NRU :: Browsing by Author "Haberer, Jessica E."

Browsing by Author "Haberer, Jessica E."

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Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12-month cohort study in urban South Africa and rural Uganda
(Journal of the International AIDS Society, 2020) Matthews, Lynn T.; Orrell, Catherine; Mwebesa, Bosco Bwana; Tsai, Alexander C.; Psaros, Christina; Asiimwe, Stephen; Amanyire, Gideon; Musinguzi, Nicholas; Bell, Kathleen; Bangsberg, David R.; Haberer, Jessica E.
We conducted a cohort study to understand patterns of anti-retroviral therapy (ART) adherence during pregnancy, postpartum and non-pregnancy follow-up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa. We collected survey data, continuously monitored ART adherence (Wisepill), HIV-RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow-up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non-pregnancy-related (neither pregnant nor postpartum). Fractional regression models included demographics and socio-behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV-RNA at 12 months by ever- versus never-pregnant status. In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non-pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/ mm3). HIV-RNA was suppressed among 91% (N = 135) ever-pregnant and 86% (N = 85) never-pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non-pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non-pregnancy-related follow-up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIVRNA was suppressed among 57% (N = 47) ever-pregnant and 86% (N = 93) never-pregnant women. Women in rural Uganda maintained high adherence with 91% of ever-pregnant and 86% of never-pregnant women suppressing HIV-RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow-up with median adherence of 40% and 57% of women with HIV-RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.
Anybody out there? A process evaluation of SMS sent to household TB contacts in Kampala, Uganda
(ResearchGate, 2018) Amanda, J. Meyer; Babirye, Diana; Armstrong-Hough, Mari; Mark, David; Ayakaka, Irene; Katamba, Achilles; Haberer, Jessica E.; Davis, J. Lucian
Previous studies have reported inconsistent effectiveness of SMS (short-messaging services) for improving health outcomes, but few have examined to what degree the quality, or “fidelity”, of implementation may explain study results. Objective: We sought to determine the fidelity of a one-time SMS intervention to promote uptake of TB evaluation services among household contacts of index TB patients. Methods: From February to June 2017, we nested a process evaluation of SMS delivery within the intervention arm of a randomized controlled trial of TB contact investigation in Kampala, Uganda. Because mobile service providers in Uganda do not provide delivery confirmations, we asked household TB contacts to confirm receipt of a one-time TB-related SMS by sending an SMS reply via a toll-free “short code.” Two weeks later, a research officer followed-up by telephone to confirm receipt of the one-time SMS and administer a survey. We considered participants lost-to-follow-up after three unsuccessful call attempts on three separate days over a one-week period. Results: Of 206 consecutive household contacts, 119 had an SMS initiated from the server. Thirty-nine (33%) were children aged 5-14, including 24 (20%) girls and 15 (13%) boys. Twenty-one (18%) were adolescents or young adults, including 14 (12%) young women and seven (6%) young men. Fifty-nine (50%) were adults, including 31 (26%) women and 28 (24%) men. Of 107 (90%) participants for whom we were able to ascertain SMS receipt status, 67% (n=72) confirmed SMS receipt, including 22% (n=24) by reply SMS and 45% (n=48) during the follow-up telephone survey. There were no significant clinical or demographic differences between those who did and did not report receiving the SMS message. 52% (n=56) reported ever reading the SMS. The cumulative likelihood of an SMS reaching its target and being read and retained by a participant was 19%. Conclusions: The fidelity of a one-time SMS intervention to increase uptake of household TB contact investigation and linkage to care was extremely low, a fact only discoverable through a detailed process evaluation. Our findings suggest the need for systematic process monitoring and reporting of implementation fidelity in both research studies and programmatic interventions employing mobile communications to improve health.
ART adherence and viral suppression are high among most non-pregnant individuals with early-stage, asymptomatic HIV infection: an observational study from Uganda and South Africa
(Journal of the International AIDS Society, 2019) Haberer, Jessica E.; Bwana, Bosco M.; Orrell, Catherine; Asiimwe, Stephen; Amanyire, Gideon; Musinguzi, Nicholas; Siedner, Mark J.; Matthews, Lynn T.; Tsai, Alexander C.; Katz, Ingrid T.; Bell, Kathleen; Kembabazi, Annet; Mugisha, Stephen; Kibirige, Victoria; Cross, Anna; Kelly, Nicola; Hedt-Gauthier, Bethany; Bangsberg, David R.
