Browsing by Author "Kamya, Moses"
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Item Acceptance of Routine Testing for HIV among Adult Patients at the Medical Emergency Unit at a National Referral Hospital in Kampala, Uganda(AIDS and Behavior, 2007) Nakanjako, Damalie; Kamya, Moses; Mayanja-Kizza, Harriet; Freers, Jurgen; Whalen, Christopher; Katabira, EllyHIV testing is an entry point to comprehensive HIV/AIDS prevention and care. In Uganda, Routine Testing and Counseling for HIV (RTC) is not widely offered as part of standard medical care in acute care settings. This study determined the acceptance of RTC in a medical emergency setting at Mulago national referral hospital. We interviewed 233 adult patients who were offered HIV testing. Overall, 83% were unaware of their HIV serostatus and 88% of these had been to a health unit in the previous six months. Of the 208 eligible for HIV testing, 95% accepted to test. Half the patients were HIV infected and 77% of these were diagnosed during the study. HIV testing was highly acceptable and detected a significant number of undiagnosed HIV infections. We recommend adoption of RTC as standard of care in the medical emergency unit in order to scale HIV diagnosis and linkage to HIV/AIDS care.Item Anti-Malarial Targeting and Dosing Practices among Health Workers at Lower Level Health Facilities in Uganda(Health, 2014) Kakeeto, Stella; Wanzira, Humphrey; Kagambirwe Karyeija, Gerald; Kamya, Moses; Bukirwa, HasifaHealth worker shortages remain a significant challenge to delivery of health care services globally. Moving tasks, where appropriate, to less specialized health workers is recommended by the World Health Organization as a strategy to address this challenge. However, this concept is feared to raise specific quality concerns. This research aimed at assessing the performance of health workers to correctly prescribe (target) appropriate antimalarial treatment. Methods: We conducted a cross sectional study at three public health centre IVs in Uganda, with varying malaria transmission intensities (Kihihi-low, Kasambya-medium and Nagongera-high). We categorized prescribers into two groups: specialized prescribers (doctors and clinical officers) and less specialized prescribers (nurses and midwives). At each site, 100 records of patients seen between September and November 2011 and prescribed an antimalarial were retrieved for each group of prescribers. Correctness of the antimalarial drug prescribed and dose given were assessed for each group and compared to the 2005 Uganda national malaria treatment guidelines which recommend Artemether Lumefantrine (AL) for treatment of uncomplicated malaria and Quinine for complicated malaria. Results: Findings of the study showed that specialized health workers were more likely to target correctly as compared to the less specialized health workers [OR = 1.49 (1.00 - 2.22), p = 0.046]. Appropriateness of dosing was higher among specialized prescribers compared to less specialized prescribers however this was not significant [OR = 1.58 0.77 - 3.25), p = 0.206]. Age of the participants, history of fever, diagnosis of malaria and prescription experience were not associated with correct targeting. Conclusion: This study shows that task shifting at the targeting level is not suitable; however, there is inadequate evidence to show that this also applies to anti-malarial dosing. Task shifting for the treatment of Malaria in Uganda should be investigated further using larger studies if it is to be considered as an option for solving the health worker shortages especially in regions with few specialized health workers but high malaria burden.Item Anti‑malarial prescription practices among children admitted to six public hospitals in Uganda from 2011 to 2013(Malaria journal, 2015) Sserwanga, Asadu; Sears, David; Kapella, Bryan K.; Kigozi, Ruth; Rubahika, Denis; Staedke, Sarah G.; Kamya, Moses; Yoon, Steven S.; Chang, Michelle A.; Dorsey, Grant; Mpimbaza, ArthurIn 2011, Uganda’s Ministry of Health switched policy from presumptive treatment of malaria to recommending parasitological diagnosis prior to treatment, resulting in an expansion of diagnostic services at all levels of public health facilities including hospitals. Despite this change, anti-malarial drugs are often prescribed even when test results are negative. Presented is data on anti-malarial prescription practices among hospitalized children who underwent diagnostic testing after adoption of new treatment guidelines. Methods: Anti-malarial prescription practices were collected as part of an inpatient malaria surveillance program generating high quality data among children admitted for any reason at government hospitals in six districts. A standardized medical record form was used to collect detailed patient information including presenting symptoms and signs, laboratory test results, admission and final diagnoses, treatments administered, and final outcome upon discharge. Results: Between July 2011 and December 2013, 58,095 children were admitted to the six hospitals (hospital range 3294–20,426).A total of 56,282 (96.9 %) patients were tested for malaria, of which 26,072 (46.3 %) tested positive (hospital range 5.9–57.3 %). Among those testing positive, only 84 (0.3 %) were first tested after admission and 295 of 30,389 (1.0 %) patients who tested negative at admission later tested positive. Of 30,210 children with only negative test results, 11,977 (39.6 %) were prescribed an anti-malarial (hospital range 14.5–53.6 %). The proportion of children with a negative test result who were prescribed an anti-malarial fluctuated over time and did not show a significant trend at any site with the exception of one hospital