NRU :: Browsing by Author "Muwonge, Timothy R."

Browsing by Author "Muwonge, Timothy R."

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Beyond HIV prevention: everyday life priorities and demand for PrEP among Ugandan HIV serodiscordant couples
(Journal of the International AIDS Society, 2019) Nakku-Joloba, Edith; Pisarski, Emily E.; Wyatt, Monique A.; Muwonge, Timothy R.; Asiimwe, Stephen; Celum, Connie L.; Baeten, Jared M.; Katabira, Elly T.; Ware, Norma C.
Pre-exposure prophylaxis (PrEP) to prevent HIV infection is being rolled out in Africa. The uptake of PrEP to date has varied across populations and locations. We seek to understand the drivers of demand for PrEP through analysis of qualitative data collected in conjunction with a PrEP demonstration project involving East African HIV serodiscordant couples. Our goal was to inform demand creation by understanding what PrEP means – beyond HIV prevention – for the lives of users. Methods: The Partners Demonstration Project evaluated an integrated strategy of PrEP and antiretroviral therapy (ART) delivery in which time-limited PrEP served as a “bridge” to long-term ART. Uninfected partners in HIV serodiscordant couples were offered PrEP at baseline and encouraged to discontinue once infected partners had taken ART for six months. We conducted 274 open-ended interviews with 93 couples at two Ugandan research sites. Interviews took place one month after enrolment and at later points in the follow-up period. Topics included are as follows: (1) discovery of serodiscordance; (2) decisions to accept/decline PrEP and/or ART; (3) PrEP and ART initiation; (4) experiences of using PrEP and ART; (5) PrEP discontinuation; (6) impact of PrEP and ART on the partnered relationship. Interviews were audio-recorded and transcribed. We used an inductive, content analytic approach to characterize meanings of PrEP stemming from its effectiveness for HIV prevention. Relevant content was represented as descriptive categories. Results: Discovery of HIV serodiscordance resulted in fear of HIV transmission for couples, which led to loss of sexual intimacy in committed relationships, and to abandonment of plans for children. As a result, partners became alienated from each other. PrEP countered the threat to the relationship by reducing fear and reinstating hopes of having children together. Condom use worked against the re-establishment of intimacy and closeness. By increasing couples’ sense of protection against HIV infection and raising the prospect of a return to “live sex” (sex without condoms), PrEP was perceived by couples as solving the problem of serodiscordance and preserving committed relationships. Conclusions: The most effective demand creation strategies for PrEP may be those that address the everyday life priorities of potential users in addition to HIV prevention.
Concordance in Reporting of Sexual Risk Behaviors in the HIV Sero Discordant Couples From Central Region, Uganda.
(MARY ANN LIEBERT, INC., 2018) Muwonge, Timothy R.; Nakku-Joloba, E.; Mugwanya, K.; Brown, Charles; Naggayi, G.; Nakyanzi, A.; Sserwada, D.; Nankabirwa, V.; Katabira, E.
Measurement and evaluation of sexual risk behavior in at-risk populations has been critical to HIV epidemiology and the targeting of HIV prevention responses. Evaluation of concordance of reports of sexual behavior within couples offers insight into potential bias and the direction of the bias in different populations, whether men or women, HIV-infected or HIV-uninfected partners tend to under or over report certain behaviors. This study examined HIV sero discordant couples (SDCs)' concordance of self-reported sexual behavior and predictors of discordant reporting for couples who had been in a relationship longer than 6 months.
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.
