Adaptation of the client diagnostic questionnaire for East Africa

Research increasingly involves cross-cultural work with non-English-speaking populations, necessitating translation and cultural validation of research tools. This paper describes the process of translating and criterion validation of the Client Diagnostic Questionnaire (CDQ) for use in a multisite study in Kenya and Uganda. The English CDQ was translated into Swahili, Dholuo (Kenya) and Runyankole/Rukiga (Uganda) by expert translators. The translated documents underwent face validation by a bilingual committee, who resolved unclear statements, agreed on final translations and reviewed back translations to English. A diagnostic interview by a mental health specialist was used for criterion validation, and Kappa statistics assessed the strength of agreement between non-specialist scores and mental health professionals’ diagnoses. Achieving semantic equivalence between translations was a challenge. Validation analysis was done with 30 participants at each site (median age 32.3 years (IQR = (26.5, 36.3)); 58 (64.4%) female). The sensitivity was 86.7%, specificity 64.4%, positive predictive value 70.9% and negative predictive value 82.9%. Diagnostic accuracy by the non-specialist was 75.6%. Agreement was substantial for major depressive episode and positive alcohol (past 6 months) and alcohol abuse (past 30 days). Agreement was moderate for other depressive disorders, panic disorder and psychosis screen; fair for generalized anxiety, drug abuse (past 6 months) and Post Traumatic Stress Disorder (PTSD); and poor for drug abuse (past 30 days). Variability of agreement between sites was seen for drug use (past 6 months) and PTSD. Our study successfully adapted the CDQ for use among people living with HIV in East Africa. We established that trained non-specialists can use the CDQ to screen for common mental health and substance use disorders with reasonable accuracy. Its use has the potential to increase case identification, improve linkage to mental healthcare, and improve outcomes. We recommend further studies to establish the psychometric properties of the translated tool

Empiric Deworming and CD4 Count Recovery in HIV-Infected Ugandans Initiating Antiretroviral Therapy

Background: There is conflicting evidence on the immunologic benefit of treating helminth co-infections (“deworming”) in HIV-infected individuals. Several studies have documented reduced viral load and increased CD4 count in antiretroviral therapy (ART) naïve individuals after deworming. However, there are a lack of data on the effect of deworming therapy on CD4 count recovery among HIV-infected persons taking ART. Methodology/Principal Findings To estimate the association between empiric deworming therapy and CD4 count after ART initiation, we performed a retrospective observational study among HIV-infected adults on ART at a publicly operated HIV clinic in southwestern Uganda. Subjects were assigned as having received deworming if prescribed an anti-helminthic agent between 7 and 90 days before a CD4 test. To estimate the association between deworming and CD4 count, we fit multivariable regression models and analyzed predictors of CD4 count, using a time-by-interaction term with receipt or non-receipt of deworming. From 1998 to 2009, 5,379 subjects on ART attended 21,933 clinic visits at which a CD4 count was measured. Subjects received deworming prior to 668 (3%) visits. Overall, deworming was not associated with a significant difference in CD4 count in either the first year on ART (β = 42.8; 95% CI, −2.1 to 87.7) or after the first year of ART (β = −9.9; 95% CI, −24.1 to 4.4). However, in a sub-analysis by gender, during the first year of ART deworming was associated with a significantly greater rise in CD4 count (β = 63.0; 95% CI, 6.0 to 120.1) in females. Conclusions/Significance: Empiric deworming of HIV-infected individuals on ART conferred no significant generalized benefit on subsequent CD4 count recovery. A significant association was observed exclusively in females and during the initial year on ART. Our findings are consistent with recent studies that failed to demonstrate an immunologic advantage to empirically deworming ART-naïve individuals, but suggest that certain sub-populations may benefit

