Browsing by Author "Nakigozi, Gertrude"
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Item Age-Disparate Relationships and HIV Prevalence among Never Married Women in Rakai, Uganda(Journal of acquired immune deficiency syndromes, 2018) Mwinnyaa, George; Gray, Ronald H.; Grabowski, Mary K.; Ssekasanvu, Joseph; Ndyanabo, Anthony; Ssekubugu, Robert; Kagaayi, Joseph; Kigozi, Godfrey; Nakigozi, Gertrude; Serwadda, David M.; Laeyendecker, OliverAge-disparate relationships are associated with increased HIV prevalence. We determined whether the frequency of age-disparate relationships in never married women changed over time and whether they are associated with HIV prevalence in Rakai, Uganda. Methods: 10,061 never married women, aged 15–49 in the Rakai Community Cohort Study provided information on the age of their male sexual partners from 1997 to 2013. Logistic regression was used to assess trends in age-disparate relationships (≥5 years) between never married women and their male partners. Log-binomial regression was used to estimate adjusted prevalence ratios (adjPR) of HIV prevalence associated with age-disparate relationships. Results: 2,992 women (30%) had a male partner ≥5 years older which remained stable over time. The prevalence of HIV among women in age-disparate relationships was 14%, 10% for women in relationships with men 0–4 years older (adjPR 1.36, 95% CI 1.22, 1.53) not controlling women’s age, however after age adjustment the impact of age-disparate relationships on HIV prevalence was attenuated. Age-disparate relationships were associated with increased HIV prevalence among women aged 15–17 (adjPR 1.83, 95% CI 1.10, 3.19), but not in other age groups. Conclusions: The frequency of age-disparate relationships among never married women were unchanged over a 15-year period in Rakai, Uganda. Age-disparate relationships were associated with increased HIV prevalence among adolescents 15–17, but not older women.Item AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV(AIDS Care, 2011) Nakigozi, Gertrude; Makumbi, Fredrick; Reynolds, Steven; Galiwango, Ronald; Kagaayi, Joseph; Nalugoda, Fred; Ssettuba, Absalom; Sekasanvu, Joseph; Musuuza, Jackson; Serwada, David; Gray, Ron; Wawer, MariaImproved understanding of HIV-related health-seeking behavior at a population level is important in informing the design of more effective HIV prevention and care strategies. We assessed the frequency and determinants of failure to seek free HIV care in Rakai, Uganda. HIV-positive participants in a community cohort who accepted VCT were referred for free HIV care (cotrimoxazole prophylaxis, CD4 monitoring, treatment of opportunistic infections, and, when indicated, antiretroviral therapy). We estimated proportion and adjusted Prevalence Risk Ratios (adj. PRR) of non-enrollment into care six months after receipt of VCT using log-binomial regression. About 1145 HIV-positive participants in the Rakai Community Cohort Study accepted VCT and were referred for care. However, 31.5% (361/1145) did not enroll into HIV care six months after referral. Non-enrollment was significantly higher among men (38%) compared to women (29%, p 0.005). Other factors associated with nonenrollment included: younger age (15 24 years, adj. PRR 2.22; 95% CI: 1.64, 3.00), living alone (adj. PRR 2.22; 95% CI: 1.57, 3.15); or in households with 1 2 co-residents (adj. PRR 1.63; 95% CI: 1.31, 2.03) compared to three or more co-residents, or a CD4 count 250 cells/ul (adj. PRR 1.81; 95% CI: 1.38, 2.46). Median (IQR) CD4 count was lower among enrolled 388 cells/ul (IQR: 211,589) compared to those not enrolled 509 cells/ul (IQR: 321,754).About one-third of HIV-positive persons failed to utilize community-based free services. Non-use of services was greatest among men, the young, persons with higher CD4 counts and the more socially isolated, suggesting a need for targeted strategies to enhance service uptakeItem Association of Medical Male Circumcision and Antiretroviral Therapy Scale-up With Community HIV Incidence in Rakai,Uganda(American Medical Association, 2016) Kong, Xiangrong; Kigozi, Godfrey; Ssekasanvu, Joseph; Nalugoda, Fred; Nakigozi, Gertrude; Ndyanabo, Anthony; Lutalo, Tom; Reynolds, Steven J.; Ssekubugu, Robert; Kagaayi, Joseph; Bugos, Eva; Chang, Larry W.; Nanlesta, Pilgrim; Mary, Grabowski; Berman, Amanda; Quinn, Thomas C.; Serwadda, David; Wawer, Maria J.; Gray, Ronald H.Randomized trials have shown that medical male circumcision( MMC)reduces maleHIVacquisition by50% to 60%,1-3 and that early initiation of antiretroviral therapy (ART) reduces HIV transmission by