Factors associated with HIV self‑testing among female university students in Uganda: a cross‑sectional study
(AIDS Research and Therapy, 2022) Segawa, Ivan; Bakeera‑Kitaka, Sabrina; Ssebambulidde, Kenneth; Muwonge, Timothy R.; Oriokot, Lorraine; Ouma Ojiambo, Kevin; Mujugira, Andrew
Adolescent girls and young women (AGYW) at institutions of higher learning are at high risk of HIV, and conventional HIV testing services may not reach them sufficiently. HIV self-testing (HIVST) scalability can be informed by identifying AGYW who have used or are interested in using HIVST. We aimed to determine factors associated with use and willingness to use HIVST among female university students. Methods: An online cross-sectional survey was conducted among 483 female students at Makerere University, Uganda. Proportions of students who have used or are willing to use HIVST and their associated factors were determined. Modified Poisson regression models were used to estimate prevalence ratios (PR) and their 95% confidence intervals (CI). Results: The median age of the participants was 22 (Interquartile range [IQR] 21–23) years, and 21% had never tested for HIV. Over 93% were willing to utilize HIVST, and 19% had ever used HIV self-test kits. Increasing age (adjusted prevalence ratio [aPR] 1.23 per year, 95% CI 1.07–1.43) was significantly associated with HIVST use. Predictors of willingness to self-test for HIV were college type (arts vs. science-based, aPR 0.92, 95% CI 0.88–0.97), number of sexual partners (one, aPR 1.07, 95% CI 1.03–1.12 or ≥ 2, aPR 1.08, 95% CI 1.04–1.19, vs. none), alcohol (aPR 1.04, 95% CI: 1.00–1.09) or injection drug (aPR 1.04, 95% CI 1.00–1.09) use, a history of sexually transmitted infections in past 12 months (aPR 1.05, 95% CI 1.01–1.09), and HIV testing experience (tested in past 12 months, aPR 1.12, 95% CI 1.02–1.22 or over 12 months, aPR 1.13, 95% CI 1.03–1.24, vs. never tested). Conclusion: HIVST was highly acceptable despite its limited use. This study demonstrates female student characteristics that can be leveraged to scale up HIVST programs in higher institutions of learning.
Health Care Worker Perspectives of HIV Pre-exposure Prophylaxis Service Delivery in Central Uganda
(Frontiers in Public Health, 2022) Muwonge, Timothy R.; Nsubuga, Rogers; Ware, Norma C.; Wyatt, Monique A.; Pisarski, Emily; Kamusiime, Brenda; Kasiita, Vicent; Kakoola Nalukwago, Grace; Brown, Charles; Nakyanzi, Agnes; Bagaya, Monica; Bambia, Felix; Ssebuliba, Timothy; Katabira, Elly; Kyambadde, Peter; Baeten, Jared M.; Heffron, Renee; Celum, Connie; Mujugira, Andrew; Haberer, Jessica E.
Scale-up of HIV pre-exposure prophylaxis (PrEP) services in Uganda is ongoing. However, health care workers (HCWs) may not be aware of PrEP nor what offering this service entails. We explored the impact of standardized HCW training on the knowledge and perspectives of PrEP service delivery in Uganda. Methods: We recruited HCWs from facilities that offered HIV-related services in Central Uganda. Using the Uganda Ministry of Health curriculum, we trained HCWs on PrEP services. We collected data about PrEP knowledge, preparedness, and willingness to deliver PrEP to multiple key populations before the training, immediately after the training, and >6 months later (exit). We additionally conducted 15 qualitative interviews after the exit survey. Quantitative data were analyzed by Fisher exact test, while qualitative interview data were analyzed inductively. Results: We recruited 80 HCWs from 35 facilities in urban (N = 24, 30%), peri-urban (N = 30, 37%), and rural (N = 26, 33%) areas. Most HCWs were nurse counselors (N = 52, 65%) or medical/clinical officers (N = 15, 18%). Surveys indicated that awareness of PrEP increased after the training and remained high. Knowledge of PrEP (i.e., as an effective, short-term antiretroviral medication to use before HIV exposure for people at high risk) generally increased with training, but significant gaps remained, and knowledge decreased with time. Most HCWs recommended PrEP for female sex workers and HIV serodifferent couples, as well as other key populations. We observed increases in the number of HCW who felt their facility was prepared to cater for HIV prevention and provide PrEP, but this view was not universal. HCWs believed in PrEP effectiveness and embraced it as an additional HIV prevention method. Concerns included patient adherence and behavioral risk compensation. HCWs noted challenges in PrEP delivery in terms of inadequate clinic preparedness, infrastructure, staff capacity, and poor attitudes toward key populations by untrained health workers. They felt further training was needed to ensure a smooth scale-up of services without stigmatization. Standardized training improved knowledge, willingness, and preparedness to offer PrEP services among most HCWs in Central Uganda. Ongoing training will be needed to optimize PrEP delivery services and expand delivery to levels needed for population-level impact.
Health Worker Perspectives on Barriers and Facilitators of Assisted Partner Notification for HIV for Refugees and Ugandan Nationals: A Mixed Methods Study in West Nile Uganda
(AIDS and Behavior, 2021) Klabbers, Robin E.; Muwonge, Timothy R.; Ayikobua, Emmanuel; Izizinga, Diego; Bassett, Ingrid V.; Kambugu, Andrew; Tsai, Alexander C.; Ravicz, Miranda; Klabbers, Gonnie; O’Laughlin, Kelli N.
