Browsing by Author "Tsai, Alexander C."
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Item Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12-month cohort study in urban South Africa and rural Uganda(Journal of the International AIDS Society, 2020) Matthews, Lynn T.; Orrell, Catherine; Mwebesa, Bosco Bwana; Tsai, Alexander C.; Psaros, Christina; Asiimwe, Stephen; Amanyire, Gideon; Musinguzi, Nicholas; Bell, Kathleen; Bangsberg, David R.; Haberer, Jessica E.We conducted a cohort study to understand patterns of anti-retroviral therapy (ART) adherence during pregnancy, postpartum and non-pregnancy follow-up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa. We collected survey data, continuously monitored ART adherence (Wisepill), HIV-RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow-up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non-pregnancy-related (neither pregnant nor postpartum). Fractional regression models included demographics and socio-behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV-RNA at 12 months by ever- versus never-pregnant status. In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non-pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/ mm3). HIV-RNA was suppressed among 91% (N = 135) ever-pregnant and 86% (N = 85) never-pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non-pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non-pregnancy-related follow-up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIVRNA was suppressed among 57% (N = 47) ever-pregnant and 86% (N = 93) never-pregnant women. Women in rural Uganda maintained high adherence with 91% of ever-pregnant and 86% of never-pregnant women suppressing HIV-RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow-up with median adherence of 40% and 57% of women with HIV-RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.Item Adverse childhood experiences, adult depression, and suicidal ideation in rural Uganda: A cross-sectional, population-based study(PLoS Med, 2021) Satinsky, Emily N.; Kakuhikire, Bernard; Baguma, Charles; Rasmussen, Justin D.; Ashaba, Scholastic; Cooper-Vince, Christine E.; Perkins, Jessica M.; Kiconco, Allen; Namara, Elizabeth B.; Bangsberg, David R.; Tsai, Alexander C.Depression is recognized globally as a leading cause of disability. Early-life adverse childhood experiences (ACEs) have been shown to have robust associations with poor mental health during adulthood. These effects may be cumulative, whereby a greater number of ACEs are progressively associated with worse outcomes. This study aimed to estimate the associations between ACEs and adult depression and suicidal ideation in a cross-sectional, population-based study of adults in Uganda.Item ART adherence and viral suppression are high among most non-pregnant individuals with early-stage, asymptomatic HIV infection: an observational study from Uganda and South Africa(Journal of the International AIDS Society, 2019) Haberer, Jessica E.; Bwana, Bosco M.; Orrell, Catherine; Asiimwe, Stephen; Amanyire, Gideon; Musinguzi, Nicholas; Siedner, Mark J.; Matthews, Lynn T.; Tsai, Alexander C.; Katz, Ingrid T.; Bell, Kathleen; Kembabazi, Annet; Mugisha, Stephen; Kibirige, Victoria; Cross, Anna; Kelly, Nicola; Hedt-Gauthier, Bethany; Bangsberg, David R.The success of universal antiretroviral therapy (ART) access and aspirations for an AIDS-free generation depend on high adherence in individuals initiating ART during early-stage HIV infection; however, adherence may be difficult in the absence of illness and associated support. From March 2015 to October 2017, we prospectively observed three groups initiating ART in routine care in Uganda and South Africa: men and non-pregnant women with early-stage HIV infection (CD4 > 350 cells/lL), pregnant women with early-stage HIV infection and men and non-pregnant women with late-stage HIV infection (CD4 < 200 cells/lL). Socio-behavioural questionnaires were administered and viral loads were performed at 0, 6 and 12 months. Adherence was monitored electronically. Adherence data were available for 869 