more than90%in HIV-discordant couples.4Mathematical modeling suggests that these interventions could mitigate the HIV epidemic in sub- Saharan Africa,5-7 but there is limited empirical evidence for the population-level effects of these interventions on HIV incidence in real-world programs. MMC provides direct protection against male HIV acquisition by removing the foreskin, which is rich in HIV target cells.8-10 The potential effect ofMMCon population-level HIV incidence depends on this biological effect, the level ofMMC coverage, risk profiles ofmenacceptingMMC,and whether behavioral disinhibition occurs following circumcision.Item Construct validity and internal consistency of the Patient Health Questionnaire-9 (PHQ-9) depression screening measure translated into two Ugandan languages(Psychiatry Research Communications, 2021) Miller, Amanda P.; Silva, Cristina Espinosa da; Ziegel, Leo; Stephen, Mugamba; Kyasanku, Emma; Bulamba, Robert M.; Wagman, Jennifer A.; Ekstromc, Anna Mia; Nalugoda, Fred; Kigozi, Grace; Nakigozi, Gertrude; Kagaayi, Joseph; Watya, Stephen; Kigozi, GodfreyIn Uganda, depression is a major public health issue. Psychometric assessment of translated depression measures is critical to public health planning to ensure proper screening, surveillance, and treatment of depression and related outcomes. We examined aspects of the validity and reliability of the Patient Health Questionnaire-9 (PHQ- 9) translated into Luganda and Runyoro among Ugandan adolescents and adults. Data from the ongoing AMBSO Population Health Surveillance study were analyzed from the Wakiso and Hoima districts in Uganda. Descriptive statistics were calculated for the overall sample and stratified by translated language. Construct validity was assessed for each translated scale using confirmatory factor analysis for ordinal data. The internal consistency of each translated scale was assessed using Cronbach's alpha, McDonald's omega total and omega hierarchical. Both the Luganda- and Runyoro-translated PHQ-9 had similar sample means (3.46 [SD ¼ 3.26] and 3.58 [SD ¼ 3.00], respectively), supported a single-factor structure, and demonstrated satisfactory internal consistency (Cronbach's alpha of 0.73 and 0.72, respectively). Our preliminary findings indicate that the Luganda and Runyoro translations of the PHQ-9 had satisfactory construct validity and internal consistency in our sample. Future studies should expand on this promising work by assessing additional psychometric characteristics of these translated measures in other communities in Uganda.Item Dynamics Of Pre-Exposure (PrEP) Eligibility due to Waxing and Waning of HIV Risk in Rakai, Uganda(JAIDS Journal of Acquired Immune Deficiency Syndromes, 2022) Ssempijja, Victor; Ssekubugu, Robert; Kigozi, Godfrey; Nakigozi, Gertrude; Kagaayi, Joseph; Nalugoda, Fred; Nantume, Betty; Batte, James; Kigozi, Grace; Nakawooya, Hadijja; Serwadda, David; Reynolds, Steven J.We conducted a retrospective population-based study to describe longitudinal patterns of prevalence, incidence, discontinuation, resumption, and durability of substantial HIV risk behaviors (SHR) for PrEP eligibility.The study was conducted among HIV-negative study participants aged 15-49 years that participated in survey rounds of the Rakai Community Cohort Study between August 2011 and June 2018. SHR was defined based on the Uganda national PrEP eligibility as either reporting sexual intercourse with >1 partner of unknown HIV status, non-marital sex without a condom or having transactional sex. Resumption of SHR meant resuming of SHR after stopping SHR, while persistence of SHR meant SHR on >1 consecutive visit. We used generalized estimation equations (GEE) with log-binomial regression models and robust variance to estimate survey-specific prevalence ratios (PR); GEE with modified Poisson regression models and robust variance to estimate incidence ratios for incidence, discontinuation, and resumption of PrEP eligibility.PrEP use should be tailored to the dynamic nature of PrEP eligibility. Preventive-effective adherence should be adopted for assessment of attrition in PrEP programs.Item Effect of Peer Health Workers on AIDS Care in Rakai, Uganda: A Cluster-Randomized Trial(PloS one, 2010) Chang, Larry W.; Kagaayi, Joseph; Nakigozi, Gertrude; Ssempijja, Victor; Packer, Arnold H.; Serwadda, David; Quinn, Thomas C.; Gray, Ronald H.; Bollinger, Robert C.; Reynolds, Steven J.Human resource limitations are a challenge to the delivery of antiretroviral therapy (ART) in low-resource settings. We conducted a cluster randomized trial to assess the effect of community-based peer health workers (PHW) on AIDS care of adults in Rakai, Uganda. Methodology/Principal Findings: 15 AIDS clinics were randomized 2:1 to receive the PHW intervention (n = 10) or control (n = 5). PHWtasks included clinic and home-based provision of counseling, clinical, adherence to ART, and social support. Primary outcomes were adherence and cumulative risk of virologic failure (.400 copies/mL). Secondary outcomes were virologic failure at each 24 week time point up to 192 weeks of ART. Analysis was by intention to treat. FromMay 2006 to July 2008, 1336 patients were followed. 