Assisted partner notification (APN) is recommended by the World Health Organization to notify sexual partners of HIV exposure. Since 2018, APN has been offered in Uganda to Ugandan nationals and refugees. Distinct challenges faced by individuals in refugee settlements may influence APN utilization and effectiveness. To explore APN barriers and facilitators, we extracted index client and sexual partner data from APN registers at 11 health centers providing care to refugees and Ugandan nationals in West Nile Uganda and conducted qualitative interviews with health workers (N = 32). Since APN started, 882 index clients participated in APN identifying 1126 sexual partners. Following notification, 95% (1025/1126) of partners tested for HIV; 22% (230/1025) were diagnosed with HIV with 14% (139/1025) of tested partners newly diagnosed. Fear of stigma and disclosure-related violence limit APN utilization and effectiveness. Prospective research involving index clients and sexual partners is needed to facilitate safe APN optimization in refugee settlements.
HIV self-testing and oral pre-exposure prophylaxis are empowering for sex workers and their intimate partners: a qualitative study in Uganda
(Journal of the International AIDS Society, 2021) Mujugira, Andrew; Nakyanzi, Agnes; Kasiita, Vicent; Kamusiime, Brenda; Nalukwago, Grace K.; Nalumansi, Alisaati; Twesigye, Chris C.; Muwonge, Timothy R.; Baeten, Jared M.; Wyatt, Monique A.; Haberer, Jessica E.; Ware, Norma C.
HIV self-testing (HIVST) and oral pre-exposure prophylaxis (PrEP) are complementary, evidence-based, selfcontrolled HIV prevention tools that may be particularly appealing to sex workers. Understanding how HIVST and PrEP are perceived and used by sex workers and their intimate partners could inform prevention delivery for this population. We conducted qualitative interviews to examine ways in which HIVST and PrEP use influence prevention choices among sex workers in Uganda. Methods: Within a randomized trial of HIVST and PrEP among 110 HIV-negative cisgender women, cisgender men and transgender women sex workers (NCT03426670), we conducted 40 qualitative interviews with 30 sex workers and 10 intimate partners (June 2018 to January 2020). Sex worker interviews explored (a) experiences of using HIVST kits; (b) how HIVST was performed with sexual partners; (c) impact of HIVST on PrEP pill taking; and (d) sexual risk behaviours after HIVST. Partner interviews covered (i) introduction of HIVST; (ii) experiences of using HIVST; (iii) HIV status disclosure; and (iv) HIVST’s effect on sexual behaviours. Data were analysed using an inductive content analytic approach centering on descriptive category development. Together, these categories detail the meaning of HIVST and PrEP for these qualitative participants. Results: Using HIVST and PrEP was empowering for this group of sex workers and their partners. Three types of empowerment were observed: (a) economic; (b) relational; and (c) sexual health. (i) Using HIVST and PrEP made sex without condoms safer. Sex workers could charge more for condomless sex, which was empowering economically. (ii) Self-testing restored trust in partners’ fidelity upon being reunited after a separation. This trust, in combination with condomless sex made possible by PrEP use, restored intimacy, empowering partnered relationships. (iii) HIVST and PrEP enabled sex workers to take control of their HIV prevention efforts and avoid the stigma of public clinic visits. In this way they were empowered to protect their sexual health. Conclusions: In this sample, sex workers’ use of HIVST and PrEP benefitted not only prevention efforts, but also economic and relational empowerment. Understanding these larger benefits and communicating them to stakeholders could strengthen uptake and use of combination prevention interventions in this marginalized population.
HIV-1-Neutralizing IgA Detected in Genital Secretions of Highly HIV- 1-Exposed Seronegative Women on Oral Preexposure Prophylaxis
(Journal of virology, 2016) Lund, Jennifer M.; Broliden, Kristina; Pyra, Maria N.; Thomas, Katherine K.; Donnell, Deborah; Irungu, Elizabeth; Muwonge, Timothy R.; Mugo, Nelly; Manohar, Madhuri; Jansson, Marianne; Mackelprang, Romel; Marzinke, Mark A.; Baeten, Jared M.; Lingappa, Jairam R.