participants: 322 (37%) early/non-pregnant, 199 (23%) early/pregnant and 348 (40%) late/non-pregnant participants. In Uganda, median adherence was 89% (interquartile range 74 to 96) and viral suppression was 90% at 12 months; neither differed among groups (p > 0.72). In South Africa, median adherence was higher in early/non-pregnant versus early/pregnant or late/non-pregnant participants (76%, 37%, 52%; p < 0.001), with similar trends in viral suppression (86%, 51%, 79%; p < 0.001). Among early/non-pregnant individuals in Uganda, adherence was higher with increasing age and lower with structural barriers; whereas in South Africa, adherence was higher with regular income, higher perceived stigma and use of other medications, but lower with maladaptive coping and cigarette smoking. ART adherence among non-pregnant individuals with early-stage infection is as high or higher than with late-stage initiation, supporting universal access to ART. Challenges remain for some pregnant women and individuals with late-stage infection in South Africa and highlight the need for differentiated care delivery.Item Association of Gut Intestinal Integrity and Inflammation with Insulin Resistance in Adults Living with HIV in Uganda(AIDS Patient Care and STDs, 2019) Reid, Michael J.A.; Ma, Yifei; Golovaty, Iya; Okello, Samson; Sentongo, Ruth; Feng, Maggie; Tsai, Alexander C.; Kakuhikire, Bernard; Tracy, Russell; Hunt, Peter W.; Siedner, Mark; Tien, Phyllis C.We conducted a cross-sectional study of 148 HIV+ on HIV antiretroviral therapy and 149 HIV- adults in Mbarara, Uganda, to estimate the association between HIV infection and homeostasis model assessment of insulin resistance (HOMA-IR) using multivariable regression analysis. In addition, we evaluated whether intestinal fatty acid-binding protein (I-FABP), monocyte activation markers soluble (s)CD14 and sCD163, and proinflammatory cytokine interleukin 6 (IL-6) mediated this association. HOMA-IR was greater among HIV+ than HIV- adults [median (interquartile range): 1.3 (0.7–2.5) vs. 0.9 (0.5–2.4); p = 0.008]. In models adjusted for sociodemographic variables, diet, hypertension, and smoking history, HIV infection was associated with 37% [95% confidence intervals (95% CIs): 5–77] greater HOMA-IR compared with HIV- participants. The magnitude of association was greater when I-FABP was included as a covariate although the additive effect was modest (40% CI: 8–82). By contrast adding sCD14 to the model was associated with greater HOMA-IR (59%; 95% CI: 21–109) among HIV+ participants compared with HIV- participants. Among HIV+ participants, greater CD4 nadir was non-significantly associated with greater HOMA-IR (22%; 95% CI: -2 to 52). Each 5-unit increase in body mass index (BMI; 49% greater HOMA-IR; 95% CI: 18–87) and female sex (71%; 95% CI: 17–150) remained associated in adjusted models. In this study of mainly normal-weight Ugandan adults, HIV infection, female sex, and greater BMI were all associated with greater insulin resistance (IR). This association was strengthened modestly after adjustment for sCD14, suggesting possible distinct immune pathways to IR that are independent of HIV or related to inflammatory changes occurring on HIV treatment.Item Blood pressure trajectories and the mediated effects of body mass index and HIV‐related inflammation in a mixed cohort of people with and without HIV in rural Uganda(The Journal of Clinical Hypertension, 2019) Okello, Samson; Kim, June‐Ho; Sentongo, Ruth N.; Tracy, Russell; Tsai, Alexander C.; Kakuhikire, Bernard; Siedner, Mark J.We sought to describe changes in blood pressure and estimate the effect of HIV on blood pressure (BP) over 4 years of observation in a cohort of 155 HIV‐infected adults (≥40 years) on antiretroviral therapy (ART) and 154 sex‐ and age‐quartilematched, population‐based, HIV‐uninfected controls for four years in rural Uganda, we compared changes in blood pressure (BP) by HIV serostatus and tested whether body mass index and inflammation (high‐sensitivity C‐reactive protein and interleukin‐ 6) and immune activation (sCD14 and sCD163) mediated the