A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study

Background: Up to 50 % of HIV-infected persons in sub-Saharan Africa are lost from care between HIV diagnosis and antiretroviral therapy (ART) initiation. Structural barriers, including cost of transportation to clinic and poor communication systems, are major contributors. Methods: We conducted a prospective, pragmatic, before-and-after clinical trial to evaluate a combination mobile health and transportation reimbursement intervention to improve care at a publicly operated HIV clinic in Uganda. Patients undergoing CD4 count testing were enrolled, and clinicians selected a result threshold that would prompt early return for ART initiation or further care. Participants enrolled in the pre-intervention period (January – August 2012) served as a control group. Participants in the intervention period (September 2012 – November 2013) were randomized to receive daily short message service (SMS) messages for up to seven days in one of three formats: 1) messages reporting an abnormal result directly, 2) personal identification number-protected messages reporting an abnormal result, or 3) messages reading “ABCDEFG” to confidentially convey an abnormal result. Participants returning within seven days of their first message received transportation reimbursements (about $6USD). Our primary outcomes of interest were time to return to clinic and time to ART initiation. Results: There were 45 participants in the pre-intervention period and 138 participants in the intervention period (46, 49, and 43 in the direct, PIN, and coded groups, respectively) with low CD4 count results. Median time to clinic return was 33 days (IQR 11–49) in the pre-intervention period and 6 days (IQR 3–16) in the intervention period (P < 0.001); and median time to ART initiation was 47 days (IQR 11–75) versus 12 days (IQR 5–19), (P < 0.001). In multivariable models, participants in the intervention period had earlier return to clinic (AHR 2.32, 95 %CI 1.53 to 3.51) and earlier time to ART initiation (AHR 2.27, 95 %CI 1.38 to 3.72). All three randomized message formats improved time to return to clinic and time to ART initiation (P < 0.01 for all comparisons versus the pre-intervention period). Conclusions: A combination of an SMS laboratory result communication system and transportation reimbursements significantly decreased time to clinic return and time to ART initiation after abnormal CD4 test results. Trial registrations Clinicaltrials.gov NCT01579214, approved 13 April 2012. Electronic supplementary material The online version of this article (doi:10.1186/s12916-015-0397-1) contains supplementary material, which is available to authorized users

Population genetic structure of the bean leaf beetle Ootheca mutabilis (Coleoptera: Chrysomelidae) in Uganda

Bean leaf beetle (BLB) (Ootheca mutabilis) has emerged as an important bean pest in Uganda, leading to devastating crop losses. There is limited information on the population genetic structure of BLB despite its importance. In this study, novel microsatellite DNA markers and the partial mitochondrial cytochrome oxidase subunit I (mtCOI) gene sequences were used to analyze the spatial population genetic structure, genetic differentiation and haplotype diversity of 86 O. mutabilis samples from 16 (districts) populations. We identified 19,356 simple sequence repeats (SSRs) (mono, di-, tri-, tetra-, penta-, and hexa-nucleotides) of which 81 di, tri and tetra-nucleotides were selected for primer synthesis. Five highly polymorphic SSR markers (4–21 alleles, heterozygosity 0.59–0.84, polymorphic information content (PIC) 50.13–83.14%) were used for this study. Analyses of the 16 O. mutabilis populations with these five novel SSRs found nearly all the genetic variation occurring within populations and there was no evidence of genetic differentiation detected for both types of markers. Also, there was no evidence of isolation by distance between geographical and genetic distances for SSR data and mtCOI data except in one agro-ecological zone for mtCOI data. Bayesian clustering identified a signature of admixture that suggests genetic contributions from two hypothetical ancestral genetic lineages for both types of markers, and the minimum-spanning haplotype network showed low differentiation in minor haplotypes from the most common haplotype with the most common haplotype occurring in all the 16 districts. A lack of genetic differentiation indicates unrestricted migrations between populations. This information will contribute to the design of BLB control strategie

Parasitoid Distribution and Parasitism of the Fall Armyworm <i>Spodoptera frugiperda</i> (Lepidoptera: Noctuidae) in Different Maize Producing Regions of Uganda

The fall armyworm (FAW) Spodoptera frugiperda (J.E. Smith) (Lepidoptera: Noctuidae) has successfully invaded Africa, where it has significantly impacted maize and sorghum production. Management of FAW in Africa predominantly relies on synthetic insecticides, which are expensive, and negatively impact the environment and beneficial insects. We, therefore, conducted field surveys in Uganda in 2017 and 2019 to identify egg and larval parasitoids of FAW for possible use in integrated pest management (IPM) programs. Parasitoids were identified by their mitochondrial DNA cytochrome c oxidase subunit 1 (mtCOI) gene sequences. We identified 13 parasitoid species belonging to three families of Hymenoptera: Platygastridae, Braconidae and Ichneumonidae, as well as one Dipteran family (Tachinidae). Coccygidium spp. and Chelonus bifoveolatus were the most abundant and widely distributed parasitoids. Overall, parasitism averaged 9.2% and ranged from 3.1% to 50% in 2017, and 0.8% to 33% in 2019. Parasitism by Sturmiopsis parasitica, Diolcogaster sp., and Cotesia flavipes on FAW in maize crops are reported for the first time. Our results suggest high biological diversity of FAW parasitoids, which should be exploited in the IPM of the FAW in Uganda