Although nonhuman primate studies have shown that simian immunodeficiency virus/simian-human immunodeficiency virus (SIV/SHIV) exposure during preexposure prophylaxis (PrEP) with oral tenofovir can induce SIV immunity without productive infection, this has not been documented in humans. We evaluated cervicovaginal IgA in Partners PrEP Study participants using a subtype C primary isolate and found that women on PrEP had IgA with higher average human immunodeficiency virus type 1 (HIV-1)-neutralizing magnitude than women on placebo (33% versus 7%; P 0.008). Using a cutoff of>90% HIV-1 neutralization, 19% of women on-PrEP had HIV-1-neutralizing IgA compared to 0% of women on placebo (P 0.09). We also estimated HIV-1 exposure and found that the proportion of women with HIV-1-neutralizing IgA was associated with the level of HIV-1 exposure (P 0.04). Taken together, our data suggest that PrEP and high levels of exposure to HIV may each enhance mucosal HIV-1-specific humoral immune responses in sexually exposed but HIV-1-uninfected individuals.
Integrated delivery of antiretroviral treatment and pre-exposure prophylaxis to HIV-1 serodiscordant couples in East Africa: a qualitative evaluation study in Uganda
(Journal of the International AIDS Society, 2018) Ware, Norma C.; Pisarski, Emily E.; Nakku-Joloba, Edith; Wyatt, Monique A.; Muwonge, Timothy R.; Turyameeba, Bosco; Asiimwe, Stephen B.; Heffron, Renee A.; Baeten, Jared M.; Celum, Connie L.; Katabira, Elly T.
Serodiscordant couples are a priority population for delivery of new HIV prevention interventions in Africa. An integrated strategy of delivering time-limited, oral pre-exposure prophylaxis (PrEP) to uninfected partners in serodiscordant couples as a bridge to long-term antiretroviral treatment (ART) for infected partners has been implemented in East Africa, nearly eliminating new infections. We conducted a qualitative evaluation of the integrated strategy in Uganda, to better understand its success. Methods: Data collection consisted of 274 in-depth interviews with 93 participating couples, and 55 observations of clinical encounters between couples and healthcare providers. An inductive content analytic approach aimed at understanding and interpreting couples’ experiences of the integrated strategy was used to examine the data. Analysis sought to characterize: (1) key aspects of services provided; (2) what the services meant to recipients; and (3) how couples managed the integrated strategy. Themes were identified in each domain, and represented as descriptive categories. Categories were grouped inductively into more general propositions based on shared content. Propositions were linked and interpreted to explain “why the integrated strategy worked.” Results: Couples found “couples-focused” services provided through the integrated strategy strengthened partnered relationships threatened by the discovery of serodiscordance. They saw in services hope for “getting help” to stay together, turned joint visits to clinic into opportunities for mutual support, and experienced counselling as bringing them closer together. Couples adopted a “couples orientation” to the integrated strategy, considering the health of partners as they made decisions about initiating ART or accepting PrEP, and devising joint approaches to adherence. A couples orientation to services, grounded in strengthened partnerships, may have translated to greater success in using antiretrovirals to prevent HIV transmission. Conclusions: Various strategies for delivering antiretrovirals for HIV prevention are being evaluated. Understanding how and why these strategies work will improve evaluation processes and strengthen implementation platforms. We highlight the role of service organization in shaping couples’ experiences of and responses to ART and PrEP in the context of the integrated strategy. Organizing services to promote positive care experiences will strengthen delivery and contribute to positive outcomes as antiretrovirals for prevention are rolled out.
Leveraging interactive voice response technology to mitigate COVID-19 risk in refugee settlements in Uganda: Lessons learned implementing “Dial-COVID” a toll-free mobile phone symptom surveillance and information dissemination tool
(https://doi.org/ 10.1371/journal.pone.0279373, 2023) Klabbers, Robin E.; Muwonge, Timothy R.; Pham, Phuong; Mujugira, Andrew; Vinck, Patrick; Borthakur, Sukanya; Sharma, Monisha; Mohammed, Numan; Parkes-Ratanshi, Rosalind; Celum, Connie; O’Laughlin, Kelli N.