effects of HIV on BP using hierarchical multivariate and two‐stage parametric regression models. Overall HIV‐uninfected participants had higher mean BP than HIV‐infected counterparts (differences in trend P < 0.0001 for diastolic BP and P = 0.164 for systolic BP). After initial declines in BP in both groups between years 1 and 2, BP moderately increased in both groups through year 4, with greater change over time observed in the HIVuninfected group. Body mass index mediated 72% (95%CI 57, 97) of the association between HIV and systolic BP. We found a minimal mediating effect of sCD14 on the relationship between HIV and SBP (9%, 95% CI 5%, 21%), but found no association between other HIV‐related biomarkers. Over four years of observation, HIV‐infected people in rural Uganda have lower BP than HIV‐uninfected counterparts despite having higher levels of inflammation. BMI, rather than measures of HIV‐associated inflammation, explained a majority of the difference in BP observed.Item Changes in Food Insecurity, Nutritional Status, and Physical Health Status After Antiretroviral Therapy Initiation in Rural Uganda(Journal of acquired immune deficiency syndromes, 2012) Weiser, Sheri D.; Gupta, Reshma; Tsai, Alexander C.; Frongillo, Edward A.; Grede, Nils; Kumbakumba, Elias; Kawuma, Annet; Hunt, Peter W.; Bangsberg, David R.; Martin, Jeffrey N.To investigate whether time on antiretroviral therapy (ART) is associated with improvements in food security and nutritional status, and the extent to which associations are mediated by improved physical health status. The Uganda AIDS Rural Treatment Outcomes study, a prospective cohort of HIV-infected adults newly initiating ART in Mbarara, Uganda. Participants initiating ART underwent quarterly structured interview and blood draws. The primary explanatory variable was time on ART, constructed as a set of binary variables for each 3-month period. Outcomes were food insecurity, nutritional status, and PHS. We fit multiple regression models with cluster-correlated robust estimates of variance to account for within-person dependence of observations over time, and analyses were adjusted for clinical and sociodemographic characteristics.Item Declining Prevalence of Probable Depression Among Patients Presenting for Antiretroviral Therapy in Rural Uganda: The Role of Early Treatment Initiation(AIDS and Behavior, 2015) Chan, Brian T.; Weiser, Sheri D.; Boum, Yap; Haberer, Jessica E.; Kembabazi, Annet; Hunt, Peter W.; Martin, Jeffrey N.; Mocello, A. Rain; Bangsberg, David R.; Tsai, Alexander C.Little is known about trends in depression at antiretroviral therapy (ART) initiation among people living with HIV (PLHIV) in low- and middle-income countries. We used data from an ongoing cohort of treatment -naı¨ve PLHIV in rural Uganda to estimate secular trends in depression among PLHIV at ART initiation. We fitted linear regression models with depression symptom severity as the outcome variable and year of cohort entry (2005–2012) as the explanatory variable, adjusting for socio-demographic variables and assessing physical health score, body mass index (BMI), and CD4 count as potential mediators of a secular trend in depression symptom severity. There was a statistically significant negative association between year of entry and depression symptom severity, suggesting a 3.1 % relative decline in the mean depression symptom severity score at ART initiation in each year of study recruitment after the first year. This trend remained statistically significant after inclusion of baseline socio demographic characteristics to the model and appeared to be driven by improved physical health scores, but not CD4 count or BMI.Item Dissemination of Research Findings to Research Participants Living with HIV in Rural Uganda: Challenges and Rewards(PLoS Medicine, 2013) Baylor, Anna; Muzoora, Conrad; Bwana, Mwebsa; Kembabazi, Annet; Haberer, Jessica E.; Matthews, Lynn T.; Tsai, Alexander C.; Hunt, Peter W.; Martin, Jeffrey N.; Bangsberg, David R.Community participatory research emphasizes communication of study findings to research participants