where a steady decline was observed. Among those with only negative test results, children 6–12 months of age (aOR 3.78; p < 0.001) and those greater than 12 months of age (aOR 4.89; p < 0.001) were more likely to be prescribed an anti-malarial compared to children less than 6 months of age. Children with findings suggestive of severe malaria were also more likely to be prescribed an anti-malarial after a negative test result (aOR 1.98; p < 0.001). Conclusions: Despite high testing rates for malaria at all sites, prescription of anti-malarials to patients with negative test results remained high, with the exception of one site where a steady decline occurred.Item Assessing temporal associations between environmental factors and malaria morbidity at varying transmission settings in Uganda(Malaria journal, 2016) Kigozi, Ruth; Zinszer, Kate; Mpimbaza, Arthur; Sserwanga, Asadu; Kigozi, Simon P.; Kamya, MosesEnvironmental factors play a major role in transmission of malaria given their relationship to both the development and survival of the mosquito and parasite. The associations between environmental factors and malaria can be used to inform the development of early warning systems for increases in malaria burden. The objective of this study was to assess temporal relationships between rainfall, temperature and vegetation with malaria morbidity across three different transmission settings in Uganda. Methods: Temporal relationships between environmental factors (weekly total rainfall, mean day time temperature and enhanced vegetation index series) and malaria morbidity (weekly malaria case count data and test positivity rate series) over the period January 2010–May 2013 in three sites located in varying malaria transmission settings in Uganda was explored using cross-correlation with pre-whitening. Sites included Kamwezi (low transmission), Kasambya (moderate transmission) and Nagongera (high transmission). Results: Nagongera received the most rain (30.6 mm) and experienced, on average, the highest daytime temperatures (29.8 °C) per week. In the study period, weekly TPR and number of malaria cases were highest at Kasambya and lowest at Kamwezi. The largest cross-correlation coefficients between environmental factors and malaria morbidity for each site was 0.27 for Kamwezi (rainfall and cases), 0.21 for Kasambya (vegetation and TPR), and −0.27 for Nagongera (daytime temperature and TPR). Temporal associations between environmental factors (rainfall, temperature and vegetation) with malaria morbidity (number of malaria cases and TPR) varied by transmission setting. Longer time lags were observed at Kamwezi and Kasambya compared to Nagongera in the relationship between rainfall and number of malaria cases. Comparable time lags were observed at Kasambya and Nagongera in the relationship between temperature and malaria morbidity. Temporal analysis of vegetation with malaria morbidity revealed longer lags at Kasambya compared to those observed at the other two sites. Conclusions: This study showed that temporal associations between environmental factors with malaria morbidity vary by transmission setting in Uganda. This suggests the need to incorporate local transmission differences when developing malaria early warning systems that have environmental predictors in Uganda. This will result in development of more accurate early warning systems, which are a prerequisite for effective malaria control in such a setting.Item Association of Implementation of a Universal Testing and Treatment Intervention With HIV Diagnosis, Receipt of Antiretroviral Therapy, and Viral Suppression in East Africa(Jama, 2017) Maya, Petersen; Balzer, Laura; Kwarsiima, Dalsone; Ayieko, James; Kabami, Jane; Owaraganise, Asiphas; Mwangwa, Florence; Kadede, Kevin; Bukusi, Elizabeth A.; Tamara, D. Clark; Charlebois, Edwin; Kamya, Moses; Havlir, DianeAntiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set global targets to diagnose 90% of HIV-positive individuals, treat 90% of diagnosed individuals with ART, and suppress viral replication among 90% of treated individuals, for a population-level target of 73% of all HIV-positive persons with HIV viral suppression. To describe changes in the proportions of HIV-positive individuals with HIV viral suppression, HIV-positive individuals who had received a diagnosis, diagnosed individuals treated with ART, and treated individuals with HIV viral suppression, following implementation of a community-based testing and treatment program in rural East Africa. Observational analysis based on interim data from 16 rural Kenyan (n = 6) and Ugandan (n = 10) intervention communities in the SEARCH Study, an ongoing cluster randomized trial. Community residents who were 15 years or older (N = 77 774) were followed up for 2 years (2013-2014 to 2015-2016). HIV serostatus and plasma HIV RNA level were measured annually at multidisease health campaigns followed by home-based testing for nonattendees. All HIV-positive individuals were offered ART using a streamlined delivery model designed to reduce structural barriers, improve patient-clinician relationships, and enhance patient knowledge and attitudes about HIV. Primary outcome was viral suppression (plasma HIV RNA<500 copies/mL) among all HIV-positive individuals, assessed at baseline and after 1 and 2 years. Secondary outcomes included HIV diagnosis, ART among previously diagnosed individuals, and viral suppression among those who had initiated ART. Among 77 774 residents (male, 45.3%; age 15-24 years, 35.1%), baseline HIV prevalence was 10.3% (7108 of 69 283 residents). The proportion of HIV-positive individuals with HIV viral suppression at baseline was 44.7% (95% CI, 43.5%-45.9%; 3464 of 7745 