Persons living in refugee settlements in sub-Saharan Africa may be at increased risk for COVID-19 and experience barriers to accessing COVID-19 information. We aimed to evaluate the implementation of “Dial-COVID” a multi-lingual, toll free, telephone platform that uses interactive voice response (IVR) to track COVID-19 symptoms/exposure and disseminate COVID-19 health information in refugee settlements in Uganda. We hypothesized that IVR could provide an alternative way to screen for COVID-19 and communicate public health information to humanitarian populations when physical access and testing capacity were limited. Methods The Dial-COVID IVR platform was created in ten languages and advertised by community health workers in refugee settlements for participants to call into toll free. In a recorded IVR symptom survey, participants were screened for COVID-19 symptoms/exposures and based on their responses, received tailored public health messages about COVID-19 risk mitigation in accordance with Uganda Ministry of Health guidelines. Here we report the challenges and lessons learned implementing this research during the pandemic. Results Between February 2021 and March 2022, 15,465 calls were received by the Dial-COVID platform from all 31 refugee settlements in Uganda through which 6,913 symptom surveys were completed and 10,411 public health messages were disseminated in all study languages. Uptake of Dial-COVID fluctuated with the national COVID-19 caseload and was impacted by phone ownership and connectivity in refugee settlements. Intensified advertising efforts promoted Dial-COVID uptake. Flexibility to adapt IVR messages was contingent on translation capacity. Conclusion Refugees living in refugee settlements across Uganda accessed Dial-COVID to share and obtain COVID-19 information suggesting that IVR holds potential for rapid information dissemination and screening of humanitarian populations during future infectious disease outbreaks and may be a valuable tool for routine public health programs. IVR adaptation flexibility and reach are influenced by language constraints and by contextual factors related to platform access.
Pre-exposure prophylaxis differentially alters circulating and mucosal immune cell activation in HSV-2 seropositive women
(AIDS (London, England), 2019) Richert-Spuhler, Laura E.; Pattacini, Laura; Plews, Margot; Irungu, Elizabeth; Muwonge, Timothy R.; Katabira, Elly; Mugo, Nelly; Meyers, Adrienne F.A.; Celum, Connie; Baeten, Jared M.; Lingappa, Jairam R.; Lund, Jennifer M.
Oral tenofovir-based pre-exposure prophylaxis (PrEP) is an important tool for prevention of new HIV infections, which also reduces subclinical HSV-2 shedding and symptomatic lesions in HIV-negative, HSV-2-seropositive individuals. However, the impact of PrEP on mucosal immunity has not been examined in detail. Design: Here we evaluate paired genital tissue and systemic immune profiles to characterize the immunological effects of PrEP in HIV-negative, HSV-2-seropositive African women sexually exposed to HIV. Methods: We compared local and systemic innate and T-cell characteristics in samples collected during PrEP usage and two months after PrEP discontinuation. Results: We found that frequencies of cervical CCR5+CD4+ cells, regulatory T-cells, and tissue macrophages were significantly reduced during PrEP use compared to after PrEP discontinuation. In contrast, peripheral blood CD4+ and CD8+ T-cells expressing markers of activation and trafficking were increased during PrEP usage. Conclusions: Together, our data are consistent with PrEP altering immunity differentially in the female genital tract compared to circulation in HSV-2+ women. Further study including comparison to HSV-2 negative women is needed to define the overall impact and mechanisms underlying these effects. These results point to the critical need to study the human mucosal compartment to characterize immune responses to mucosal infections
PrEP Discontinuation and Prevention-Effective Adherence: Experiences of PrEP Users in Ugandan HIV Serodiscordant Couples
(Journal of acquired immune deficiency syndromes, 2019) Gilbert, Hannah N.; Wyatt, Monique A.; Pisarski, Emily E.; Muwonge, Timothy R.; Heffron, Renee; Katabira, Elly T.; Celum, Connie L.; Baeten, Jared M.; Haberer, Jessica E.; Ware, Norma C.
Optimal adherence to oral pre-exposure prophylaxis (PrEP) for HIV prevention involves aligning consistent PrEP use with periods of risk to achieve prevention-effective adherence. Prevention-effective adherence is predicated on individuals discontinuing PrEP during periods without expected risk. For stable, serodiscordant couples, ART adherence by the HIV-positive partner markedly decreases HIV transmission risk, potentially obviating the need for continued PrEP use; yet little is known about actual lived experiences of discontinuing PrEP. Methods: In-depth qualitative interviews were carried out with HIV-uninfected PrEP users in serodiscordant couples taking part in the Partners Demonstration Project at IDI-Kasangati, Kampala, Uganda. Open-ended interviews elicited information on the partnered relationship; understandings of PrEP; prevention strategies; and experiences of PrEP discontinuation. An inductive, thematic, content-analytic approach was used to analyze study data. Results: Uninfected partners experienced PrEP as a valued resource for preventing HIV acquisition. Despite ongoing ART use by HIV-positive partners for a period of time consistent with viral suppression, discontinuation of PrEP was experienced as a loss of protection and a corresponding increase in risk of HIV acquisition. Uninfected partners responded with strategies aimed at offsetting this subjective sense of increased risk, specifically: (1) changing sexual practices; (2) prioritizing fidelity in the relationship; (3) increasing reliance on condoms; and (4) seeking evidence of partners’ ART adherence. Conclusions: These experiences highlight the challenges PrEP users in serodiscordant couples face in discontinuing PrEP for prevention-effective adherence. Flexible interventions that support individuals during this transition may increase comfort with discontinuing PrEP when alternative prevention strategies provide protection, such as a partner’s consistent adherence to ART.