of vulnerable populations [1]. Most dissemination activities in sub-Saharan Africa have occurred after the completion (or termination) of randomized clinical trials of a defined intervention [2–4]. Sharing research findings with participants during observational research can avoid therapeutic misconception [5] as well as evaluate the validity of research involving knowledge, attitudes, or behavior through a ‘‘member check’’ procedure in which investigators conduct interviews regarding the relevancy and saliency of their findings [6]. Nonetheless, the communication of research findings to participants living with HIV enrolled in observational research in a rural sub- Saharan African setting is less straight forward and presents significant challenges respect to literacy, language, logistics, and confidentiality.Item The Dynamic Relationship Between Social Support and HIV-Related Stigma in Rural Uganda(Annals of Behavioral Medicine, 2014) Takada, Sae; Weiser, Sheri D.; Kumbakumba, Elias; Muzoora, Conrad; Martin, Jeffrey N.; Hunt, Peter W.; Haberer, Jessica E.; Kawuma, Annet; Bangsberg, David R.; Tsai, Alexander C.Cross-sectional studies show that human immunodeficiency virus (HIV) stigma is negatively correlated with social support. Purpose The purpose of this study is to examine the bidirectional relationship between social support and HIV stigma. We collected quarterly data from a cohort of 422 people living with HIV in Uganda, followed for a median of 2.1 years. We used multilevel regression to model the contemporaneous and 3-month-lagged associations between social support and both enacted and internalized stigma. Lagged enacted stigma was negatively correlated with emotional and instrumental social support, and lagged instrumental social support was negatively correlated with enacted stigma. Internalized stigma and emotional social support had reciprocal lagged associations. Interventions to reduce enacted stigma may strengthen social support for people living with HIV. Improved social support may in turn have a protective influence against future enacted and internalized stigmaItem Electrocardiographic Evidence of Cardiac Disease by Sex and HIV Serostatus in Mbarara, Uganda(Global heart, 2019) Kentoffio, Katie; Albano, Alfred; Koplan, Bruce; Feng, Maggie; Muthalaly, Rahul G.; Campbell, Jeffrey I.; Sentongo, Ruth; Tracy, Russell P.; Peck, Robert; Okello, Samson; Tsai, Alexander C.; Siedner, Mark J.Numerous studies in the United States and Europe have demonstrated an increased risk for cardiovascular disease (CVD) among persons living with HIV (PLWH).[1] The relationship between HIV and subsequent CVD has not been as well-established in sub-Saharan Africa (SSA). PLWH in SSA have a high burden of untreated risk factors, but results vary regarding surrogate markers of CVD. Data on outcomes, such as stroke or myocardial infarction, are limited. An analysis of data from the SMART trial found that PLWH had a high prevalence of ECG abnormalities at baseline, which predicted CVD risk over the study period.[2] We investigated the prevalence of ECG abnormalities by HIV serostatus in rural Uganda to estimate differences in CVD risk. As secondary aims, we assessed a) ECG evidence of ischemic coronary artery disease by HIV serostatus and b) sex-based differences in ECG findings.Item Evidence for the Reliability and Validity of the Internalized AIDS-Related Stigma Scale in Rural Uganda(AIDS and Behavior, 2013) Tsai, Alexander C.; Weiser, Sheri D.; Steward, Wayne T.; Mukiibi, Nozmo F. B.; Kawuma, Annet; Kembabazi, Annet; Muzoora, Conrad; Hunt, Peter W.; Martin, Jeffrey N.; Bangsberg, David R.HIV infection remains highly stigmatized throughout sub-Saharan Africa despite the increasing availability of treatment. HIV-related stigma is commonly described to be highly prevalent in East Africa, but none of these studies have employed validated scales for measurement. We used data from 456 people living with HIV/ AIDS in rural Uganda to validate the six-item Internalized AIDS-Related Stigma Scale. The scale demonstrated acceptable internal consistency (Cronbach’s alpha = 0.73) and time stability. Exploratory factor analysis indicated the presence of a single factor. Construct validity was supported by observations that the scale was correlated with related constructs such as depression and mental health related quality of life. The scale was able to discriminate between groups of persons who were different in terms of treatment status and their experience of HIV-related self-blame. Taken together, these findings suggest that the Internalized AIDS-Related Stigma Scale may be a useful tool for socio-behavioral HIV research.Item Food insecurity is associated with morbidity and patterns of healthcare utilization among HIV-infected individuals in a resource-poor setting(AIDS (London, England), 2012) Weiser, Sheri D.; Tsai, Alexander C.; Gupta, Reshma; Frongillo, Edward A.; Kawuma, Annet; Senkungu, Jude; Hunta, Peter W.; Emenyonue, Nneka I.; Mattson, Jennifer E.; Martin, Jeffrey N.; Bangsberg, David R.We undertook a longitudinal study in rural Uganda to understand the association of food insecurity with morbidity and patterns of healthcare utilization among HIV-infected individuals enrolled in an antiretroviral therapy program. Longitudinal cohort study. Participants were enrolled from the Uganda AIDS Rural Treatment Outcomes cohort, and underwent quarterly structured interviews and blood draws. The primary predictor was food insecurity measured by the validated Household Food Insecurity Access Scale. Primary outcomes included health-related quality of life measured by the validated Medical Outcomes Study-HIV Physical Health Summary (PHS), incident self-reported opportunistic infections, number of hospitalizations, and missed clinic visits. To estimate model parameters, we used the method of generalized estimating equations, adjusting for sociodemographic and clinical variables. Explanatory variables were lagged by 3 months to strengthen causal interpretations.Item 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.Item HIV infection, pulmonary tuberculosis and COPD in rural Uganda: A cross-sectional study(Lung, 2018) North, Crystal M.; Allen, Joseph G.; Okello, Samson; Sentongo, Ruth; Kakuhikire, Bernard; Ryan, Edward T.; Tsai, Alexander C.; Christiani, David C.; Siedner, Mark J.HIV is associated with chronic obstructive pulmonary disease (COPD) in high resource settings. Similar relationships are less understood in low resource settings. We aimed to estimate the association between HIV infection, tuberculosis and COPD in rural Uganda. Methods: The Uganda Non-Communicable Diseases and Aging Cohort study observes people 40 years and older living with HIV (PLWH) on antiretroviral therapy, and population-based HIV-uninfected controls in rural Uganda. Participants completed respiratory questionnaires and post-bronchodilator spirometry. Results: Among 269 participants with spirometry, median age was 52 (IQR 48–55), 48% (n=130) were ever-smokers, and few (3%, n=9) reported a history of COPD or asthma. All participants with prior tuberculosis (7%, n=18) were PLWH. Among 143 (53%) PLWH, median CD4 count was 477 cells/mm3 and 131 (92%) were virologically suppressed. FEV1 was lower among older individuals (−0.5 %pred/year, 95% CI 0.2–0.8, p<0.01) and those with a history of tuberculosis (−14.4 %pred, 95% CI −23.5 - −5.3, p < 0.01). COPD was diagnosed in 9 (4%) participants, eight of whom (89%) were PLWH, 6 of whom (67%) had a history of tuberculosis, and all of whom (100%) were men. Among 287 participants with complete symptom questionnaires, respiratory symptoms were more likely among women (AOR 3.9, 95% CI 2.0–7.7, p<0.001) and those in homes cooking with charcoal (AOR 3.2, 95% CI 1.4–7.4, p=0.008).Item HIV-related stigma and its association with HIV transmission risk behaviors among boda boda motorcyclists in Mbarara Municipality, southwestern Uganda(International journal of STD & AIDS, 2021) Nabifo, Stella C.; Tsai, Alexander C.; Bajunirwe, FrancisKey populations have a disproportionate burden of HIV compared with the general population. HIV-related stigma has been recognized as a major barrier to HIV