444 (33%) of these patients were already on ART at the start of the study. No significant differences were found in lack of adherence (,95% pill count adherence risk ratio [RR] 0.55, 95% confidence interval [CI] 0.23–1.35; ,100% adherence RR 1.10, 95% CI 0.94–1.30), cumulative risk of virologic failure (RR 0.81, 95% CI 0.61–1.08) or in shorter-term virologic outcomes (24 week virologic failure RR 0.93, 95% CI 0.65–1.32; 48 week, RR 0.83, 95% CI 0.47–1.48; 72 week, RR 0.81, 95% CI 0.44–1.49). However, virologic failure rates$96 weeks into ART were significantly decreased in the intervention armcompared to the control arm (96 week failure RR 0.50, 95% CI 0.31–0.81; 120 week, RR 0.59, 95% CI 0.22–1.60; 144 week, RR 0.39, 95% CI 0.16–0.95; 168 week, RR 0.30, 95% CI 0.097–0.92; 192 week, RR 0.067, 95% CI 0.0065–0.71). Conclusions/Significance: A PHW intervention was associated with decreased virologic failure rates occurring 96 weeks and longer into ART, but did not affect cumulative risk of virologic failure, adherence measures, or shorter-term virologic outcomes. PHWs may be an effective intervention to sustain long-term ART in low-resource settingsItem Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda(Clinical Infectious Diseases, 2021) Loevinsohn, Gideon; Kigozi, Godfrey; Kagaayi, Joseph; Wawer, Maria J.; Nalugoda, Fred; Chang, Larry W.; Quinn, Thomas C.; Serwadda, David; Reynolds, Steven J.; Nelson, Lisa; Mills, Lisa; Alamo, Stella; Nakigozi, Gertrude; Kabuye, Geoffrey; Ssekubugu, Robert; Tobian, Aaron A. R.; Gray, Ronald H.; Grabowski, M. KathrynThe efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men.Item Efficacy of Knowledge and Competence-Based Training of Non-Physicians in the Provision of Early Infant Male Circumcision using the Mogen Clamp in Rakai, Uganda(BJU international, 2017) Kankaka, Edward Nelson; Kigozi, Godfrey; Kayiwa, Daniel; Kighoma, Nehemiah; Makumbi, Frederick; Murungi, Teddy; Nabukalu, Dorean; Nampijja, Resty; Watya, Stephen; Namuguzi, Daniel; Nalugoda, Fred; Nakigozi, Gertrude; Serwadda, David; Wawer, Maria; Gray, Ronald H.To assess acquisition of knowledge and competence in performing Early Infant Male Circumcision (EIMC) by non-physicians trained using a structured curriculum.Training in provision of EIMC using the Mogen clamp was conducted for 10 Clinical Officers (COs) and 10 Registered Nurse Midwives (RNMWs), in Rakai, Uganda. Healthy infants whose mothers consented to study participation were assigned to the trainees, each of whom performed at least 10 EIMCs. Ongoing assessment and feedback for competency were done, and safety assessed by adverse events.Despite similar baseline knowledge, COs acquired more didactic knowledge than RNMWs (P = 0.043). In all, 100 EIMCs were assessed for gain in competency. The greatest improvement in competency was between the first and third procedures, and all trainees achieved 80% competency and retention of skills by the seventh procedure. The median (interquartile range) time to complete a procedure was 14.5 (10-47) min for the COs, and 15 (10-50) min for the RNMWs (P = 0.180). The procedure times declined by 2.2 min for each subsequent EIMC (P = 0.005), and rates of improvement were similar for COs and RNMWs. Adverse events were comparable between providers (3.5%), of which 1% were of moderate severity.Competence-based training of non-physicians improved knowledge and competency in EIMC performed by COs and RNMWs in Uganda.Item Evaluation of current rapid HIV test algorithms in Rakai, Uganda(Journal of virological methods, 2013) Galiwango, Ronald M.; Musoke, Richard; Lubyayi, Lawrence; Ssekubugu, Robert; Kalibbala, Sarah; Ssekweyama, Viola; Mirembe, Viola; Nakigozi, Gertrude; Reynolds, Steven J.; Serwadda, David; Gray, Ronald H.; Kigozi, GodfreyRapid HIV tests are a crucial component of HIV diagnosis in resource limited settings. In Uganda, the Ministry of Health allows for both serial and parallel HIV rapid testing using Determine, Stat- Pak and Uni-Gold. In serial