Traditional processing, microbial and physicochemical changes during fermentation of malwa

A survey was conducted to characterise production methods of malwa; a Ugandan traditional fermented millet beverage, in four divisions of Kampala district using a questionnaire. Lactobacillus and Lactococcus spp and coliforms were enumerated in the raw materials and during fermentation using standard microbiological methods. Changes in chemical parameters were determined using standard methods. Similarities in production methods were observed among the malwa producers. All producers germinated millet grains (2-3 days) to make green malt. The germinated grains were sun-dried for 2-3 days. Moistened millet flour was subjected to solid state pit fermentation for one week to produce acidified fermented dough. The acidified fermented dough was roasted over an open fire to produce roasted acidified dough. The duration of fermentation of malwa varied between 2 and 4 days. Only 5% of the producers practiced back slopping. Producers (90%) reported that consumers preferred sour malwa. Lactobacillus and Lactococcus spp numbers in the sour dough, roasted sour dough and green malt varied between 3.48 and 5.38, 2.02 and 2.60, and 4.45 and 6.25 log cfug–1 respectively. Coliforms in sour dough, roasted sour dough and green malt varied between 1.36 and 5.53 log cfug–1. Lactobacillus spp increased from 2.73 to 6.60 log cfu mL–1 whereas Lactococcus spp increased from 2.67 to 6.22 log cfu mL–1 during 72 h of fermentation. The greatest increase in numbers was observed during the first 24 h. Coliforms decreased from 2.80 to 1.19 log cfu mL–1after 24 h with a slight increase to 1.26 log cfu mL–1 after 48 h due to further addition of green malt. Coliforms were still detectable after 72 h. The pH decreased from 4.3 to 3.65 as titratable acidity increased from 0.69 to 1.47% lactic acid after 72 h of fermentation. Total soluble solids decreased from 17.7 to 7.7 oBrix during 72 h fermentation. Ethanol increased from 1.07 to 12% v\v. Carbohydrates and tannins decreased during germination and fermentation. Apparent increase in protein contentwas observed. The high numbers of Lactobacillus and Lactococcus spp and coliforms in the sour dough suggest their involvement in the solid state pit fermentation of millet flour. Higher numbers of Lactobacillus and Lactococcus spp in the green malt indicates that these organisms play a big role in the fermentation process of malwa.Key words: Lactococcus, Lactobacillus, Millet, Fermentation, Malw

“Vital”: HIV counselling and testing staff’s views of addressing mental health with HIV in Uganda

BACKGROUND: Mental health is linked to HIV outcomes, including linkage into care and adherence to medication. Integrated care for mental and physical health is recommended. HIV testing and counselling sessions represent an opportunity to implement interventions to address mental health, however it is first necessary to understand the roles, current practice, knowledge and attitudes of the testing and counselling staff. METHODS: This qualitative study used semi-structured interviews with HIV testing and counselling staff at four centres of a HIV healthcare provider charity in Uganda. Interviews focused on their current practice, perceptions of mental health and their role in supporting this, challenges of this work, training and support needs, and views of potential greater emphasis on mental health work in their role. Data were audio-recorded, transcribed verbatim, and analysed thematically. RESULTS: Data from twenty-one testing and counselling staff revealed five themes. Clients presented to counselling staff with needs spanning bio-psycho-social domains, where psychological health was intertwined with HIV management, medication adherence, and seen as "inseparable" from HIV itself. Mental health was largely thought about as "madness", identifiable from extreme behaviour. As such, common mental health problems of anxiety and depression were not often seen as part of mental health. Approaches to intervening with mental health were seen as behavioural, with some ideas about changing thinking styles. Participants demonstrated significant practice of common techniques to address mental health. Needs were identified for further training in suicide risk assessment and identification of depression, together with greater clinical supervision. Participants described significant conflict within their roles, particularly balancing time demands and need to achieve testing targets against the need to offer adequate mental health support to clients in need. CONCLUSIONS: HIV testing and counselling staff described a diverse role that already includes addressing mental health. Mental health is "vital" to their work, however the time needed to address it is at odds with current testing targets. They require more training and resources to effectively address mental health, which is vital to optimising HIV outcomes. Interventions to integrate mental health support into HIV testing and counselling sessions need to be further researched and optimised

Life expectancy of persons receiving combination antiretroviral therapy in low-income countries: a cohort analysis from Uganda

Little is known about the effect of combination antiretroviral therapy (cART) on life expectancy in sub-Saharan Africa

Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial

BACKGROUND: Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up ‘one-stop’ integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration. METHODS: The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner’s ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro). RESULTS: Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care. CONCLUSIONS: Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma. TRIAL REGISTRATION NUMBER: ISRCTN43896688

Women living with HIV, diabetes and/or hypertension multi-morbidity in Uganda: a qualitative exploration of experiences accessing an integrated care service