The success of universal antiretroviral therapy (ART) access and aspirations for an AIDS-free generation depend on high adherence in individuals initiating ART during early-stage HIV infection; however, adherence may be difficult in the absence of illness and associated support. From March 2015 to October 2017, we prospectively observed three groups initiating ART in routine care in Uganda and South Africa: men and non-pregnant women with early-stage HIV infection (CD4 > 350 cells/lL), pregnant women with early-stage HIV infection and men and non-pregnant women with late-stage HIV infection (CD4 < 200 cells/lL). Socio-behavioural questionnaires were administered and viral loads were performed at 0, 6 and 12 months. Adherence was monitored electronically. Adherence data were available for 869 participants: 322 (37%) early/non-pregnant, 199 (23%) early/pregnant and 348 (40%) late/non-pregnant participants. In Uganda, median adherence was 89% (interquartile range 74 to 96) and viral suppression was 90% at 12 months; neither differed among groups (p > 0.72). In South Africa, median adherence was higher in early/non-pregnant versus early/pregnant or late/non-pregnant participants (76%, 37%, 52%; p < 0.001), with similar trends in viral suppression (86%, 51%, 79%; p < 0.001). Among early/non-pregnant individuals in Uganda, adherence was higher with increasing age and lower with structural barriers; whereas in South Africa, adherence was higher with regular income, higher perceived stigma and use of other medications, but lower with maladaptive coping and cigarette smoking. ART adherence among non-pregnant individuals with early-stage infection is as high or higher than with late-stage initiation, supporting universal access to ART. Challenges remain for some pregnant women and individuals with late-stage infection in South Africa and highlight the need for differentiated care delivery.
Beyond HIV-serodiscordance: Partnership communication dynamics that affect engagement in safer conception care
(PloS one, 2017) Matthews, Lynn T.; Burns, Bridget F.; Bajunirwe, Francis; Kabakyenga, Jerome; Bwana, Mwebesa; Ng, Courtney; Kastner, Jasmine; Kembabazi, Annet; Sanyu, Naomi; Kusasira, Adrine; Haberer, Jessica E.; Bangsberg, David .R; Kaida, Angela
We explored acceptability and feasibility of safer conception methods among HIV-affected couples in Uganda. We recruited HIV-positive men and women on antiretroviral therapy (ART) (‘index’) from the Uganda Antiretroviral Rural Treatment Outcomes cohort who reported an HIV-negative or unknown-serostatus partner (‘partner’), HIV-serostatus disclosure to partner, and personal or partner desire for a child within two years. We conducted in-depth interviews with 40 individuals from 20 couples, using a narrative approach with tailored images to assess acceptability of five safer conception strategies: ART for the infected partner, pre-exposure prophylaxis (PrEP) for the uninfected partner, condomless sex timed to peak fertility, manual insemination, and male circumcision. Translated and transcribed data were analyzed using thematic analysis. 11/20 index participants were women, median age of 32.5 years, median of 2 living children, and 80% had HIV-RNA <400 copies/mL. Awareness of HIV prevention strategies beyond condoms and abstinence was limited and precluded opportunity to explore or validly assess acceptability or feasibility of safer conception methods. Four key partnership communication challenges emerged as primary barriers to engagement in safer conception care, including: (1) HIV-serostatus disclosure: Although disclosure was an inclusion criterion, partners commonly reported not knowing the index partner’s HIV status. Similarly, the partner’s HIV-serostatus, as reported by the index, was frequently inaccurate. (2) Childbearing intention: Many couples had divergent childbearing intentions and made incorrect assumptions about their partner’s desires. (3) HIV risk perception: Participants had disparate understandings of HIV transmission and disagreed on the acceptable level of HIV risk to meet reproductive goals. (4) Partnership commitment: Participants revealed significant discord in perceptions of partnership commitment. All four types of partnership miscommunication introduced constraints to autonomous reproductive decision-making, particularly for women. Such miscommunication was common, as only 2 of 20 partnerships in our sample were mutually-disclosed with agreement across all four communication themes. Enthusiasm for safer conception programming is growing. Our findings highlight the importance of addressing gendered partnership communication regarding HIV disclosure, reproductive goals, acceptable HIV risk, and commitment, alongside technical safer conception advice. Failing to consider partnership dynamics across these domains risks limiting reach, uptake, adherence to, and retention in safer conception programming.