testing, a non-reactive result on Determine ends testing. The performance of serial and parallel algorithms with Determine and Stat-Pak test kits was assessed. A cross-sectional diagnostic test accuracy evaluation using three rapid HIV test kits as per the recommended parallel test algorithm was followed by EIA-WB testing with estimates of the performance of serial testing algorithm. In 2520 participants tested by parallel rapid algorithms, 0.6% had weakly reactive result. Parallel testing had 99.7% sensitivity and 99.8% specificity. If Stat-Pak was used as the first screening test for a serial algorithm, the sensitivity was 99.6% and specificity 99.7%. However, if Determine was used as the screening test, sensitivity was 97.3% and specificity 99.9%. Serial testing with Stat-Pak as the initial screening test performed as well as parallel testing, but Determine was a less sensitive screen. Serial testing could be cost saving.Item Failure of immunologic criteria to appropriately identify antiretroviral treatment failure in Uganda(AIDS, 2009) Reynolds, Steven J.; Nakigozi, Gertrude; Newell, Kevin; Ndyanabo, Anthony; Galiwongo, Ronald; Iga, Boaz; Quinn, Thomas C.; Gray, Ron; Wawer, Maria; Serwadda, DavidMost antiretroviral treatment program in resource-limited settings use immunologic or clinical monitoring to measure response to therapy and to decide when to change to a second line regimen. Our objective was to evaluate immunologic failure criteria against gold standard virologic monitoring. Design—Observation cohort Methods—Participants enrolled in an antiretroviral treatment program in rural Uganda who had at least 6 months of follow-up were included in this analysis. Immunologic monitoring was performed by CD4 cell counts every 3 months during the first year, and every 6 months thereafter. HIV-1 viral loads were performed every 6 months. Results—1133 participants enrolled in the Rakai Health Sciences Program antiretroviral treatment program between June 2004 and September 2007 were followed for up to 44.4 months (median follow-up 20.2 months; IQR 12.4–29.5 months). WHO immunologic failure criteria were reached by 125 (11.0%) participants. A virologic failure endpoint defined as HIV-1 viral load (VL) >400 copies/ml on two measurements was reached by 112 participants (9.9%). Only 26 participants (2.3%) experiencedItem Failure of immunologic criteria to appropriately identify antiretroviral treatment failure in Uganda(AIDS (London, England), 2009-03) Reynolds, Steven J.; Nakigozi, Gertrude; Newell, Kevin; Ndyanabo, Anthony; Ronald, Galiwongo; Iga, Boaz; . Quinn, Thomas C; Gray, Ron; Wawer, Maria; Serwadda, DavidObjective—Most antiretroviral treatment program in resource-limited settings use immunologic or clinical monitoring to measure response to therapy and to decide when to change to a second line regimen. Our objective was to evaluate immunologic failure criteria against gold standard virologic monitoring. Design—Observation cohort Methods—Participants enrolled in an antiretroviral treatment program in rural Uganda who had at least 6 months of follow-up were included in this analysis. Immunologic monitoring was performed by CD4 cell counts every 3 months during the first year, and every 6 months thereafter. HIV-1 viral loads were performed every 6 months. Results—1133 participants enrolled in the Rakai Health Sciences Program antiretroviral treatment program between June 2004 and September 2007 were followed for up to 44.4 months (median follow-up 20.2 months; IQR 12.4–29.5 months). WHO immunologic failure criteria were reached by 125 (11.0%) participants. A virologic failure endpoint defined as HIV-1 viral load (VL) >400 copies/ml on two measurements was reached by 112 participants (9.9%). Only 26 participants (2.3%) experienced both an immunologic and virologic failure endpoint (2 VL>400 copies/ml) during follow-up. Conclusions—Immunologic failure criteria performed poorly in our setting and would have resulted in a substantial proportion of participants with suppressed HIV-1 VL being switched unnecessarily. These criteria also lacked sensitivity to identify participants failing virologically. Periodic viral load measurements may be a better marker for treatment failure in our settingItem High Rates of Pre-exposure Prophylaxis Eligibility and Associated HIV Incidence in a Population With a Generalized HIV Epidemic in Rakai, Uganda(Journal of Acquired Immune Deficiency Syndromes, 2022) Ssempijja, Victor; Nakigozi, Gertrude; Ssekubugu, Robert; Kagaayi, Joseph; Kigozi, Godfrey; Nalugoda, Fred; Nantume, Betty; Batte, James; Kigozi, Grace; Nakawooya, Hadijja; Serwadda, David; Cobelens, Frank; Reynolds, Steven