PrEP uptake and HIV viral suppression when PrEP is integrated into Ugandan ART clinics for HIV-negative members of HIV-serodifferent couples: A stepped wedge cluster randomized trial
(EClinicalMedicine, 2022) Heffron, Renee; Muwonge, Timothy R.; Thomas, Katherine K.; Nambi, Florence; Nakabugo, Lylianne; Kibuuka, Joseph; Thomas, Dorothy; Feutz, Erika; Meisner, Allison; Ware, Norma C.; Wyatt, Monique A.; Simoni, Jane M.; Katz, Ingrid T.; Kadama, Herbert; Baeten, Jared M.; Mujugira, Andrew
Global scale-up of HIV pre-exposure prophylaxis (PrEP) includes services to HIV-negative people in partnerships with people living with HIV (serodifferent couples). Data are needed on HIV outcomes, including uptake and adherence to PrEP and antiretroviral treatment (ART), to describe the impact of integrating PrEP into an existing HIV program. Methods Using a stepped-wedge cluster randomized trial design, we launched PrEP delivery for HIV-negative members of serodifferent couples in Uganda by integrating PrEP into existing ART programs for people living with HIV. The program provided PrEP training for ART providers, ongoing technical assistance, and a provisional supply chain mechanism for PrEP medication. Primary data on PrEP initiation, PrEP refills, ART initiation, and HIV viremia at 6 months (measured at 42-270 days) were collected through data abstraction of medical records from HIV-serodifferent couples sequentially enrolling at the ART clinics. Modified Poisson regression models, controlling for time and cluster, compared viral suppression (<1000 copies/ml) before and after launch of the PrEP program. This trial was registered at ClinicalTrials.gov, NCT03586128. Findings From June 1, 2018-December 15, 2020, 1,381 HIV-serodifferent couples were enrolled across 12 ART clinics in Kampala and Wakiso, Uganda, including 730 enrolled before and 651 after the launch of PrEP delivery. During the baseline period, 99.4% of partners living with HIV initiated ART and 85.0% were virally suppressed at 6 months. Among HIV-negative partners enrolled after PrEP launched, 81.0% (527/651) initiated PrEP within 90 days of enrolling; among these 527, 11.2% sought a refill 6 months later. In our powered intent-to-treat analysis, 82.1% and 76.7% of partners living with HIV were virally suppressed, respectively, which was not a statistically significant difference (RR=0.94, 95% CI: 0.82-1.07) and was stable across sensitivity analyses. Interpretation Integration of PrEP into ART clinics reached a high proportion of people in HIV-serodifferent relationships and did not improve the already high frequency of HIV viral suppression among partners living with HIV.
Short message service (SMS) surveys assessing pre-exposure prophylaxis (PrEP) adherence and sexual behavior are highly acceptable among HIV-uninfected members of serodiscordant couples in East Africa: A mixed methods study
(AIDS and Behavior, 2019) Muwonge, Timothy R.; Ngure, Kenneth; Katabira, Elly; Mugo, Nelly; Kimemia, Grace; O'Rourke Burns, Bridget Frances; Musinguzi, Nicholas; Bambia, Felix; Baeten, Jared M.; Heffron, Renee; Haberer, Jessica E.
Short message service (SMS) surveys are a promising data collection method and were used to measure sexual behavior and adherence to HIV pre-exposure prophylaxis (PrEP) among HIV-uninfected partners of serodiscordant couples enrolled in a sub-study of the Partners Demonstration Project (an open-label study of integrated antiretroviral therapy and PrEP for HIV prevention in Kenya and Uganda). Questionnaires were completed by 142 participants after study exit. Median age was 29 years; 69% were male. Ninety-five percent (95%) felt SMS surveys were “easy” or “very easy”, 74% reported no challenges, and 72% preferred SMS surveys over in-person study visits. Qualitative interviews involving 32 participants confirmed the ease of responding to SMS surveys. Participants also indicated that surveys acted as reminders for adherence to PrEP and condom use and were experienced as support from the study. SMS surveys were generally found to be acceptable in this population and provided real-time context of PrEP use.