residents) and after 2 years of intervention was 80.2% (95% CI, 79.1%-81.2%; 5666 of 7068 residents), an increase of 35.5 percentage points (95% CI, 34.4-36.6). After 2 years, 95.9% of HIV-positive individuals had been previously diagnosed (95% CI, 95.3%-96.5%; 6780 of 7068 residents); 93.4% of those previously diagnosed had received ART (95% CI, 92.8%-94.0%; 6334 of 6780 residents); and 89.5% of those treated had achieved HIV viral suppression (95% CI, 88.6%-90.3%; 5666 of 6334 residents). Among individuals with HIV in rural Kenya and Uganda, implementation of community-based testing and treatment was associated with an increased proportion of HIV-positive adults who achieved viral suppression, along with increased HIV diagnosis and initiation of antiretroviral therapy. In these communities, the UNAIDS population-level viral suppression target was exceeded within 2 years after program implementation.Item The burden of severe asthma in sub-Saharan Africa: Findings from the African Severe Asthma Project(Elsevier Inc, 2024-01-09) Kirenga, Bruce J; Chakaya, Jeremiah; Yimer, Getnet; Nyale, George; Haile, Tewodros; Muttamba, Winters; Mugenyi, Levicatus; Katagira, Winceslaus; Worodria, William; Aanyu-Tukamuhebwa, Hellen; Lugogo, Njira; Joloba, Moses; Mersha, Tesfaye B.; Bekele, Amsalu; Makumbi, Fred; Mekasha, Amha; Green, Cynthia L.; de Jong, Corina; Kamya, Moses; van der Molen, ThysBackground: Severe asthma is associated with high morbidity, mortality, and health care utilization, but its burden in Africa is unknown. Objective: We sought to determine the burden (prevalence, mortality, and activity and work impairment) of severe asthma in 3 countries in East Africa: Uganda, Kenya, and Ethiopia. Methods: Using the American Thoracic Society/European Respiratory Society case definition of severe asthma, we analyzed for the prevalence of severe asthma (requiring Global Initiative for Asthma [GINA] steps 4-5 asthma medications for the previous year to achieve control) and severe refractory asthma (remains uncontrolled despite treatment with GINA steps 4-5 asthma medications) in a cohort of 1086 asthma patients who had been in care for 12 months and had received all GINA-recommended medications. Asthma control was assessed by the asthma control questionnaire (ACQ). Results: Overall, the prevalence of severe asthma and severe refractory asthma was 25.6% (95% confidence interval [CI], 23.1-28.3) and 4.6% (95% CI, 3.5-6.0), respectively. Patients with severe asthma were (nonsevere vs severe vs severe refractory) older (39, 42, 45 years, P = .011), had high skin prick test reactivity (67.1%, 76.0%, 76.0%, P = .004), had lower forced expiratory volume in 1 second percentage (81%, 61%, 55.5%, P < .001), had lower quality of life score (129, 127 vs 121, P < .001), and had higher activity impairment (10%, 30%, 50%, P < .001). Factors independently associated with severe asthma were hypertension comorbidity; adjusted odds ratio 2.21 (1.10-4.47), P = .027, high bronchial hyperresponsiveness questionnaire score; adjusted odds ratio 2.16 (1.01-4.61), P = .047 and higher ACQ score at baseline 2.80 (1.55-5.08), P = .001. Conclusion: The prevalence of severe asthma in Africa is high and is associated with high morbidity and poor quality of life.Item Burden of tuberculosis in Kampala, Uganda(World Health Organization, 2003) Guwatudde, David; Zalwango, Sarah; Kamya, Moses; Debanne, Sara; Mireya, Diaz; Okwera, Alphonse; Mugerwa, Roy; King, Charles; Christopher, WhalenOver the past two decades, the number of tuberculosis cases has risen worldwide, especially in the developing countries of southeast Asia and sub-Saharan Africa, where co-infection with human immunodeficiency virus (HIV) and tuberculosis is common (1, 2). Case notification data often are used to assess the burden of tuberculosis. The wide belief, however, is that a substantial number of cases of tuberculosis are not detected by the health care systems in most of these countries (3, 4), and surveys of the prevalence of tuberculosis in some of these countries support this belief (5, 6). Furthermore, the poor peri-urban areas of developing countries, where living conditions are unsatisfactory with overcrowding, poor hygiene and inadequate sanitation, are usually most affected by tuberculosis (7, 8). Such living conditions, coupled with high prevalence of HIV infection and lack of access to health care and/or poor health-seeking behavior (8, 9), may lead to a vicious circle of transmission of diseases, including tuberculosis. National average notification data often do not reveal the overwhelming burden of tuberculosis in these settings.Item Changing malaria fever test positivity among paediatric admissions to Tororo district hospital, Uganda 2012–2019(Malaria journal, 2020) Mpimbaza, Arthur; Sserwanga, Asadu; Rutazaana, Damian; Kapisi, James; Walemwa, Richard; Suiyanka, Laurissa; Kyalo, David; Kamya, Moses; Opigo, Jimmy; Snow, Robert W.The World Health Organization (WHO) promotes long-lasting insecticidal nets (LLIN) and indoor residual house-spraying (IRS) for malaria control in endemic countries. However, long-term impact data of vector control interventions is rarely measured empirically. Methods: Surveillance data was collected from paediatric admissions at Tororo district hospital for the period January 2012 to December 2019, during which LLIN and IRS campaigns were implemented in the district. Malaria test positivity rate (TPR) among febrile admissions aged 1 month to 14 years was aggregated at baseline and three intervention periods (first LLIN campaign; Bendiocarb IRS; and Actellic IRS + second LLIN campaign) and compared using before-and-after analysis. Interrupted time-series analysis (ITSA) was used to determine