J.The utility of using pre-exposure prophylaxis (PrEP) eligibility assessments to identify eligibility in general populations has not been well studied in sub-Saharan Africa. We used the Rakai Community Cohort Study to conduct a cross-sectional analysis to estimate PrEP eligibility and a cohort analysis to estimate HIV incidence associated with PrEP eligibility. Based on Uganda's national PrEP eligibility tool, we defined eligibility as reporting at least one of the following HIV risks in the past 12 months: sexual intercourse with more than one partner of unknown HIV status; nonmarital sex act without a condom; sex engagement in exchange for money, goods, or services; or experiencing genital ulcers. We used log-binomial and modified Poisson models to estimate prevalence ratios for PrEP eligibility and HIV incidence, respectively.Item HIV viral suppression and geospatial patterns of HIV antiretroviral therapy treatment facility use in Rakai, Uganda(AIDS (London, England), 2018) Billioux, Veena G.; Grabowski, Mary K.; Ssekasanvu, Joseph; Reynolds, Steven J.; Berman, Amanda; Bazaale, Jeremiah; Patel, Eshan U.; Bugos, Eva; Ndyanabo, Anthony; Kisakye, Alice; Kagaayi, Joseph; Gray, Ronald H.; Nakigozi, Gertrude; Ssekubugu, Robert; Nalugoda, Fred; Serwadda, David; Wawer, Maria J.; Chang, Larry W.To assess geospatial patterns of HIV antiretroviral therapy (ART) treatment facility use and whether they were impacted by viral load (VL) suppression. Methods—We extracted data on the location and type of care services utilized by HIV-positive persons accessing ART between February 2015 and September 2016 from the Rakai Community Cohort Study (RCCS) in Uganda. The distance from RCCS households to facilities offering ART was calculated using the open street map road network. Modified Poisson regression was used to identify predictors of distance traveled and, for those traveling beyond their nearest facility, the probability of accessing services from a tertiary care facility. Results—1554 HIV-positive participants were identified, of whom 68% had initiated ART. The median distance from households to the nearest ART facility was 3.10 km (Interquartile range, IQR, 1.65–5.05), but the median distance traveled was 5.26 km (IQR, 3.00–10.03, p<0.001) and 57% of individuals travelled further than their nearest facility for ART. Those with higher education and wealth were more likely to travel further. 93% of persons on ART were virally suppressed, and there was no difference in the distance traveled to an ART facility between those with suppressed and unsuppressed VLs (5.26 km vs. 5.27 km, p=0.650). Conclusions—Distance traveled to HIV clinics was increased with higher socioeconomic status, suggesting that wealthier individuals exercise greater choice. However, distance traveled did not vary by those who were or were not virally suppressed.Item Household food insecurity and its association with self-reported male perpetration of intimate partner violence: a survey of two districts in central and western Uganda(BMJ Open, 2021) Awungafac, George; Mugamba, Stephen; Nalugoda, Fred; Sjöland, Carl Fredrik; Kigozi, Godfrey; Rautiainen, Susanne; Bulamba Malyabe, Robert; Ziegel, Leo; Nakigozi, Gertrude; Kigozi Nalwoga, Grace; Kyasanku, Emmanuel; Nkale, James; Watya, Stephen; Ekström, Anna Mia; Kågesten, AnnaThis study aimed to determine the lifetime prevalence of male-perpetrated intimate partner violence (IPV), and to assess the association with food insecurity, sociodemographic factors and health risk behaviors in Uganda in the year preceding COVID-19- associated lockdowns. Population-based, cross-sectional household survey. Urban, semi urban and rural communities of the Wakiso and Hoima districts in Uganda. Participants A total of N=2014 males aged 13–80 years participated in the survey. The current study included males who reported having ever been in a sexual union and responded to the IPV questions (N=1314).Item Human immunodeficiency virus care cascade among sub-populations in Rakai, Uganda: an observational study(Journal of the International AIDS Society, 2017) Billioux, Veena G.; Chang, Larry W.; Reynolds, Steven J.; Nakigozi, Gertrude; Ssekasanvu, Joseph; Grabowski, Mary K.; Ssekubugu, Robert; Nalugoda, Fred; Kigozi, Godfrey; Kagaayi, Joseph; Serwadda, David; Gray, Ronald H.; Wawer, Maria J.To assess progress towards the UNAIDS 90–90–90 initiative targets, we examined the HIV care cascade in the population-based Rakai Community Cohort Study (RCCS) in rural Uganda and examined differences