Challenges in Accessing Maternal and Child Health Services During COVID-19 and the Potential Role of Social Networking Technologies
(Digital Health, 2022) Musiimenta, Angella; Tumuhimbise, Wilson; Atukunda, Esther C.; Ayebaza, Sandrah; Kobutungi, Phionah; Zender, Raphael; Haberer, Jessica E.
The COVID-19 pandemic causes new challenges to women and their babies who still need to access postnatal care amidst the crisis. The novel application of social network technologies (SNTs) could potentially enhance access to healthcare during this difficult time. This study describes the challenges experienced in accessing maternal and child health services by women with limited or no education during this COVID-19 pandemic and discusses the potential of SNTs to support maternal and child health amidst this crisis. We administered surveys to women who had recently given birth in a rural setting and interviewed a purposively selected subset to ascertain their experiences of accessing maternal and child health services during the COVID-19 pandemic. Our analysis involved descriptive analysis of quantitative data using STATA 13 to describe study participants’ characteristics, and content analysis of qualitative data to derive categories describing maternal health challenges. Among 50 women, the median age was 28 years (interquartile range 24–34), 42 (84%) completed upper primary education. Access to the health facility was constrained by transport challenges, fear of contracting COVID-19, and delays at the facility. Due to the COVID-19 crisis, 42 (84%) women missed facility visits, 46 (92%) experienced financial distress, 43 (86%) had food insecurity, and 44 (88%) felt stressed. SNTs can facilitate remote and timely access to health services and information, and enable virtual social connections and support. SNTs have the potential to mitigate the challenges faced in accessing maternal and child health services amidst the ongoing COVID-19 pandemic.
Changes in Immune Activation During Pregnancy and the Postpartum Period in Treated HIV Infection
(Oxford University Press, 2021) Schnittman, Samuel R.; Byakwaga, Helen; Boum, Yap; Kabakyenga, Jerome; Matthews, Lynn T.; Burdo, Tricia H.; Huang, Yong; Tracy, Russell P.; Haberer, Jessica E.; Kembabazi, Annet; Kaida, Angela; Moisi, Daniela; Lederman, Michael M.; Bangsberg, David R.; Martin, Jeffrey N.; Hunt, Peter W.
Pregnant women with HIV (PWWH) have high postpartum morbidity and mortality from infections like tuberculosis. Immunologic changes during pregnancy and postpartum periods may contribute to these risks, particularly the immunoregulatory kynurenine pathway of tryptophan catabolism, which contributes to both HIV and tuberculosis pathogenesis and increases in the early postpartum period. Women with HIV initiating antiretroviral therapy (ART) in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort who were pregnant at enrollment or became pregnant during observation were studied (n = 54). Plasma kynurenine/tryptophan (KT) ratio, soluble CD14 (sCD14), sCD163, sCD27, interferon-inducible protein 10 (IP-10), D-dimer, interleukin-6, and intestinal fatty-acid binding protein levels were assessed through the first year of ART and at 3-month intervals throughout pregnancy and 1 year postpartum. Biomarker changes were assessed with linear mixed models adjusted for ART duration. Hemoglobin concentration changes were used to estimate pregnancy-related changes in plasma volume. Results. The median pre-ART CD4 count was 134. D-dimer increased through the third trimester before returning to baseline postpartum, while most other biomarkers declined significantly during pregnancy, beyond what would be expected from pregnancy associated plasma volume expansion. IP-10 and sCD14 remained suppressed for at least 12 months postpartum. KT ratio was the only biomarker that increased above prepregnancy baseline postpartum (mean + 30%; P < .001) and remained higher than baseline for ≥9 months (P ≤ .045 for all time points). Several immune activation markers decline during pregnancy and remain suppressed postpartum, but the kynurenine pathway of tryptophan catabolism increases above baseline for ≥9 months postpartum. The mechanisms underlying postpartum kynurenine pathway activity are incompletely understood but may contribute to increased tuberculosis risk in this setting.