the effect of IRS (Bendiocarb + Actellic) with the second LLIN campaign on monthly TPR compared to the combined baseline and first LLIN campaign periods controlling for age, rainfall, type of malaria test performed. The mean and median ages were examined between intervention intervals and as trend since January 2012. Results: Among 28,049 febrile admissions between January 2012 and December 2019, TPR decreased from 60% at baseline (January 2012–October 2013) to 31% during the final period of Actellic IRS and LLIN (June 2016–December 2019). Comparing intervention intervals to the baseline TPR (60.3%), TPR was higher during the first LLIN period (67.3%, difference 7.0%; 95% CI 5.2%, 8.8%, p < 0.001), and lower during the Bendiocarb IRS (43.5%, difference − 16.8%; 95% CI − 18.7%, − 14.9%) and Actellic IRS (31.3%, difference − 29.0%; 95% CI − 30.3%, − 27.6%, p < 0.001) periods. ITSA confirmed a significant decrease in the level and trend of TPR during the IRS (Bendicarb + Actellic) with the second LLIN period compared to the pre-IRS (baseline + first LLIN) period. The age of children with positive test results significantly increased with time from a mean of 24 months at baseline to 39 months during the final IRS and LLIN period. Conclusion: IRS can have a dramatic impact on hospital paediatric admissions harbouring malaria infection. The sustained expansion of effective vector control leads to an increase in the age of malaria positive febrile paediatric admissions. However, despite large reductions, malaria test-positive admissions continued to be concentrated in children aged under five years. Despite high coverage of IRS and LLIN, these vector control measures failed to interrupt transmission in Tororo district. Using simple, cost-effective hospital surveillance, it is possible to monitor the public health impacts of IRS in combination with LLIN.Item Client and Provider Perspectives of the Efficiency and Quality of Care in the Context of Rapid Scale-Up of Antiretroviral Therapy(AIDS patient care and STDs, 2010) Amanyire, Gideon; Wanyenze, Rhoda K.; Alamo, Stella; Kwarisiima, Dalsone; Sunday, Pamela; Sebikaari, Gloria; Kamya, Moses; Wabwire-Mangen, Fred; Wagner, GlennGlobal scale-up of antiretroviral therapy (ART) has focused on clinical outcomes with little attention on its impact on existing health systems. In June–August 2008, we conducted a formative evaluation on ART scale-up and clinic operations at three clinics in Uganda to generate lessons for informing policy and larger public health care systems. Site visits and semistructured interviews with 10 ART clients and 6 providers at each clinic were used to examine efficiency of clinic operations (patient flow, staff allocation to appropriate duties, scheduling of clinic visits, record management) and quality of care (attending to both client and provider needs, and providing support for treatment adherence and retention). Clients reported long waiting times but otherwise general satisfaction with the quality of care. Providers reported good patient adherence and retention, and support mechanisms for clients. Like clients, providers mentioned long waiting times and high workload as major challenges to clinic expansion. Providers called for more human resources and stress-release mechanisms to prevent staff burnout. Both providers and clients perceive these clinics to be delivering good quality care, despite the recognition of congested clinics and long waiting times. These findings highlight the need to address clinic efficiency as well as support for providers in the context of rapid scale-up.Item A Cross-Cutting Approach to Surveillance and Laboratory Capacity as a Platform to Improve Health Security in Uganda(Health security, 2018) Lamorde, Mohammed; Mpimbaza, Arthur; Walwema, Richard; Kamya, Moses; Kajumbula, Henry; Sserwanga, Asadu; Namuganga, Jane FrancesGlobal health security depends on effective surveillance for infectious diseases. In Uganda, resources are inadequate to support collection and reporting of data necessary for an effective and responsive surveillance system. We used a cross-cutting approach to improve surveillance and laboratory capacity in Uganda by leveraging an existing pediatric inpatient malaria sentinel surveillance system to collect data on expanded causes of illness, facilitate development of real-time surveillance, and provide data on antimicrobial resistance. Capacity for blood culture collection was established, along with options for serologic testing for select zoonotic conditions, including arboviral infection, brucellosis, and leptospirosis. Detailed demographic, clinical, and laboratory data for all admissions were captured through a web-based system accessible at participating hospitals, laboratories, and the Uganda Public Health Emergency Operations Center. Between July 2016 and December 2017, the expanded system was activated in pediatric wards of 6 regional government hospitals. During that time, patient data were collected from 30,500 pediatric admissions, half of whom were febrile but lacked evidence of malaria. More than 5,000 blood cultures were performed; 4% yielded bacterial pathogens, and another 4% yielded likely contaminants. Several WHO antimicrobial resistance priority pathogens were identified, some with multidrug-resistant phenotypes, including Acinetobacter spp., Citrobacter spp., Escherichia coli, Staphylococcus aureus, and typhoidal and nontyphoidal Salmonella spp. Leptospirosis and arboviral infections (alphaviruses and flaviviruses) were documented. The lessons learned and early results from the development of this multisectoral surveillance system provide the knowledge, infrastructure, and workforce capacity to serve as a foundation