% power to detect a 10% or greater increase in treatment completion between the routine care and intervention periods. Secondary outcomes include more proximal effectiveness measures as well as quantitative and qualitative assessments of the reach, adoption and implementation of the intervention. Ethics and dissemination Ethics approval was granted by institutional review boards at Makerere University School of Public Health and the University of California San Francisco. Findings will be disseminated through peer-reviewed publications, presentations at scientific conferences and presentations to key stakeholders.Item Uptake of Home-Initiated Tuberculosis Evaluation During Household Contact Investigation in Kampala, Uganda: A Mixed Methods Study(PeerJ Preprints, 2017) Armstrong-Hough, Mari; Ggita, Joseph; Turimumahoro, Patricia; Meyer, Amanda J.; Ochom, Emmanuel; Katamba, Achilles; Davis, J. LucianHome-initiated tuberculosis (TB) evaluation could improve test uptake and linkage to care among at-risk contacts of active TB index patients. However, there is a need to systematically explore why contacts accept, decline, or are unable to complete these services. We sought to describe the barriers to home-based sputum collection as part of enhanced household contact investigation for TB in Kampala, Uganda. Methods Using a parallel convergent mixed-methods design, we collected quantitative data describing home sputum collection among 82 household contacts of active TB patients and qualitative interviews from a sub-sample of 19 of those contacts. Data were analyzed in parallel to produce a more complete picture of the underlying barriers to home sputum collection. Results Men were significantly more likely than women to provide sputum when eligible (p=0.04). Contacts who reported risk factors for or symptoms of TB but no active cough where significantly less likely to provide sputum (p=0.05). Education level was not associated with differences in home sputum collection success. In interviews, contacts pointed to support from and for the index patient as a facilitator. Contacts were particularly enthusiastic about the convenience of home-based sputum collection compared to visiting a clinic. Lost or insufficient sputum containers, difficulty producing sputum on demand, and shame emerged as barriers to collecting sputum at home. Conclusions Uptake of sputum collection might be improved by addressing opportunity barriers prior to the visit, possibly through equipment checklists and improved community health worker training. More research is needed on the effects of TB stigma on willingness to produce sputum, even in the privacy of one’s own home.Item Variation in tuberculosis treatment outcomes and treatment supervision practices in Uganda(Journal of clinical tuberculosis and other mycobacterial diseases, 2020) Bergera, Christopher A.; Kityamuwesi, Alex; Crowder, Rebecca; Lamunu, Maureen; Kunihira Tinka, Lynn; Ggita, Joseph; Sanyu Nakate, Agnes; Namale, Catherine; Oyuku, Denis; Chenc, Katherine; Turyahabwe, Stavia; Cattamanchi, Adithya; Katamba, AchillesVariation in healthcare delivery is increasingly recognized as an important metric of healthcare quality. Directly observed therapy (DOT) has been the standard of care for tuberculosis (TB) treatment supervision for decades based on World Health Organization (WHO) guidelines. However, variation in implementation of DOT and associated TB treatment supervision practices remains poorly defined. Methods: We collected individual patient data from TB treatment registers at 18 TB treatment units in Uganda including District Health Centers, District Hospitals, and Regional Referral Hospitals. We also administered a survey and did observations of TB treatment supervision practices by health workers at each site. We describe variation in TB treatment outcomes and TB treatment supervision practices. Results: Of 2767 patients treated for TB across the 18 clinical sites between January 1 and December 31, 2017, 1740 (62.9%) were men, most were of working age (median 35 years, interquartile range [IQR] 27 – 46), 2546 (92.0%) had a new TB diagnosis, and nearly half (45.9%, n = 1283) were HIV positive. The pooled treatment success proportion was 69.4% (95% confidence interval [CI] 67.8 – 71.1) but there was substantial variation across sites (range 42.6 – 87.6%, I-squared 92.7%, p < 0.001). The survey and observation of TB treatment practices revealed that the majority of sites practice community-based DOT (66.7%, n = 12) and request a family member, who receives no additional training or supervision, to serve as a treatment supporter (77.8%, n = 14). At TB medication refill visits, all sites screen for side effects and most assess adherence via self-report (83.3%, n = 15). Only 7 (38.9%) sites followed-up patients who missed appointments using either phone calls (22.2%, n = 4/7) or community health workers (16.7%, n = 3/7). All 18 sites counseled patients at treatment initiation, but none provided additional counseling at refill visits other than addressing poor adherence or missed appointments. Conclusion: There was substantial variation in implementation of DOT, including observation and documentation of daily dosing, training and supervision of treatment supporters, and follow-up for missed clinic visits. Identifying best practices and reducing uncontrolled variation in the delivery of TB treatment is critical to improving treatment outcomes.