Understanding early implementation of pre-exposure prophylaxis for HIV prevention in public health facilities in Uganda using the Consolidated Framework for Implementation Research
(Clinics, 2019) Ortblad, Katrina; Brown, Charles; Muwonge, Timothy R.; Scoville, Caitlin; Izizinga, Diego; Namanda, Sylvia; Nambi, Florence; Nakabugo, Lylianne; Mujugira, Andrew; Heffron, Renee
In sub-Saharan Africa, a number of countries are starting to deliver oral preexposure prophylaxis (PrEP) for HIV prevention in public health facilities. • We are conducting a stepped-wedge cluster-randomized trial in 12 health facilities in Kampala & Wakiso, Uganda to launch delivery of a PrEP program within HIV clinics targeting HIV-negative members of HIV serodiscordant couples and determine the impact of the PrEP program on HIV viral suppression in partners living with HIV (ClinicalTrials.gov)
Understanding PrEP Acceptability Among Priority Populations: Results from a Qualitative Study of Potential Users in Central Uganda
(AIDS and Behavior, 2022) Sundararajan, Radhika; Wyatt, Monique A.; Muwonge, Timothy R.; Pisarski, Emily E.; Mujugira, Andrew; Haberer, Jessica E.; Ware, Norma C.
Daily oral pre-exposure prophylaxis (PrEP) can safely and effectively prevent HIV acquisition in HIV-negative individuals. However, uptake of PrEP has been suboptimal in sub-Saharan Africa. The goal of this qualitative study was to identify facilitators of and barriers to PrEP acceptability among target users not taking PrEP. Fifty-nine individuals belonging to Ugandan priority populations participated in a single in-depth interview. Participants perceived themselves as being at high risk for HIV acquisition, and expressed interest in PrEP as an HIV prevention strategy. Two forms of stigma emerged as potential barriers to PrEP use: (1) misidentification as living with HIV; and (2) disclosure of membership in a priority population. Acceptability of PrEP was dampened for this sample of potential PrEP users due to anticipated stigmatization. Mitigating stigma should be a key component of effective PrEP delivery to reach UNAIDS goal of ending the AIDS epidemic by 2030.
Understanding the role of interpersonal violence in assisted partner notification for HIV: a mixed-methods study in refugee settlements in West Nile Uganda
(Journal of global health, 2020) Klabbers, Robin E.; Muwonge, Timothy R.; Ayikobua, Emmanuel; Izizinga, Diego; Bassett, Ingrid V.; Kambugu, Andrew; Tsai, Alexander C.; Ravicz, Miranda; Klabbers, Gonnie; O’Laughlin, Kelli N
Assisted partner notification (APN) for HIV was introduced in refugee settlements in West Nile Uganda in 2018 to facilitate testing of sexual partners. While APN is an effective strategy recommended by the World Health Organization, its safety has not been evaluated in a refugee settlement context in which participants have high prior exposure to interpersonal violence. The extent to which interpersonal violence influences APN utilization and the frequency with which post-APN interpersonal violence occurs remains unknown. Methods To explore the relationship between APN and interpersonal violence, a cross-sectional mixed-methods study was conducted at 11 health centers in or near refugee settlements serving refugee and national populations in West Nile Uganda. Routinely collected index client and sexual partner data were extracted from APN registers and semi-structured interviews were conducted with health workers. Results Through APN, 1126 partners of 882 distinct index clients were identified. For 8% (75/958) of partners, index clients reported a history of intimate partner violence (IPV). For 20% (226/1126) of partners, index clients were screened for post-APN IPV; 8 cases were reported of which 88% (7/8) concerned partners with whom index clients reported prior history of IPV. In qualitative interviews (N = 32), health workers reported HIV disclosure-related physical, sexual and psychological violence and deprivation or neglect. Incidents of disclosure-related violence against health workers and dependents of index clients were also reported. Fear of disclosure-related violence was identified as a major barrier to APN that prevents index clients from listing sexual partners. Conclusions Incidents of interpersonal violence have been reported following HIV-disclosure and fear of interpersonal violence strongly influences APN participation. Addressing HIV perception and stigma may contribute to APN uptake and program safety. Prospective research on interpersonal violence involving index clients and sexual partners in refugee settlements is needed to facilitate safe engagement in APN for this vulnerable population.