to enhance the capacity to detect, report, and rapidly respond to wide-ranging public health concerns in Uganda. Fever may be the initial or sole symptom of many infectious diseases, including some with outbreak potential.1,2 Although clinical practice in many malaria-endemic areas has been to presumptively treat febrile patients for malaria, improved access to malaria diagnostics in recent years has revealed that a substantial proportion of acutely ill, febrile patients in sub-Saharan Africa do not have malaria.3-5 Yet, many countries lack resources and capacity for accurate diagnosis of most infectious conditions. Rapid response to diverse and emerging public health threats is severely challenged by lack of appropriate laboratory capacity and timely surveillance networks.6 These gaps foster antimicrobial and antimalarial resistance, limit evidence-based care and policy to improve population health, and hinder the ability to detect outbreaks early. Uganda, an inland East African country with a rapidly growing population estimated at 43 million people in 2017, has made progress in recent decades to improve life expectancy, reduce poverty and food insecurity, and expand access to immunizations and clean water.7 Yet, as with many African countries, Uganda faces diverse health challenges in a weak health infrastructure that limits the rapid detection and confirmation of infections with epidemic potential. In the past 2 decades, Uganda has experienced outbreaks of emerging and reemerging infectious diseases including Ebola, Marburg, Crimean-Congo hemorrhagic fever, Rift Valley fever, yellow fever, hepatitis E, cholera, typhoid fever, plague, and anthrax.8-16 Effective laboratory capacity and disease surveillance are critical to global health security and the basis for the 2005 International Health Regulations (IHR) signed by all World Health Organization (WHO) member states. IHR compliance has proven challenging for many low-income countries, including Uganda.17,18 The Global Health Security Agenda (GHSA), a multisectoral and multilateral partnership intended to support countries toward IHR compliance, launched officially in 2014 (www.ghsagenda.org). The government of Uganda and the US Centers for Disease Control and Prevention (CDC) jointly implemented a demonstration project a year earlier, in 2013. The pilot project improved specimen referral networks and information systems associated with outbreak response and created an emergency operations center; these activities set the stage for multiple GHSA activities in the country.19 Through GHSA-initiated partnerships, we introduced a cross-cutting surveillance approach to advance ability to detect unusual health events in Uganda. As conceived, this effort would provide comprehensive patient data and facilitate electronic systems infrastructure that could ultimately improve early detection of novel infections or outbreaks, define conditions causing human illness to inform appropriate and targeted laboratory capacity building efforts, and generate data for an antimicrobial resistance surveillance and intervention program in its infancy.Item Effects of a multicomponent intervention to streamline initiation of antiretroviral therapy in Africa: a stepped-wedge cluster randomised tria(The lancet HIV, 2016) Amanyire, Gideon; Semitala, Fred C.; Namusobya, Jennifer; Katuramu, Richard; Kampiire, Leatitia; Wallenta, Jeanna; Chang, Wei; Kamya, MosesIn Africa, up to 30% of HIV-infected patients who are clinically eligible for antiretroviral therapy (ART) do not start timely treatment. We assessed the effects of an intervention targeting prevalent health systems barriers to ART initiation on timing and completeness of treatment initiation. In this stepped-wedge, non-blinded, cluster-randomised controlled trial, 20 clinics in southwestern Uganda were randomly assigned in groups of five clinics every 6 months to the intervention by a computerised random number generator. This procedure continued until all clinics had crossed over from control (standard of care) to the intervention, which consisted of opinion-leader-led training and coaching of front-line health workers, a point-of-care CD4 cell count testing platform, a revised counselling approach without mandatory multiple pre-initiation sessions, and feedback to the facilities on their ART initiation rates and how they compared with other facilities. Treatment-naive, HIV-infected adults (aged ≥18 years) who were clinically eligible for ART during the study period were included in the study population. The primary outcome was ART initiation 14 days after first clinical eligibility for ART. This study is registered with ClinicalTrials.gov, number NCT01810289. Between April 11, 2013, and Feb 2, 2015, 12 024 eligible patients visited one of the 20 participating clinics. Median CD4 count was 310 cells per μL (IQR 179–424). 