Comparison of Self-Reported Alcohol Consumption to Phosphatidylethanol Measurement among HIV-Infected Patients Initiating Antiretroviral Treatment in Southwestern Uganda
(PLoS One, 2014) Bajunirwe, Francis; Haberer, Jessica E.; Boum II, Yap; Hunt, Peter; Mocello, Rain; Martin, Jeffrey N.; Bangsberg, David R.; Hahn, Judith A.
Alcohol consumption among HIV-infected patients may accelerate HIV disease progression or reduce antiretroviral therapy adherence. Self-reported alcohol use is frequently under-reported due to social desirability and recall bias. The aim of this study was to compare self-reported alcohol consumption to phosphatidylethanol (PEth), a biomarker of alcohol consumption, and to estimate the correlation between multiple measures of self-reported alcohol consumption with PEth. The Uganda AIDS Rural Treatment Outcomes (UARTO) cohort is located in southwestern Uganda and follows patients on ART to measure treatment outcomes. Patients complete standardized questionnaires quarterly including questions on demographics, health status and alcohol consumption. Baseline dried blood spots (DBS) were collected and retrieved to measure PEth. One hundred fifty samples were tested, and 56 (37.3%) were PEth positive (≥8 ng/mL). Of those, 51.7% did not report alcohol use in the past month. Men were more likely to under-report compared to women, OR 2.9, 95% CI = 1.26, 6.65) and those in the higher economic asset categories were less likely to under-report compared to those in the lowest category (OR = 0.41 95% CI: 0.17, 0.94). Among self-reported drinkers (n = 31), PEth was highly correlated with the total number of drinking days in the last 30 (Spearman R = 0.73, p<0.001). Approximately half of HIV infected patients initiating ART and consuming alcohol under-report their use of alcohol. Given the high prevalence, clinicians should assess all patients for alcohol use with more attention to males and those in lower economic asset categories who deny alcohol use. Among those reporting current drinking, self-reported drinking days is a useful quantitative measure.
Comparison of short messaging service self-reported adherence with other adherence measures in a demonstration project of HIV preexposure prophylaxis in Kenya and Uganda
(AIDS (London, England), 2018) Musinguzi, Nicholas; Muwonge, Timothy; Ngure, Kenneth; Katabira, Elly; Mugo, Nelly; O’Rourke Burns, Bridget Frances; Baeten, Jared M.; Heffron, Renee; Haberer, Jessica E.
Short messaging service (SMS) can collect adherence data on a frequent basis and is relatively anonymous, and therefore could potentially reduce recall and social desirability biases prevalent in other self-reported measures. Methods: We compared SMS self-reported adherence with three self-reported adherence questions (rating of ability to adhere, frequency of doses taken, percentage of doses taken) and two objective adherence measures [electronic adherence monitoring (EAM) and plasma tenofovir levels] using data from HIV-uninfected members of serodiscordant couples enrolled in a preexposure prophylaxis demonstration project in Kenya and Uganda. Results: Of 373 enrolled participants, 256 (69%) were male and median age at enrolment was 29 years (26, 35). Fifty-two percent were from Kenya and median education at enrolment was 10 years (7,12). Overall, median adherence was 90, 75, 85,94 and 79%, respectively, for self-report by SMS, rating, frequency, percentage and EAM adherence. Spearman’s correlation coefficient between SMS and interviewer- administered self-reported measures was 0.18 for rating and frequency, 0.22 for percentage and 0.14 for EAM (all P< 0.001). The estimated difference in average adherence between SMS and self-reported rating, frequency, percentage adherence and EAM was 8.1 (P < 0.001), 0.3 (P = 0.81), −5.2 (P < 0.001) and 9.5 (P < 0.001), respectively. Area under the receiver-operating curve assessing the ability of SMS self-report to discriminate between detectable and undetectable tenofovir was 0.51. Conclusion: Our study found low correlation between SMS self-report and other self-reported and objective adherence measures and did not discriminate between detectable and undetectable plasma tenofovir levels. Future use of SMS self-report should explore alternative means for reducing potential biases.