between sub-groups. Methods: Self-reports and clinical records were used to assess the proportion achieving each stage in the cascade. Statistical inference based on a 2 test for categorical variables and modified Poisson regression were used to estimate prevalence risk ratios (PRRs) and 95% confidence intervals (CI) for enrolment into care and initiating antiretroviral therapy (ART). Results: From September 2013 through December 2015, 3,666 HIV-positive participants were identified in the RCCS. As of December 2015, 98% had received HIV Counseling and Testing (HCT), 74% were enrolled in HIV care, and 63% had initiated ART of whom 92% were virally suppressed after 12 months on ART. Engagement in care was lower among men than women (enrolment in care: adjPRR 0.84, 95% CI 0.77–0.91; ART initiation: adjPRR 0.75, 95% CI 0.69–0.82), persons aged 15–24 compared to those aged 30–39 (enrolment: adjPRR 0.72, 95% CI 0.63–0.82; ART: adjPRR 0.69, 95%CI 0.60–0.80), unmarried persons (enrolment: adjPRR 0.84, 95% CI 0.71–0.99; ART adjPRR 0.80, 95% CI 0.66–0.95), and new in-migrants (enrolment: adjPRR 0.75, 95% CI 0.67–0.83; ART: adjPRR 0.76, 95% CI 0.67–0.85). This cohort achieved 98–65–92 towards the UNAIDS “90–90–90” targets with an estimated 58% of the entire HIV-positive RCCS population virally suppressed. Conclusions: This cohort achieved over 90% in both HCT and viral suppression among ART users, but only 65% in initiating ART, likely due to both an ART eligibility criterion of <500 CD4 cells/mL and suboptimal entry into care among men, younger individuals, and in-migrants. Interventions are needed to promote enrolment in HIV care, particular for hard-to-reach subpopulations.Item Impact of combination HIV interventions on HIV incidence in hyperendemic fishing communities in Uganda: a prospective cohort study(The lancet HIV,, 2019) Kagaayi, Joseph; Chang, Larry W.; Ssempijja, Victor; Grabowski, M. Kate; Ssekubugu, Robert; Nakigozi, Gertrude; Kigozi, Godfrey; Serwadda, David M.; Gray, Ronald H.; Nalugoda, Fred; Sewankambo, Nelson K; Nelson, Lisa; Mills, Lisa A.; Kabatesi, Donna; Alamo, Stella; Kennedy, Caitlin E.; Tobian, Aaron A. R.; Santelli, John S.; Mia Ekström, Anna; Nordenstedt, Helena; Quinn, Thomas C.; Wawer, Maria J.; Reynolds, Steven J.Targeting combination HIV interventions to locations and populations with high HIV burden is a global priority, but the impact of these strategies on HIV incidence is unclear. We assessed the impact of combination HIV interventions on HIV incidence in four HIV-hyperendemic communities in Uganda. Methods We did an open population-based cohort study of people aged 15–49 years residing in four fishing communities on Lake Victoria. The communities were surveyed five times to collect self-reported demographic, behavioural, and service-uptake data. Free HIV testing was provided at each interview, with referral to combination HIV intervention services as appropriate. From November, 2011, combination HIV intervention services were rapidly expanded in these geographical areas. We evaluated trends in HIV testing coverage among all participants, circumcision coverage among male participants, antiretroviral therapy (ART) coverage and HIV viral load among HIV-positive participants, and sexual behaviours and HIV incidence among HIV-negative participants. Findings From Nov 4, 2011, to Aug 16, 2017, data were collected from five surveys. Overall, 8942 participants contributed 20 721 person-visits; 4619 (52%) of 8942 participants were male. HIV prevalence was 41% (1598 of 3870) in the 2011–12 baseline survey and declined to 37% (1740 of 4738) at the final survey (p<0·0001). 3222 participants who were HIV-negative at baseline, and who had at least one repeat visit, contributed 9477 person-years of follow-up, and 230 incident HIV infections occurred. From the first survey in 2011–12 to the last survey in 2016–17, HIV testing coverage increased from 68% (2613 of 3870) to 96% (4526 of 4738; p<0·0001); male circumcision coverage increased from 35% (698 of 2011) to 65% (1630 of 2525; p<0·0001); ART coverage increased from 16% (254 of 1598) to 82% (1420 of 1740; p<0·0001); and population HIV viral load suppression in all HIV-positive participants increased from 34% (546 of 1596) to 80% (1383 of 1734; p<0·0001). Risky sexual behaviours did not decrease over this period. HIV incidence decreased from 3·43 per 100 person-years (95% CI 2·45–4·67) in 2011–12 to 1·59 per 100 person-years (95% CI 1·19–2·07) in 2016–17; adjusted incidence rate ratio (IRR) 0·52 (95% CI 0·34–0·79). Declines in HIV incidence were similar among men (adjusted IRR 