3753 of 4747 patients (weighted proportion 80%) in the intervention group had started ART by 2 weeks after eligibility compared with 2585 of 7066 patients (38%) in the control group (risk difference 41·9%, 95% CI 40·1–43·8). Vital status was ascertained in a random sample of 208 patients in the intervention group and 199 patients in the control group. Four deaths (2%) occurred in the intervention group and five (3%) occurred in the control group. A multicomponent intervention targeting health-care worker behaviour increased the probability of ART initiation 14 days after eligibility. This intervention consists of widely accessible components and has been tested in a real-world setting, and is therefore well positioned for use at scale.Item Electronic Medical Records and Same Day Patient Tracing Improves Clinic Efficiency and Adherence to Appointments in a Community Based HIV/AIDS Care Program, in Uganda(AIDS and Behavior, 2012) Alamo, Stella T.; Wagner, Glenn J.; Sunday, Pamela ,; Wanyenze, Rhoda K.; Ouma, Joseph; Kamya, Moses; Colebunders, Robert; Wabwire-Mangen, FredPatients who miss clinic appointments make unscheduled visits which compromise the ability to plan for and deliver quality care. We implemented Electronic Medical Records (EMR) and same day patient tracing to minimize missed appointments in a community-based HIV clinic in Kampala. Missed, early, on-schedule appointments and waiting times were evaluated before (pre- EMR) and 6 months after implementation of EMR and patient tracing (post-EMR). Reasons for missed appointments were documented pre and post-EMR. The mean daily number of missed appointments significantly reduced from 21 pre-EMR to 8 post-EMR. The main reason for missed appointments was forgetting (37%) but reduced significantly by 30% post-EMR. Loss to followup (LTFU) also significantly decreased from 10.9 to 4.8% The total median waiting time to see providers significantly decreased from 291 to 94 min. Our findings suggest that EMR and same day patient tracing can significantly reduce missed appointments, and LTFU and improve clinic efficiency.Item Growth Recovery Among HIV-Infected Children Randomized to Lopinavir/Ritonavir or NNRTI-Based Antiretroviral Therapy(The Pediatric infectious disease journal, 2016) Achan, Jane; Kakuru, Abel; Ikilezi, Gloria; Mwangwa, Florence; Charlebois, Edwin; Young, Sera; Havlir, Diane; Kamya, Moses; Ruel, TheodoreDiminished growth is highly prevalent among HIV-infected children and might be improved by antiretroviral therapy (ART). We examined growth recovery in a rural Ugandan cohort of HIV-infected children randomized to lopinavir/ritonavir or non-nucleoside-reverse-transcription-inhibitor-based ART. HIV-infected children 2 months to 6 years of age were randomized to Lopinavir/ritonavir- or non-nucleoside-reverse-transcription-inhibitor-based ART. Changes in weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) Z-scores for 24 months were evaluated using generalized linear repeated-measures models. Recovery from being underweight (WAZ<−2), stunted (HAZ<−2) and wasted (WHZ<−2) to Z-scores > −2 was also compared by arm using Kaplan-Meier survival and Cox proportional hazard modeling. A total of 129 children with median age of 3 years initiated therapy; 64 received Lopinavir/ritonavir-based and 65 non-nucleoside-reverse-transcription-inhibitor-based ART (nevirapine: 36 and efavirenz: 29). The median (IQR) difference in growth measures between baseline and 24 months for Lopinavir/ritonavir (n= 45) vs. non-nucleoside-reverse-transcription-inhibitor-based therapy (n=40) were as follows, WAZ: 0.47 (0.10, 1.62) vs. 0.53 (0.03, 1.14) (p=0.59) and HAZ: median 1.55 (0.78, 1.86) vs. 1.19 (0.62, 1.65) (p=0.23), respectively. ART regimen was not predictive of change in WAZ (beta: −0.02, 95%CI: −0.25, 0.20) or HAZ (beta: 0.05, 95%CI: −0.10, 0.19). Presence of confirmed virologic failure was not associated with growth. Most ART-naive children experienced recovery of both WAZ and HAZ over the 24 months following ART-initiation, with no significant difference between those receiving Lopinavir/ritonavir vs. non-nucleoside-reverse-transcriptase-inhibitor-based ART. However, the persistence of median Z-scores below zero underscores the need for additional strategies to improve growth outcomes in HIV+ African children.Item Is it safe to switch from stavudine to zidovudine after developing symptomatic hyperlactatemia?(African Health Sciences, 2008) Castelnuovo, Barbara; Nanyonjo, Agnes; Kamya, Moses; Ocama, PonsianoIn resource limited settings patients on antiretroviral treatment who develop stavudine induced hyperlactatemia are often switched to zidovudine on the basis of published studies that demonstrate that this agent can be a safe alternative. Case report: We describe here a case of a 60 year old female that experienced a relapse of symptomatic hyperlactatemia after being switched from stavudine to zidovudine and how the case was managed at the Infectious Diseases Institute, Kampala, Uganda. Discussion: This case shows that switching to zidovudine potentially can lead to a hyperlactatemia relapse. Therefore we recommend close follow up for patients that are switched from stavudine to zidovudine and, in case lactate measurement is not possible, free programs should provide safer drugs such as abacavir and tenofovir for patients that develop hyperlactatemia.Item Participant perspectives on incentives for TB preventative therapy adherence and reduced alcohol use: A qualitative study(Public Library of Science, 2024-04) Appa, Ayesha; Miller, Amanda P; Fatch, Robin; Kekibiina, Allen; Beesiga, Brian; Adong, Julian; Emenyonu, Nneka; Marson, Kara; Getahun, Monica; Kamya, Moses; Muyindike, Winnie; McDonell, Michael; Thirumurthy, Harsha; Hahn, Judith A; Chamie, Gabriel; Camlin, Carol SEconomic incentives to promote health behavior change are highly efficacious for substance use disorders as well as increased medication adherence. Knowledge about participants’ experiences with and perceptions of incentives is needed to understand their mechanisms of action and optimize future incentive-based interventions. The Drinkers’ Intervention to Prevent Tuberculosis (DIPT) trial enrolled people with HIV (PWH) in Uganda with latent tuberculosis and unhealthy alcohol use in a 2x2 factorial trial that incentivized recent alcohol abstinence and isoniazid (INH) adherence on monthly urine testing while on INH preventive therapy. We interviewed 32 DIPT study participants across trial arms to explore their perspectives on this intervention. Participants described 