Context matters: PrEP adherence is associated with sexual behavior among HIV serodiscordant couples in East Africa
(Journal of acquired immune deficiency syndromes, 2017) Haberer, Jessica E.; Ngure, Kenneth; Muwonge, Timothy; Mugo, Nelly; Katabira, Elly; Heffron, Renee; Musinguzi, Nicholas; Bangsberg, David R.; Celum, Connie; Baeten, Jared M.
Short message service (SMS) surveys are a promising tool for understanding whether pre-exposure prophylaxis (PrEP) adherence aligns with risk for HIV acquisition— a concept known as prevention-effective adherence. Methods—The Partners Demonstration Project was an open-label study of integrated PrEP and antiretroviral therapy (ART) delivery among high-risk HIV serodiscordant couples in East Africa. HIV-uninfected partners were offered PrEP until their HIV-infected partner had taken ART for ≥6 months. At 2 study sites, HIV-uninfected partners were offered enrollment into the Partners Mobile Adherence to PrEP (PMAP) sub-study based on ongoing PrEP use, personal cell phone ownership, and ability to use SMS. SMS surveys asked about PrEP adherence and sexual activity in the prior 24 hours; these surveys were sent daily for the 7 days prior and 7 days after routine study visits in the Partners Demonstration Project. Results—The PMAP sub-study enrolled 373 HIV-uninfected partners; 69% were male and mean age was 31 years. Participants completed 17,030 of 23,056 SMS surveys sent (74%) with a mean of 47 surveys per participant over 9.8 months of follow-up. While HIV-infected partner use of ART was <6 months, mean reported PrEP adherence was 92% on surveys concurrently reporting sex within the serodiscordant partnership and 84% on surveys reporting no sex (p<0.001). Discussion—SMS surveys provided daily assessment of concurrent PrEP adherence and sexual behavior. Higher PrEP adherence was temporally associated with increased risk for HIV acquisition.
Contraceptive use following unintended pregnancy among Ugandan women living with HIV
(PLoS ONE, 2018) Jarolimova, Jana; Kabakyenga, Jerome; Bennett, Kara; Muyindike, Winnie; Kembabazi, Annet; Martin, Jeffrey N.; Hunt, Peter W.; Boum, Yap; Haberer, Jessica E.; Bangsberg, David R.; Kaida, Angela; Matthews, Lynn T.
Preventing unintended pregnancy is critical for women living with HIV (WLWH) to safely achieve their reproductive goals. Family planning services should support WLWH at risk of repeat unintended pregnancies. We examined the relationship between unintended pregnancy and subsequent contraception use among WLWH in Uganda. This was a retrospective analysis of data from a longitudinal cohort of individuals initiating antiretroviral therapy (ART), restricted to women with pregnancy (confirmed via urine β-hcg testing) between 2011–2013. The exposure of interest was intended vs unintended pregnancy, and the outcome was self-report of modern contraceptive use (hormonal methods, intrauterine device, sterilization, and/or consistent condom use) at 12 (range 6–18) months post-partum. A log-binomial model was used to estimate relative risks of modern contraceptive use post-partum based on intent of the index pregnancy, adjusted for age, socioeconomic status, education, relationship and HIV status of pregnancy partner, contraceptive use prior to pregnancy, years since HIV diagnosis, ART regimen, and CD4 cell count.
Declining Prevalence of Probable Depression Among Patients Presenting for Antiretroviral Therapy in Rural Uganda: The Role of Early Treatment Initiation
(AIDS and Behavior, 2015) Chan, Brian T.; Weiser, Sheri D.; Boum, Yap; Haberer, Jessica E.; Kembabazi, Annet; Hunt, Peter W.; Martin, Jeffrey N.; Mocello, A. Rain; Bangsberg, David R.; Tsai, Alexander C.
Little is known about trends in depression at antiretroviral therapy (ART) initiation among people living with HIV (PLHIV) in low- and middle-income countries. We used data from an ongoing cohort of treatment -naı¨ve PLHIV in rural Uganda to estimate secular trends in depression among PLHIV at ART initiation. We fitted linear regression models with depression symptom severity as the outcome variable and year of cohort entry (2005–2012) as the explanatory variable, adjusting for socio-demographic variables and assessing physical health score, body mass index (BMI), and CD4 count as potential mediators of a secular trend in depression symptom severity. There was a statistically significant negative association between year of entry and depression symptom severity, suggesting a 3.1 % relative decline in the mean depression symptom severity score at ART initiation in each year of study recruitment after the first year. This trend remained statistically significant after inclusion of baseline socio demographic characteristics to the model and appeared to be driven by improved physical health scores, but not CD4 count or BMI.