0·53, 95% CI 0·30–0·93) and women (0·51, 0·27–0·96). The risk of incident HIV infection was lower in circumcised men than in uncircumcised men (0·46, 0·32–0·67). Interpretation Rapid expansion of combination HIV interventions in HIV-hyperendemic fishing communities is feasible and could have a substantial impact on HIV incidence. However, incidence remains higher than HIV epidemic control targets, and additional efforts will be needed to achieve this global health priority. Funding The National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, the National Cancer Institute, the National Institute for Allergy and Infectious Diseases Division of Intramural Research, Centers for Disease Control and Prevention Uganda, Karolinska Institutet, and the Johns Hopkins University Center for AIDS Research.Item The longitudinal impact of an evidence-based multiple family group intervention (Amaka Amasanyufu) on family cohesion among children in Uganda: Analysis of the cluster randomized SMART Africa-Uganda scale-up study (2016–2022)(PubMed, 2024-05) Byansi, William; Sensoy Bahar, Ozge; Small, Latoya; Namatovu, Phionah; Nabayinda, Josephine; Kiyingi, Joshua; Mwebembezi, Abel; Nakigozi, Gertrude; Hoagwood, Kimberly; McKay, Mary M; Ssewamala, Fred MFamily functioning plays a critical role in childhood disruptive behavior disorders (The Family Journal, 2003, 11(1), 33-41; Research in Nursing and Health, 2016, 39(4), 229-243). Yet, there is limited research on the impact of evidence-based family strengthening interventions on improving family cohesion as a protective factor among children experiencing behavioral challenges. To address this gap, we analyzed data (N = 636) from the SMART Africa-Uganda study (2016-2022), a cluster randomized clinical trial testing an evidence-based family-strengthening intervention called Amaka Amasanyufu (translated as "Happy Families" in the local language). Children aged 8-13 and their caregivers were recruited from 26 public primary schools that were randomized to: (1) control condition receiving generalized psychosocial literature (10 schools), (2) intervention delivered via parent peers (eight schools), and (3) intervention delivered via community healthcare workers (eight schools). Children completed the family cohesion questionnaire at baseline, 8 weeks, 16 weeks, and 6 months post-intervention completion. The intervention effectiveness was evaluated via a three-level logistic mixed effects model with pairwise comparisons across study conditions within each time point. Participants in the parent-peer intervention group had greater odds of being in the higher family cohesion group than participants in the control group at 8 weeks (OR = 3.24), 16 weeks (OR = 1.88) and 6 months (OR = 2.07). At 8 weeks, 16 weeks, and 6 months, participants in the community health worker group had 3.98, 2.08, and 1.79 times greater odds of being in the higher family cohesion group than participants in the control group, respectively. Our findings strengthen the evidence base for Amaka Amansayufu as an effective intervention that can be utilized in SSA to improve family cohesion in families with children experiencing behavioral challenges. PubMedItem Migration and risk of HIV acquisition in Rakai, Uganda: a population-based cohort study(The lancet HIV, 2018) Olawore, Oluwasolape; Tobian, Aaron A. R.; Kagaayi, Joseph; Bazaale, Jeremiah M.; Nantume, Betty; Kigozi, Grace; Nankinga, Justine; Nalugoda, Fred; Nakigozi, Gertrude; Kigozi, Godfrey; Gray, Ronald H.; Wawer, Maria J.; Ssekubugu, Robert; Santelli, John S.; Reynolds, Steven J.; Chang, Larry W.; Serwadda, David; Grabowski, Mary K.In sub-Saharan Africa, migrants typically have higher HIV prevalence than non-migrants; however, whether HIV acquisition typically precedes or follows migration is unknown. We aimed to investigate the risk of HIV after migration in Rakai District, Uganda. Methods In a prospective population-based cohort of HIV-negative participants aged 15–49 years in Rakai, Uganda, between April 6, 1999, and Jan 30, 2015, we assessed the association between migration and HIV acquisition. Individuals were classified as recent in-migrants (≤2 years in community), non-recent in-migrants (>2 years in community), or permanent residents with no migration history. The primary outcome was incident HIV infection. We used Poisson regression to estimate incidence rate ratios (IRRs) of HIV associated with residence status with adjustment for demographics, sexual behaviours, and time. Data were also stratified and analysed within three periods (1999–2004, 2005–11, and 2011–15) in relation to the introduction of combination HIV prevention (CHP; pre-CHP, early CHP, and late CHP). Findings Among 26 995 HIV-negative people who participated in the Rakai Community Cohort Study survey, 15 187 (56%) contributed one or more follow-up visits (89 292 person-years of follow-up) and were included in our final analysis. 