Implementation and Operational Research

BackgroundThe uptake of intensified active TB case-finding among HIV-infected patients using symptom screening is not well understood. We evaluated the rate and completeness of each interim step in the TB pulmonary "diagnostic cascade" to understand real-world barriers to active TB case detection.MethodsWe conducted a cohort analysis of new, antiretroviral therapy-naive, HIV-infected patients who attended a large HIV clinic in Mbarara, Uganda (March 1, 2012-September 30, 2013). We used medical records to extract date of completion of each step in the diagnostic cascade: symptom screen, order, collection, processing, and result. Factors associated with lack of sputum order were evaluated using multivariate Poisson regression and chart review of 50 screen-positive patients.ResultsOf 2613 patients, 2439 (93%) were screened for TB and 682 (28%) screened positive. Only 90 (13.2%) had a sputum order. Of this group, 83% completed the diagnostic cascade, 13% were diagnosed with TB, and 50% had a sputum result within 1 day of their visit. Sputum ordering was associated with WHO stage 3 or 4 HIV disease and greater number of symptoms. The main identifiable reasons for lack of sputum order in chart review were treatment of presumed malaria (51%) or bacterial infection (43%).ConclusionsThe majority of newly enrolled HIV-infected patients who screened positive for suspected TB did not have a sputum order, and those who did were more likely to have more symptoms and advanced HIV disease. Further evaluation of provider behavior in the management of screen-positive patients could improve active TB case detection rates

Genetic analyses and detection of point mutations in the acetylcholinesterase-1 gene associated with organophosphate insecticide resistance in fall armyworm (Spodoptera frugiperda) populations from Uganda

Abstract Background The fall armyworm (FAW), Spodoptera frugiperda; J.E. Smith (Lepidoptera: Noctuidae), is now an economically important pest that causes huge losses to maize productivity in sub-Saharan Africa. Variations in sub-population genetics and the processes of rapid adaptation underpinning the invasion remain unclear. For this, the genetic identity and diversity of FAW populations in Uganda were revealed by sequencing 87 samples (collected across the country). Based on the partial mitochondrial cytochrome oxidase I (COI) gene polymorphisms, we further examined the mitochondrial haplotype configuration and compared the FAW in Uganda with sequences from other parts of the world. The molecular target for organophosphate and carbamate resistance, acetylcholinesterase, was also investigated. Results Analysis of the partial COI gene sequences showed the presence of both rice (predominant) and corn strain haplotypes, with a haplotype diversity of 0.382. Based on the COI marker, pairwise difference distribution analyses, and neutrality tests, showed that the FAW populations in Uganda and the rest of Africa are evolving neutrally, but those in America and Asia are undergoing expansion. Our findings support observations that invasive FAW populations throughout the rest of Africa and Asia share a common origin. Sequencing of the S. frugiperda ace-1 gene revealed four amino acid substitutions, two of which (A201S and F290V) were previously shown to confer organophosphate resistance in both S. frugiperda and several other insect species. The other two previously reported new variations in positions g-396 and g-768, are presumed to be related to the development of insecticide resistance. Conclusions This research has increased our knowledge of the genetics of FAW in Uganda, which is critical for pest surveillance and the detection of resistance. However, due to the low gene polymorphism of COI, more evolutionary studies incorporating the Spodoptera frugiperda whole-genome sequence are required to precisely understand the FAW population dynamics, introduction paths, origin, and subsequent spread

Incidence and predictors of hypertension in adults with HIV-initiating antiretroviral therapy in south-western Uganda

ObjectiveThe successful scale-up of antiretroviral therapy (ART) in sub-Saharan Africa has led to increasing life expectancy, and thus increased risk of hypertension. We aimed to describe the incidence and predictors of hypertension in HIV patients receiving ART at a publicly funded clinic in rural Uganda.MethodsWe abstracted data from medical records of adult patients who initiated ART at an HIV clinic in south-western Uganda during 2010-2012. We defined hypertension as at least two consecutive clinical visits, with a SBP at least 140 mmHg and/or SBP of at least 90 mmHg, or prescription for an antihypertensive medication. We calculated the incidence of hypertension and fit multivariable Cox proportional-hazards models to identify predictors of hypertension.ResultsA total of 3389 patients initiated ART without a prior diagnosis of hypertension during the observation period. Over 3990 person-years of follow-up, 445 patients developed hypertension, for a crude incidence of 111.5/1000 (95% confidence interval 101.9-121.7) person-years. Rates were highest among men aged at least 40 years (158.8 per/1000 person-years) and lowest in women aged 30-39 years (80/1000 person-years). Lower CD4 cell count at ART initiation, as well as traditional risk factors including male sex, increasing age, and obesity, were independently associated with hypertension.ConclusionWe observed a high incidence of hypertension in HIV-infected persons on ART in rural Uganda, and increased risk with lower nadir CD4 cell counts. Our findings call for increased attention to screening of and treatment for hypertension, along with continued prioritization of early ART initiation

Behavioral Predictors of Intention to Use a Text Messaging Reminder System Among People Living With HIV in Rural Uganda: Survey Study