Disinhibition in Risky Sexual Behavior in Men, but Not Women, during Four Years of Antiretroviral Therapy in Rural, Southwestern Uganda
(PLoS One, 2013) Kembabazi, Annet; Bajunirwe, Francis; Hunt, Peter W.; Martin, Jeffrey N.; Muzoora, Conrad; Haberer, Jessica E.; Bangsberg, David R.; Siedner, Mark J.
In resource-rich areas, risky sexual behavior (RSB) largely diminishes after initiation of anti-retroviral therapy, with notable exceptions among some populations who perceive a protected benefit from anti-retroviral therapy (ART). Yet, there is limited data about long-term trends in risky sexual behavior among HIV-infected people in sub-Saharan Africa after initiation of anti-retroviral therapy.We administered questionnaires every three months to collect sexual behavior data among patients taking ART in southwestern Uganda over four years of follow-up time. We defined RSB as having unprotected sex with an HIV-negative or unknown status partner, or unprotected sex with a casual partner. We fit logistic regression models to estimate changes in RSB by time on ART, with and without adjustment for calendar year and CD4 count.506 participants were enrolled between 2005 and 2011 and contributed a median of 13 visits and 3.5 years of observation time. The majority were female (70%) and median age was 34 years (interquartile range 29–39). There was a decrease in the proportion of men reporting RSB from the pre-ART visit to the first post-ART visit (16.2 to 4.3%, p<0.01) but not women (14.1 to 13.3%, p = 0.80). With each year of ART, women reported decreasing RSB (OR 0.85 per year, 95%CI 0.74–0.98, p = 0.03). In contrast, men had increasing odds of reporting RSB with each year of ART to near pre-treatment rates (OR 1.41, 95%CI 1.14–1.74, p = 0.001), which was partially confounded by changes in calendar time and CD4 count (AOR = 1.24, 95%CI 0.92–1.67, p = 0.16).Men in southwestern Uganda reported increasing RSB over four years on ART, to levels approaching pre-treatment rates. Strategies to promote long-term safe sex practices targeted to HIV-infected men on ART might have a significant impact on preventing HIV transmission in this setting.
Dissemination of Research Findings to Research Participants Living with HIV in Rural Uganda: Challenges and Rewards
(PLoS Medicine, 2013) Baylor, Anna; Muzoora, Conrad; Bwana, Mwebsa; Kembabazi, Annet; Haberer, Jessica E.; Matthews, Lynn T.; Tsai, Alexander C.; Hunt, Peter W.; Martin, Jeffrey N.; Bangsberg, David R.
Community participatory research emphasizes communication of study findings to research participants of vulnerable populations [1]. Most dissemination activities in sub-Saharan Africa have occurred after the completion (or termination) of randomized clinical trials of a defined intervention [2–4]. Sharing research findings with participants during observational research can avoid therapeutic misconception [5] as well as evaluate the validity of research involving knowledge, attitudes, or behavior through a ‘‘member check’’ procedure in which investigators conduct interviews regarding the relevancy and saliency of their findings [6]. Nonetheless, the communication of research findings to participants living with HIV enrolled in observational research in a rural sub- Saharan African setting is less straight forward and presents significant challenges respect to literacy, language, logistics, and confidentiality.
Does Adherence Change When No One is Looking? Comparing Announced and Unannounced Tenofovir Levels in a PrEP Trial
(Journal of acquired immune deficiency syndromes, 2017) Musinguzi, Nicholas; Muwonge, Timothy; Thomas, Katherine; Baeten, Jared M.; Bangsberg, David R.; Haberer, Jessica E.