Users May Lack Confidence in ART for HIV Prevention: A Qualitative Analysis
(Conference on retroviruses and opportunistic infections (CROI), 2017) Wyatt, Monique A.; Pisarski, Emily E.; Baeten, Jared M.; Heffron, Renee; Nakku-Joloba, Edith; Muwonge, Timothy R.; Katabira, Elly T.; Celum, Connie L.; Ware, Norma C.
Antiretroviral-based approaches to HIV prevention have been shown to reduce new infections in clinical trials and demonstration settings. To optimize uptake and anticipate barriers to effective rollout, we must understand users’ perspectives on antiretroviral treatment (ART) for prevention of HIV transmission. We explored serodiscordant couples’ understandings of and feelings about treatment as prevention using qualitative data from the Partners Demonstration Project. The Partners Demonstration Project employed an integrated delivery strategy of daily oral pre-exposure prophylaxis (PrEP) and ART for serodiscordant couples in Kenya and Uganda. PrEP use was time-limited and discontinued after HIVinfected partners had been on ART for 6 months. Multiple in-depth qualitative interviews were conducted with a subset of 48 couples from the Kampala, Uganda Partners Demonstration Project site (N interviews=195). Interview topics included: (a) perceived purpose and meanings of PrEP and ART; (b) adherence; (c) experiences of PrEP discontinuation; and (d) understandings of antiretroviral treatment as prevention. Interviews were audio-recorded, transcribed into English and coded using Atlas.ti software by two trained analysts. Coded data were inductively analyzed to identify themes representing couples’ understandings of and feelings about using ART for prevention of HIV transmission. Categories were developed to represent the themes.
“You are not a man”: a multi-method study of trans stigma and risk of HIV and sexually transmitted infections among trans men in Uganda
(Journal of the International AIDS Society, 2021) Mujugira, Andrew; Kasiita, Vicent; Bagaya, Monica; Nakyanzi, Agnes; Bambia, Felix; Nampewo, Oliva; Kamusiime, Brenda; Mugisha, Jackson; Nalumansi, Alisaati; Twesigye, Collin C.; Muwonge, Timothy R.; Baeten, Jared M.; Wyatt, Monique A.; Tsai, Alexander C.; Ware, Norma C.; Haberer, Jessica E.
Transgender (trans) men in sub-Saharan Africa are a hidden and vulnerable population who may engage in sex work due to socio-economic exclusion and lack of alternative employment opportunities. Little is known about HIV and sexually transmitted infection (STI) risk among trans men in this setting. We conducted a multi-method study to characterize HIV/STI risk among trans men in Uganda. Methods: Between January and October 2020, we enrolled 50 trans men into a cross-sectional study through snowball sampling. Data were collected on socio-demographic characteristics, sexual practices and depression. We conducted 20 qualitative interviews to explore: (1) descriptions of sexual practices that could increase HIV/STI exposure; (2) experiences of accessing public healthcare facilities; (3) perceptions of HIV or STI testing; (4) HIV and STI service delivery; and (5) drug and alcohol use. We used an inductive content analytic approach centring on descriptive category development to analyse the data. Results: The median age was 25 years (interquartile range 23–28). The prevalence of HIV, syphilis and hepatitis B was 4%, 6% and 8%, respectively. We observed multiple levels of intersecting individual, interpersonal and structural stigmas. (1) Trans men reported transphobic rape motivated by interpersonal stigma that was psychologically traumatizing to the survivor. The resultant stigma and shame hindered healthcare access. (2) Structural stigma and economic vulnerability led to sex work, which increased the risk of HIV and other STIs. Sex work stigma further compounded vulnerability. (3) Individualized stigma led to fear of disclosure of gender identity and HIV status. Concealment was used as a form of stigma management. (4) Multiple levels of stigma hampered access to healthcare services. Preference for trans-friendly care was motivated by stigma avoidance in public facilities. Overall, the lived experiences of trans men highlight the intertwined relationship between stigma and sexual health. Conclusions: In this sample from Uganda, trans men experienced stigma at multiple levels, highlighting the need for gendersensitive healthcare delivery. Stigma reduction interventions, including provider training, non-discrimination policies, support groups and stigma counselling, could strengthen uptake and utilization of prevention services by this marginalized population.

Browsing by Author "Muwonge, Timothy R."

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