prevention and treatment efforts. It remains unclear whether HIV-related stigma is a significant driver of HIV transmission risk behavior among boda boda (motorcycle taxi) riders, a key population in Uganda.We conducted a cross-sectional study among boda boda motorcyclists in Mbarara Municipality of southwestern Uganda. Using multistage sampling, we recruited participants aged 18–59 years who had been riding for at least 6 months. The primary explanatory variable of interest was HIV-related stigma, measured using the 7-item STRIVE scale and dichotomized at “no stigma” versus “any stigma.” Self-reported HIV transmission risk behaviors included: condomless sexual intercourse, sexual intercourse under the influence of alcohol, having non-primary sexual partners, and sexual intercourse with a commercial sex worker. We used multivariable logistic regression to estimate the association between HIV-related stigma and HIV transmission risk behavior.We enrolled 401 boda boda motorcyclists. All were men. Most [330 (82%)] were classified as having HIV-related stigma, particularly among younger men aged 18–29 years. One hundred and thirty-two (34%) participants reported their last sexual encounter was with a non-primary partner, 153 (39%) did not know the serostatus of their last sexual partner, and 138 (36%) reported sexual intercourse with a sex worker in the past 6 months. In multivariable logistic regression, HIV-related stigma (adjusted odds ratio [aOR] = 1.88, 95% CI: 1.06–3.34) had a statistically significant association with any HIV transmission risk behavior. Men who reported either minimal alcohol use (aOR = 1.81, 95% CI: 1.07–2.95) or harmful alcohol use (aOR = 3.5, 95% CI: 1.92–6.54), compared with men who reported no alcohol use, also reported greater odds of HIV transmission risk behavior.HIV transmission risk behavior is common among boda boda motorcyclists in the municipality and is associated with both HIV-related stigma and alcohol use. Interventions aimed at reducing HIV-related stigma and alcohol use may potentially reduce the high rates of HIV transmission risk behavior in this key population.Item Ideal Cardiovascular Health and Carotid Atherosclerosis in a Mixed Cohort of HIV-Infected and Uninfected Ugandans(AIDS research and human retroviruses, 2017) Feinstein, Matthew J.; Kim, June-Ho; Bibangambah, Prossy; Sentongo, Ruth; Martin, Jeffrey N.; Tsai, Alexander C.; Bangsberg, David R.; Hemphill, Linda; Triant, Virginia A.; Boum II, Yap; Hunt, Peter W.; Okello, Samson; Siedner, Mark J.Preventable cardiovascular disease (CVD) risk factors are responsible for the majority of CVD-related deaths, and are increasingly recognized as a cause of morbidity and mortality for HIV-infected persons taking antiretroviral therapy (ART). Simplified tools such as the American Heart Association’s ideal cardiovascular health (iCVH) construct may identify and prognosticate CVD risk in resource-limited settings. No studies have evaluated iCVH metrics in sub-Saharan Africa or among HIV-infected adults. Thus, the central aim of this study was to compare levels of iCVH metrics and their correlations with carotid atherosclerosis for HIV-infected adults versus uninfected controls in a well-phenotyped Ugandan cohort. We analyzed the prevalence of iCVH metrics in a mixed cohort of HIV-infected persons on stable ART and uninfected, population-based comparators in Mbarara, Uganda. We also assessed the validity of iCVH by correlating iCVH values with common carotid intima media thickness (CCIMT). HIV-infected persons had a mean of 4.9 (SD 1.1) iCVH metrics at ideal levels versus 4.3 (SD 1.2) for uninfected controls ( p = .002). This difference was largely driven by differences in blood pressure, blood glucose, and diet. In multivariable-adjusted linear regression models, each additional iCVH metric at an ideal level was associated with a significant 0.024mm decrease in CCIMT ( p < .001).HIV-infected persons on ART in rural Uganda had more iCVH metrics at ideal levels than uninfected persons. The difference appeared driven by factors that are putatively influenced