Differences between unannounced and announced tenofovir levels as measures of PrEP adherence are not well understood. In an ancillary adherence study involving one urban site (Kampala) and two rural sites (Kabwohe and Tororo) from the Partners PrEP study, 268 specimen pairs from chronologically proximal clinic and home visits were tested for plasma tenofovir levels. Comparing clinic and home specimens, 89 versus 89 % were classified as detectable ([0.31 ng/ml; p = 0.77), 87 versus 86 % as recent dosing ([10 ng/ml; p = 0.80), and 82 versus 80 % as steady-state ([40 ng/ml; p = 0.44). Mean difference between announced and unannounced drug levels, adjusted for specimen collection time was 3.2 ng/ml (p = 0.50) for Kabwohe, 23.2 ng/ml (p = 0.003) for Kampala and -3.3 ng/ml p = 0.69) for Tororo. In the setting of high adherence, plasma tenofovir levels tested at the clinic were categorically similar as levels tested at home; however, differences were seen between urban and rural settings.
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. Lucian
Seven 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.
The Dynamic Relationship Between Social Support and HIV-Related Stigma in Rural Uganda
(Annals of Behavioral Medicine, 2014) Takada, Sae; Weiser, Sheri D.; Kumbakumba, Elias; Muzoora, Conrad; Martin, Jeffrey N.; Hunt, Peter W.; Haberer, Jessica E.; Kawuma, Annet; Bangsberg, David R.; Tsai, Alexander C.
Cross-sectional studies show that human immunodeficiency virus (HIV) stigma is negatively correlated with social support. Purpose The purpose of this study is to examine the bidirectional relationship between social support and HIV stigma. We collected quarterly data from a cohort of 422 people living with HIV in Uganda, followed for a median of 2.1 years. We used multilevel regression to model the contemporaneous and 3-month-lagged associations between social support and both enacted and internalized stigma. Lagged enacted stigma was negatively correlated with emotional and instrumental social support, and lagged instrumental social support was negatively correlated with enacted stigma. Internalized stigma and emotional social support had reciprocal lagged associations. Interventions to reduce enacted stigma may strengthen social support for people living with HIV. Improved social support may in turn have a protective influence against future enacted and internalized stigma
Effect of HIV Self-Testing on PrEP Adherence Among Gender-Diverse Sex Workers in Uganda: A Randomized Trial
(Journal of acquired immune deficiency syndromes, 2022) Mujugira, Andrew; Nakyanzi, Agnes; Nabaggala, Maria S.; Muwonge, Timothy R.; Ssebuliba, Timothy; Bagaya, Monica; Nampewo, Olivia; Sapiri, Oliver; Nyanzi, Kikulwe R.; Bambia, Felix; Nsubuga, Rogers; Serwadda, David M.; Ware, Norma C.; Baeten, Jared M.; Haberer, Jessica E.
HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) are complementary tools that could empower sex workers to control their HIV protection, but few studies have jointly evaluated PrEP and HIVST in any setting. Methods: The Empower Study was an open-label randomized trial in Uganda. Sex workers were offered F/tenofovir disoproxil fumarate and randomized 1:1 to monthly HIVST and quarterly in-clinic testing (intervention) or quarterly in-clinic HIV testing alone (standard of care) and followed up for 12 months. PrEP adherence was measured using electronic adherence monitoring and tenofovir diphosphate (TFV-DP) levels in dried blood spots. Adherence outcomes and sexual behaviors were compared by arm using generalized estimating equation models. Results: We enrolled 110 sex workers: 84 cisgender women, 14 transgender women, 10 men who have sex with men, and 2 transgender men. The median age was 23 years. The 12-month retention was 75%. Nearly all (99.4%) used $1 HIVST kit. The proportion with TFV-DP levels $700 fmol/punch in the HIVST and standard of care arms at the 3-, 6-, 9-, and 12-month visits was 2.4%, 2.3%, 0%, and 0% and 7.9%, 0%, 0%, and 0%, respectively, with no differences by randomization arm (P . 0.2). Self-reported condomless sex acts with paying partners was similar by arm [adjusted incidence rate ratio 0.70; 95% confidence interval (CI): 0.42 to 1.17; P = 0.18]. One seroconversion occurred (HIV incidence, 0.9/100 person-years); TFV-DP was not detected at any visit. Conclusions: A gender-diverse sample of sex workers in Uganda used HIVST but not daily oral PrEP for HIV protection. Alternate approaches to promote PrEP use, including long-acting formulations, should be considered in this population.