Purpose: Women experience a triple burden of ill-health spanning non-communicable diseases (NCDs), reproductive and maternal health conditions and human immunodeficiency virus (HIV) in sub-Saharan Africa. Whilst there is research on integrated service experiences of women living with HIV (WLHIV) and cancer, little is known regarding those of WLHIV, diabetes and/or hypertension when accessing integrated care. Our research responds to this gap. Design/methodology/approach: The INTE-AFRICA project conducted a pragmatic parallel arm cluster randomised trial to scale up and evaluate “one-stop” integrated care clinics for HIV-infection, diabetes and hypertension at selected primary care centres in Uganda. A qualitative process evaluation explored and documented patient experiences of integrated care for HIV, diabetes and/or hypertension. In-depth interviews were conducted using a phenomenological approach with six WLHIV with diabetes and/or hypertension accessing a “one stop” clinic. Thematic analysis of narratives revealed five themes: lay health knowledge and alternative medicine, community stigma, experiences of integrated care, navigating personal challenges and health service constraints. Findings: WLHIV described patient pathways navigating HIV and diabetes/hypertension, with caregiving responsibilities, poverty, travel time and cost and personal ill health impacting on their ability to adhere to multi-morbid integrated treatment. Health service barriers to optimal integrated care included unreliable drug supply for diabetes/hypertension and HIV linked stigma. Comprehensive integrated care is recommended to further consider gender sensitive aspects of care. Originality/value: This study whilst small scale, provides a unique insight into the lived experience of WLHIV navigating care for HIV and diabetes and/or hypertension, and how a “one stop” integrated care clinic can support them (and their children) in their treatment journeys

Strengthening integration of chronic care in Africa: protocol for the qualitative process evaluation of integrated HIV, diabetes and hypertension care in a cluster randomised controlled trial in Tanzania and Uganda.

INTRODUCTION: In sub-Saharan Africa, the burden of non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension, has increased rapidly in recent years, although HIV infection remains a leading cause of death among young-middle-aged adults. Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions. METHODS AND ANALYSIS: This protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors. ETHICS AND DISSEMINATION: Ethical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services. TRIAL REGISTRATION NUMBER: ISRCTN43896688; Pre-results

Lack of effectiveness of adherence counselling in reversing virological failure among patients on long-term antiretroviral therapy in rural Uganda.

OBJECTIVES: The current World Health Organization and Uganda Ministry of Health HIV treatment guidelines recommend that asymptomatic patients who have a viral load (VL) ≥ 1000 HIV-1 RNA copies/mL should receive adherence counselling and repeat VL testing before switching to second-line therapy. We evaluated the effectiveness of this strategy in a large HIV treatment programme of The AIDS Support Organisation Jinja in Jinja, Uganda. METHODS: We measured the HIV VL at enrolment, and for participants with VL ≥ 1000 copies/mL we informed them of their result, offered enhanced adherence counselling and repeated the VL measurement after 3 months. All blood samples with VL ≥ 1000 copies/mL were sequenced in the polymerase (pol) region, a 1257-bp fragment spanning the protease and reverse transcriptase genes. RESULTS: One thousand and ninety-one participants were enrolled in the study; 74.7% were female and the median age was 44 years [interquartile range (IQR) 39-50 years]. The median time on antiretroviral therapy (ART) at enrolment was 6.75 years (IQR 5.3-7.6 years) and the median CD4 cell count was 494 cells/μL (IQR 351-691 cells/μL). A total of 113 participants (10.4%) had VLs ≥ 1000 copies/mL and were informed of the VL result and its implications and given adherence counselling. Of these 113 participants, 102 completed 3 months of follow-up and 93 (91%) still had VLs ≥ 1000 copies/mL. We successfully genotyped HIV for 105 patients (93%) and found that 103 (98%) had at least one mutation: eight (7.6%) had only one mutation, 94 (89.5%) had two mutations and one sample (1%) had three mutations. CONCLUSIONS: In this study, enhanced adherence counselling was not effective in reversing virologically defined treatment failure for patients on long-term ART who had not previously had a VL test

The experience of “medicine companions” to support adherence to antiretroviral therapy: quantitative and qualitative data from a trial population in Uganda

Good adherence is critical for antiretroviral therapy (ART) in sub-Saharan Africa. We report on the characteristics of medicine companions (MCs) chosen by Ugandan patients enrolling on ART, and on how MCs were chosen, and what roles they played. Baseline data on MCs of 1453 participants in a randomized controlled trial comparing facility and home-based delivery of ART in Jinja, Uganda were analyzed. Textual data on experience with MCs were collected through in-depth interviews among a subsample of 40 trial participants equally divided by sex and trial arm. Significantly more women (71%) than men (29%) were recruited. The majority (75%) of women participants were either widowed (51%) or separated or divorced (24%), whereas most of the men (66%) were married. Women were most likely to choose a child as their MC while men were most likely to choose their spouse; 41% of women chose an MC under 21 compared with only 14% of men. Only 31% of married women chose their husband, compared with 66% of married men who chose their wife. Qualitative interviews suggested MCs proved useful for reminding and other supportive tasks in the first three months but were generally less essential by six months and beyond. Convenience, reliability, and trust were key considerations in choosing an MC. Children provided the only alternative for many unmarried women, but even some married women felt children made more reliable MCs than husbands. Participants who had disclosed their serostatus usually received drug-taking reminders from multiple household members. One participant in the qualitative sample with poor family relations delayed starting treatment due to unwillingness to identify an MC. MCs were generally welcome and useful in supporting early adherence. However, disclosure to an MC should not be a condition of obtaining treatment