4451 (29%) were ever in-migrants and 10 736 (71%) were permanent residents. 841 incident HIV events occurred, including 243 (29%) among in-migrants. HIV incidence per 100 person-years was significantly increased among recent in-migrants compared with permanent residents, for both women (1·92, 95% CI 1·52–2·43 vs 0·93, 0·84–1·04; IRR adjusted for demographics 1·75, 95% CI 1·33–2·33) and men (1·52, 0·99–2·33 vs 0·84, 0·74–0·94; 1·74, 1·12–2·71), but not among non-recent in-migrants (IRR adjusted for demographics 0·94, 95% CI 0·74–1·19 for women and 1·28, 0·94–1·74 for men). Between the pre-CHP and late-CHP periods, HIV incidence declined among permanent resident men (p<0·0001) and women (p=0·002) and non-recent in-migrant men (p=0·031), but was unchanged among non-recent in-migrant women (p=0·13) and recent in-migrants (men p=0·76; women p=0·84) Interpretation The first 2 years after migration are associated with increased risk of HIV acquisition. Prevention programmes focused on migrants are needed to reduce HIV incidence in sub-Saharan Africa. Funding National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, the National Institute for Allergy and Infectious Diseases Division of Intramural Research, National Institutes of Health; the Centers for Disease Control and Prevention; the Bill & Melinda Gates Foundation; and the Johns Hopkins University Center for AIDS Research.Item Not Enough Money and Too Many Thoughts: Exploring Perceptions of Mental Health in Two Ugandan Districts Through the Mental Health Literacy Framework(Qualitative Health Research, 2021) Miller, Amanda P.; Ziegel, Leo; Mugamba, Stephen; Kyasanku, Emmanuel; Wagman, Jennifer A.; Nkwanzi-Lubega, Violet; Nakigozi, Gertrude; Kigozi, Godfrey; Nalugoda, Fred; Kigozi, Grace; Nkale, James; Watya, Stephen; Ddaaki, WilliamMental health disorders account for a heavy disease burden in Uganda. In order to provide culturally appropriate mental health prevention and treatment approaches, it is necessary to understand how mental health is conceptualized in the population. Three focus group discussions (FGDs) and 31 in-depth interviews (IDIs) were conducted with men and women aged 14 to 62 years residing in rural, urban, and semi-urban low-income communities in central and western Uganda to explore perceptions and knowledge of mental health. Interpretive thematic analysis was undertaken; results were organized through the lens of the mental health literacy framework. Environmental and societal stressors were identified as primary underlying causes of poor mental health. While participants recognized symptoms of poor mental health, gaps in mental health literacy also emerged. Mental health resources are needed in this setting and additional qualitative work assessing knowledge and attitudes toward mental health care seeking behavior can inform the development of acceptable integrated services.Item Postcoital penile washing and the risk of HIV acquisition in uncircumcised men(AIDS, 2016) Makumbi, Fredrick E.; Ssempijja, Victor; Sekasanvu, Joseph; Ssekubugu, Robert; Kigozi, Godfrey; Watya, Stephen; Nakigozi, Gertrude; Serwadda, David; Wawer, Maria; Gray, Ronald H.Postcoital genital washing by uncircumcised men may affect the risk of male HIV acquisition. Method: We assessed the association between self-reported washing after sex in 2976 initially HIV-negative, uncircumcised men enrolled in a prospective cohort study in Rakai, Uganda. Results: Data from the 2976 participants who reported sexual intercourse in the past 12 months contributed 4290 visits, with 7316.6 person-years of observation during the 2-year follow-up. The overall HIV-incidence was 1.28/100 person-years 95%CI (1.04–1.57). About 91.0% of men reported washing their penis after sex, and their HIV incidence was 1.34/100 person-years (95%CI 1.08–1.66), compared with an incidence of 0.62/100 person-years (95%CI 0.17–1.60) in men who did not wash their penis after intercourse. Using Poisson multivariable regression, the adjusted incidence rate ratio of HIV acquisition associated with postcoital washing was 1.94 (95%CI 0.71–5.29). Conclusion: Postcoital penile washing, as practiced in this rural African population does not afford protection from HIV acquisition among uncircumcised men, and may increase risk.