1) satisfaction with incentives of sufficient size that allowed them to purchase items that improved their quality of life, 2) multiple ways in which incentives were motivating, from gamification of “winning” through support of pre-existing desire to improve health to suggesting variable effects of extrinsic and intrinsic motivation, and 3) finding value in learning results of increased clinical monitoring. To build effective incentive programs to support both reduced substance use and increased antimicrobial adherence, we recommend carefully selecting incentive magnitude as well as harnessing both intrinsic motivation to improve health and extrinsic reward of target behavior. In addition to these participant-described strengths, incorporating results of clinical monitoring related to the incentive program that provide participants more information about their health may also contribute to health-related empowerment.Item Protocol for the 3HP Options Trial: a hybrid type 3 implementation-effectiveness randomized trial of delivery strategies for short-course tuberculosis preventive therapy among people living with HIV in Uganda(Implementation Science, 2020) Kadota, Jillian L.; Musinguzi, Allan; Nabunje, Juliet; Welishe, Fred; Ssemata, Jackie L.; Bishop, Opira; Berger, Christopher A.; Patel, Devika; Sammann, Amanda; Katahoire, Anne; Nahid, Payam; Belknap, Robert; Phillips, Patrick P. J.; Namusobya, Jennifer; Kamya, Moses; Handley, Margaret A.; Kiwanuka, Noah; Katamba, Achilles; Dowdy, David; Semitala, Fred C.; Cattamanchi, AdithyaRecently, a 3-month (12-dose) regimen of weekly isoniazid and rifapentine (3HP) was recommended by the World Health Organization for the prevention of tuberculosis (TB) among people living with HIV (PLHIV) on common antiretroviral therapy regimens. The best approach to delivering 3HP to PLHIV remains uncertain. Methods: We developed a three-armed randomized trial assessing optimized strategies for delivering 3HP to PLHIV. The trial will be conducted at the Mulago Immune Suppression Syndrome (i.e., HIV/AIDS) clinic in Kampala, Uganda. We plan to recruit 1656 PLHIV, randomized 1:1 to each of the three arms (552 per arm). Using a hybrid type 3 effectivenessimplementation design, this pragmatic trial aims to (1) compare the acceptance and completion of 3HP among PLHIV under three delivery strategies: directly observed therapy (DOT), self-administered therapy (SAT), and informed patient choice of either DOT or SAT (with the assistance of a decision aid); (2) to identify processes and contextual factors that influence the acceptance and completion of 3HP under each delivery strategy; and (3) to estimate the costs and compare the costeffectiveness of three strategies for delivering 3HP. The three delivery strategies were each optimized to address key barriers to 3HP completion using a theory-informed approach. We hypothesize that high levels of treatment acceptance and completion can be achieved among PLHIV in sub-Saharan Africa and that offering PLHIV an informed choice between the optimized DOT and SAT delivery strategies will result in greater acceptance and completion of 3HP. The design and planned evaluation of the delivery strategies were guided by the use of implementation science conceptual frameworks. Discussion: 3HP—one of the most promising interventions for TB prevention—will not be scaled up unless it can be delivered in a patient-centered fashion. We highlight shared decision-making as a key element of our trial design and theorize that offering PLHIV an informed choice between optimized delivery strategies will facilitate the highest levels of treatment acceptance and completion.Item Socioeconomic position and ten-year survival and virologic outcomes in a Ugandan HIV cohort receiving antiretroviral therapy(PloS one, 2017) Flynn, Andrew G.; Anguzu, Godwin; Mubiru, Frank; Kiragga, Agnes N.; Kamya, Moses; Meya, David B.; Boulware, David R.; Kambugu, Andrew; Castelnuovo, Barbara C.Lifelong ART is essential to reducing HIV mortality and ending the epidemic, however the interplay between socioeconomic position and long-term outcomes of HIV-infected persons receiving antiretroviral therapy (ART) in sub-Saharan Africa is unknown. Furthering the understanding of factors related to long-term ART outcomes in this important region will aid the successful scale-up of ART programs. We enrolled 559 HIV-infected Ugandan adults starting ART in 2004–2005 at the Infectious Diseases Institute in Kampala, Uganda and followed them for 10 years. We documented baseline employment status, regular household income, education level, housing description, physical ability, and CD4 count. Viral load was measured every six months. Proportional hazard regression tested for associations between baseline characteristics and 1) mortality, 2) virologic failure, and 3) mortality or virologic failure as a composite outcome. Over ten years 23% (n = 127) of participants died, 6% (n = 31) were lost-to-follow-up and 23% (107/472) experienced virologic treatment failure. In Kaplan-Meier analysis we observed an association between employment and mortality, with the highest cumulative probability of death occurring in unemployed individuals. In univariate analysis unemployment and disease severity were associated with mortality, but in multivariable analysis the only association with mortality was disease severity. We observed an association between higher household income and an increased incidence of both virologic failure and the combined outcome, and an association between self-employment and lower incidence of virologic failure and the combined outcome when compared to unemployment. Formal education level and housing status were unrelated to outcomes. It is