Experiences and intentions of Ugandan household tuberculosis contacts receiving test results via text message: an exploratory study
(BMC public health, 2020) Ggita, Joseph M.; Katahoire, Anne; Meyer, Amanda J.; Nansubuga, Elizabeth; Nalugwa, Talemwa; Turimumahoro, Patricia; Ochom, Emmanuel; Ayakaka, Irene; Haberer, Jessica E.; Katamba, Achilles; Armstrong-Hough, Mari; Davis, J. Lucian
The World Health Organization (WHO) recommends household contact investigation for tuberculosis (TB) in high-burden countries. However, household contacts who complete evaluation for TB during contact investigation may have difficulty accessing their test results. Use of automated short-messaging services (SMS) to deliver test results could improve TB status awareness and linkage to care. We sought to explore how household contacts experience test results delivered via SMS, and how these experiences influence follow-up intentions. Methods: We conducted semi-structured interviews with household contacts who participated in a randomized controlled trial evaluating home sputum collection and delivery of TB results via SMS (Pan-African Clinical Trials Registry #201509000877140). We asked about feelings, beliefs, decisions, and behaviors in response to the SMS results. We analyzed the content and emerging themes in relation to the Theory of Planned Behavior. Results: We interviewed and achieved thematic saturation with ten household contacts. Nine received TB-negative results and one a TB-positive result. Household contacts reported relief upon receiving SMS confirming their TB status, but also said they lacked confidence in the results delivered by SMS. Some worried that negative results were incorrect until they spoke to a lay health worker (LHW). Household contacts said their long-term intentions to request help or seek care were influenced by perceived consequences of not observing the LHW’s instructions related to the SMS and follow-up procedures; beliefs about the curability of TB; anticipated support from LHWs; and perceived barriers to responding to an SMS request for further evaluation. Conclusion: Household contacts experienced relief when they received results. However, they were less confident about results delivered via SMS than results delivered by LHWs. Delivery of results by SMS should complement continued interaction with LHWs, not replace them.
Feasibility, acceptability, and adoption of fingerprint scanning during contact investigation for tuberculosis in Kampala, Uganda: A parallel-convergent, mixed-methods analysis
(PeerJ Preprints, 2018) White, Elizabeth B.; Meyer, Amanda J.; Ggita, Joseph M.; Babirye, Diana; Mark, David; Ayakaka, Irene; Haberer, Jessica E.; Katamba, Achilles; Armstrong-Hough, Mari; Davis, J. Lucian
In resource-constrained settings, challenges with unique patient identification may limit continuity of care, monitoring and evaluation, and data integrity. Biometrics offer an appealing but understudied potential solution. Methods We conducted a mixed-methods study to understand feasibility, acceptability, and adoption of digital fingerprinting for patient identification in a study of household TB contact investigation in Kampala, Uganda. We tested associations between demographic, clinical, and temporal characteristics and failure to capture a digital fingerprint. We used generalized estimating equations and a robust covariance estimator to account for clustering. We evaluated clustering of outcomes by household and community health worker by calculating intra-class correlation coefficients. To understand determinants of intended and actual use of fingerprinting technology, we conducted fifteen in-depth interviews with community health workers and applied a widely used conceptual framework, the Technology Acceptance Model 2. Results Digital fingerprints were captured in 74% of participants, with extensive clustering by household (ICC = 0.99) arising from hardware (XX%) and software (XX%) failures. Clinical and demographic characteristics were not significantly associated with fingerprint capture. Community health workers successfully fingerprinted all contacts in 70% of households, with modest clustering of outcomes by CHW (ICC = 0.18). Fingerprinting success at the household level declined over time (Spearman’s rho = 0.30, P < 0.001). In interviews, CHWs reported that fingerprinting non-capture events lowered their own perception of the quality of the technology, threatened their social image, and made the technology more difficult to use. Conclusions We found digital fingerprinting to be feasible and acceptable for indvidual identification, but problems implementing the hardware and software led to a high failure rate. Although CHWs found fingerprinting to be acceptable in principle, their intention to use the technology was tempered by perceptions that it was inconsistent and of questionable value. We emphasize the need for routine process evaluation of biometrics and other digital technologies during implementation in resource-constrained settings.
“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. Lucian
Integrating 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.

Browsing by Author "Haberer, Jessica E."

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