by access to routine medical care. Composite scores of iCVH metrics were associated with subclinical atherosclerosis and more predictive of atherosclerosis for uninfected persons.Item Internalized stigma, depressive symptoms, and the modifying role of antiretroviral therapy: A cohort study in rural Uganda(SSM-Mental Health, 2021) Bebell, Lisa M.; Kembabazi, Annet; Musinguzi, Nicholas; Martin, Jeffrey N.; Hunt, Peter W.; Boum, Yap; O'Laughlin, Kelli N.; Muzoora, Conrad; Haberer, Jessica E.; Mwebesa, Bosco Bwana; Bangsberg, David R.; Siedner, Mark J.; Tsai, Alexander C.Depression affects over 40% of people with HIV (PHIV) in low- and middle-income countries, and over half of PHIV report HIV related internalized stigma. However, few longitudinal studies of PHIV have examined the relationship between HIV-related stigma and depression. Data were analyzed from the 2007-15 Uganda AIDS Rural Treatment Outcomes (UARTO) Study, a cohort of 454 antiretroviral therapy (ART)-naïve PHIV (68% women) starting ART. Our primary outcome was depression symptom severity over the first two years of ART, measured using a locally adapted version of the Hopkins Symptom Checklist; our primary exposure was the 6-item Internalized AIDS-Related Stigma Scale. Both scores were measured at enrollment and at quarterly follow-up visits. We fit linear generalized estimating equations (GEE) regression models to estimate the association between stigma and depression symptom severity, adjusting for potential confounders. We included a stigma timeproduct term to assess the modifying effect of ART on the association between internalized stigma and depression symptom severity. UARTO participants had a median age of 32 years and median enrollment CD4 count of 217 cells/mm3. Both depression symptom severity and internalized stigma declined on ART, particularly during the first treatment year. In multivariable regression models, depression symptom severity was positively associated with internalized stigma (b ¼ 0.03; 95% confidence interval [CI], 0.02 to 0.04) and negatively associated with ART duration >6 months (b ¼ 0.16; 95% CI, 0.19 to 0.13). The estimated product term coefficient was negative and statistically significant (P ¼ 0.004), suggesting that the association between internalized stigma and depression symptom severity weakened over time on ART. Thus, in this large cohort of PHIV initiating ART in rural Uganda, depression symptom severity was associated with internalized stigma but the association declined with time on ART. These findings underscore the potential value of ART as a stigma reduction intervention for PHIV, particularly during early treatment.Item Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda(AIDS (London, England), 2014) Weiser, Sheri D.; Palar, Kartika; Frongillo, Edward A.; Tsai, Alexander C.; Kumbakumba, Elias; dePee, Saskia; Hunta, Peter W.; Ragland, Kathleen; Martin, Jeffrey; Bangsber, David R.Food insecurity is a potentially important barrier to the success of antiretroviral therapy (ART) programs in resource-limited settings. We undertook a longitudinal study in rural Uganda to estimate the associations between food insecurity and HIV treatment outcomes. Longitudinal cohort study. Participants were from the Uganda AIDS Rural Treatment Outcomes study and were followed quarterly for blood draws and structured interviews. We measured food insecurity with the validated Household Food Insecurity Access Scale. Our primary outcomes were: ART nonadherence (adherence <90%) measured by visual analog scale; incomplete viral load suppression (>400 copies/ml); and low CD4þ T-cell count (<350 cells/ml). We used generalized estimating equations to estimate the associations, adjusting for socio-demographic and clinical variables.Item Low population prevalence of atrial fibrillation in rural Uganda: A community-based cross-sectional study(International journal of cardiology, 2018) Muthalaly, Rahul G.; Koplan, Bruce A.; Albano, Alfred; North, Crystal; Campbell, Jeffrey I.; Kakuhikire, Bernard; Vořechovská, Dagmar; Kraemer, John D.; Tsai, Alexander C.; Siedner, Mark