feasible to achieve good ten-year survival, retention-in-care, and viral suppression in a socioeconomically diverse population in a resource-limited setting. Unemployment appears to be related to adverse 10-year ART outcomes. A low level of formal education does not appear to be a barrier to successful long-term ART.Item Temporal Changes in Prevalence of Molecular Markers Mediating Antimalarial Drug Resistance in a High Malaria Transmission Setting in Uganda(The American journal of tropical medicine and hygiene, 2014) Mbogo, George W.; Nankoberanyi, Sheila; Tukwasibwe, Stephen; Baliraine, Frederick N.; Nsobya, Samuel L.; Conrad, Melissa D.; Arinaitwe, Emmanuel; Kamya, Moses; Tappero, Jordan; Staedke, Sarah G.; Dorsey, GrantStandard therapy for malaria in Uganda changed from chloroquine to chloroquine + sulfadoxine-pyrimethamine in 2000, and artemether-lumefantrine in 2004, although implementation of each change was slow. Plasmodium falciparum genetic polymorphisms are associated with alterations in drug sensitivity. We followed the prevalence of drug resistancemediating P. falciparum polymorphisms in 982 samples from Tororo, a region of high transmission intensity, collected from three successive treatment trials conducted during 2003–2012, excluding samples with known recent prior treatment. Considering transporter mutations, prevalence of the mutant pfcrt 76T, pfmdr1 86Y, and pfmdr1 1246Y alleles decreased over time. Considering antifolate mutations, the prevalence of pfdhfr 51I, 59R, and 108N, and pfdhps 437G and 540E were consistently high; pfdhfr 164L and pfdhps 581G were uncommon, but most prevalent during 2008–2010. Our data suggest sequential selective pressures as different treatments were implemented, and they highlight the importance of genetic surveillance as treatment policies change over time.Item Ugandan Medical Student Career Choices Relate to Foreign Funding Priorities(World Journal of Surgery, 2020) Kakembo, Nasser; Situma, Martin; Williamson, Hannah; Kisa, Phyllis; Kamya, Moses; Ozgediz, Doruk; Sekabira, John; Fitzgerald, Tamara N.The surgical workforce in sub-Saharan Africa is insufficient to meet population needs. Therefore, medical students should be encouraged to pursue surgical careers and “brain drain” must be minimized. It is unknown to what extent foreign aid priorities influence medical student career choices in Uganda.Medical students in Uganda completed an online survey examining their career choices and attitudes regarding career opportunities and funding priorities. Data were analyzed using descriptive statistics, and responses among men and women were compared using Fisher’s exact tests.Ninety-eight students participated. Students were most influenced by inspiring role models, employment opportunities and specialty fit with personal skills. Filling an underserved specialty was near the bottom of the influence scale. Women placed higher importance on advice from mentors (p = 0.049) and specialties with lower stress burden (p = 0.027). Men placed importance on opportunities in non-governmental organizations (p = 0.033) and academia (p = 0.050). Students expressed that the most supported specialties were infectious disease (n = 65, 66%), obstetrics (n = 15, 15%) and pediatrics (n = 7, 7%). Most students (n = 91, 93%) were planning a career in infectious disease. Fifty-three students (70%) indicated plans to leave Africa for residency. Female students were more likely to have a plan to leave (p = 0.027).Medical students in Uganda acknowledge the career opportunities for physicians in specialties prioritized by the Sustainable Development Goals. In order to avoid “brain drain” and encourage students to pursue careers in surgery, career opportunities including surgical residencies must be prioritized and supported in sub-Saharan Africa.Item Virologic versus immunologic monitoring and the rate of accumulated genotypic resistance to first-line antiretroviral drugs in Uganda(BMC infectious diseases, 2012) Reynolds, Steven J; Sendagire, Hakim; Newell, Kevin; Castelnuovo, Barbara; Nankya, Immaculate; Kamya, Moses; Quinn, Thomas C.; Manabe, Yukari C.; Kambugu, AndrewViral load monitoring (VLM) to identify individuals failing antiretroviral therapy (ART) is not widely available in resource-limited settings. We compared the genotypic resistance patterns between clients with VLM versus immunological monitoring (IM).Between 2004–2008, 559 ART naïve clients were enrolled in a prospective cohort, initiated on ART, and monitored with viral load (VL) and CD4+ cell counts every 6 months (VLM group). From February 2008 through June 2009, 998 clients on ART for 36–40 months (corresponding to the follow-up time of the VLM group) at the same clinic and monitored with CD4+ cell counts every 6 months were recruited into a cross sectional study (IM group). Samples from VLM clients at 12, 24 and 36 months and IM clients at 36–40 months with VL > 2000 copies/ml underwent genotypic drug resistance testing.Baseline characteristics were similar. Virologic failure (VL > 400 copies/ml) at 12, 24 and 36 months in the VLM group were 12%, 6% and 8% respectively, and in the IM group 10% at 36–40 months. Samples from 39 VLM and 70 IM clients were genotyped. 23/39 (59%) clients in the VLM group (at 12, 24 or 36 months) compared to 63/70 (90%) in the IM group, (P < 0.0001) had at least 1 non-nucleoside reverse transcriptase mutation. 19/39 (49%) of VLM clients had an M184V mutation compared to 61/70 (87%) in the IM group (P < 0.0001). Only 2/39 (5%) of VLM clients developed thymidine analogue mutations compared to 34/70 (49%) of IM clients (P < 0.0001).Routine VL monitoring reduced the rate of accumulated genotypic resistance to commonly used ART in Uganda.