BackgroundThe expansion of cellular phones in sub-Saharan Africa spurred the development of SMS text message–based mobile health (mHealth) technology. Numerous SMS text message–based interventions have attempted to increase retention in care for people living with HIV in sub-Saharan Africa. Many of these interventions have failed to scale. Understanding theory-grounded factors leading to mHealth acceptability is needed to create scalable, contextually appropriate, and user-focused interventions to improve longitudinal HIV care for people living with HIV in sub-Saharan Africa. ObjectiveIn this study, we aimed to understand the relationship between constructs from the Unified Theory of Acceptance and Use of Technology (UTAUT), constructs identified in previous qualitative research, and behavioral intention to use a novel SMS text message–based mHealth intervention designed to improve care retention among people living with HIV initiating treatment in rural Uganda. MethodsWe conducted a survey of people living with HIV who were newly initiating HIV care in Mbarara, Uganda, and had agreed to use a novel SMS text message–based system that notified them of abnormal laboratory results and reminded them to return to the clinic. Survey items assessed behavioral intention to use the SMS text messaging system; constructs from UTAUT; and demographics, literacy, SMS text messaging experience, HIV status disclosure, and social support. We used factor analysis and logistic regression to estimate the relationships between UTAUT constructs and the behavioral intention to use the SMS text messaging system. ResultsA total of 249 participants completed the surveys, of whom 115 (46.2%) expressed high behavioral intention to use the SMS text messaging intervention. In a multivariable analysis, we found that performance expectancy (adjusted odds ratio [aOR] of the scaled factor score 5.69, 95% CI 2.64-12.25; P<.001), effort expectancy (aOR of the scaled factor score 4.87, 95% CI 1.75-13.51; P=.002), and social influence (measured as a 1-unit Likert score increase in the perception that clinical staff have been helpful in the use of the SMS text messaging program; aOR 3.03, 95% CI 1.21-7.54; P=.02) were significantly associated with high behavioral intention to use the SMS text messaging program. SMS text messaging experience (aOR/1-unit increase 1.48, 95% CI 1.11-1.96; P=.008) and age (aOR/1-year increase 1.07, 95% CI 1.03-1.13; P=.003) were also significantly associated with increased odds of high intention to use the system. ConclusionsPerformance expectancy, effort expectancy, and social influence, as well as age and SMS experience, were drivers of high behavioral intention to use an SMS text messaging reminder system among people living with HIV initiating treatment in rural Uganda. These findings highlight salient factors associated with SMS intervention acceptability in this population and indicate attributes that are likely to be key to the successful development and scaling of novel mHealth interventions

Detection of sister-species in invasive populations of the fall armyworm <i>Spodoptera frugiperda</i> (Lepidoptera: Noctuidae) from Uganda

<div><p>The fall armyworm (FAW) <i>Spodoptera frugiperda</i> (J. E. Smith) is a species native to the Americas. This polyphagous lepidopteran pest was first reported in Nigeria and the Democratic Republic of São Tomé and Principe in 2016, but its presence in eastern Africa has not been confirmed via molecular characterisation. In this study, FAW specimens from western and central Uganda were identified based on the partial mtDNA COI gene sequences, with mtDNA COI haplotypes matching those identified in Nigeria and São Tomé. In this study, we sequence an additional partial mtDNA Cyt <i>b</i> gene and also the partial mtDNA COIII gene in Ugandan FAW samples. We detected identical mitochondrial DNA haplotypes for both the mtDNA Cyt <i>b</i> and COI partial genes, while combining the mtDNA COI/Cyt <i>b</i> haplotypes and mtDNA COIII haplotypes enabled a new maternal lineage in the Ugandan corn-preferred FAW samples to be identified. Our results suggested that the African incursions of <i>S</i>. <i>frugiperda</i> involved at least three maternal lineages. Recent full genome, phylogenetic and microsatellite analyses provided evidence to support <i>S</i>. <i>frugiperda</i> as likely consisted of two sympatric sister species known as the corn-preferred and rice-preferred strains. In our Ugandan FAW populations, we identified the presence of mtDNA haplotypes representative of both sister species. It is not known if both FAW sister species were originally introduced together or separately, and whether they have since spread as a single population. Further analyses of additional specimens originally collected from São Tomé, Nigeria and throughout Africa would be required to clarify this issue. Importantly, our finding showed that the genetic diversity of the African corn-preferred FAW species is higher than previously reported. This potentially contributed to the success of FAW establishment in Africa. Furthermore, with the additional maternal lineages detected, there is likely an increase in paternal lineages, thereby increasing the diversity of the African FAW population. Knowledge of the FAW genetic diversity will be needed to assess the risks of introducing Bt-resistance traits and to understand the FAW incursion pathways into the Old World and its potential onward spread. The agricultural implications of the presence of two evolutionary divergent FAW lineages (the corn and the rice lineage) in the African continent are further considered and discussed.</p></div