J.Atrial fibrillation (AF) is a major risk factor for stroke, which is the leading cause of cardiovascular mortality in sub-Saharan Africa. However, there is limited population-based epidemiological data on AF in sub-Saharan Africa. We sought to estimate the prevalence and correlates of AF in rural Uganda.We conducted a cross-sectional study using community health fairs in 2015 targeting eight villages in rural Uganda. Study participants completed a medical history, a clinical exam, blood collection, and 12‑lead electrocardiographic (ECG) screening. Of 1814 participants enrolled in a parent cohort study that includes 98% of adults residing in the geographic area, 856 attended a health fair and were included in this study. Our primary outcome was AF or atrial flutter. We modelled population prevalence of the outcome with inverse probability of treatment weighting using data collected from the full population.856 (47.2%) adults in the area attended a health fair and were included in the analysis. Health fair attendees were older (42 vs 34 years, P < 0.0001), in worse self-reported health (P < 0.0001) and more likely to be female (62% vs 49%, P < 0. 0001) compared with non-attendees. After applying weights, the estimated population mean age was 37.7 ± 14.9 years. 15% of the population was overweight or obese and 1.9% had left atrial enlargement on ECG. Despite this, the weighted estimate of AF was 0% (95%CI 0–0.54%).AF appears less prevalent in rural Uganda than in developed countries. The explanations for this finding may be genetic, environmental or related to survivorship bias.Item Lung function and atherosclerosis: a cross‑sectional study of multimorbidity in rural Uganda(BMC pulmonary medicine, 2022) Gilbert, Rebecca F.; Cichowitz, Cody; Bibangambah, Prossy; Kim, June‑Ho; Hemphill, Linda C.; Yang, Isabelle T.; Sentongo, Ruth N.; Kakuhikire, Bernard; Christiani, David C.; Tsai, Alexander C.; Okello, Samson; Siedner, Mark J.; North, Crystal M.Chronic obstructive pulmonary disease (COPD) is a leading cause of global mortality. In high-income settings, the presence of cardiovascular disease among people with COPD increases mortality and complicates longitudinal disease management. An estimated 26 million people are living with COPD in sub-Saharan Africa, where risk factors for co-occurring pulmonary and cardiovascular disease may differ from high-income settings but remain uncharacterized. As non-communicable diseases have become the leading cause of death in sub-Saharan Africa, defining multimorbidity in this setting is critical to inform the required scale-up of existing healthcare infrastructure. Methods: We measured lung function and carotid intima media thickness (cIMT) among participants in the UGANDAC Study. Study participants were over 40 years old and equally divided into people living with HIV (PLWH) and an age- and sex-similar, HIV-uninfected control population. We fit multivariable linear regression models to characterize the relationship between lung function (forced expiratory volume in one second, FEV1) and pre-clinical atherosclerosis (cIMT), and evaluated for effect modification by age, sex, smoking history, HIV, and socioeconomic status. Results: Of 265 participants, median age was 52 years, 125 (47%) were women, and 140 (53%) were PLWH. Most participants who met criteria for COPD were PLWH (13/17, 76%). Median cIMT was 0.67 mm (IQR: 0.60 to 0.74), which did not differ by HIV serostatus. In models adjusted for age, sex, socioeconomic status, smoking, and HIV, lower FEV1 was associated with increased cIMT (β = 0.006 per 200 mL FEV1 decrease; 95% CI 0.002 to 0.011, p = 0.01). There was no evidence that age, sex, HIV serostatus, smoking, or socioeconomic status modified the relationship between FEV1 and cIMT. Conclusions: Impaired lung function was associated with increased cIMT, a measure of pre-clinical atherosclerosis, among adults with and without HIV in rural Uganda. Future work should explore how co-occurring lung and cardiovascular disease might share risk factors and contribute to health outcomes in sub-Saharan Africa.