Modern contraceptive use among postpartum women living with HIV attending mother baby care points in Kabarole District, Uganda

Background: Preventing unintended pregnancies among women living with HIV is important for improving maternal and child health outcomes. Despite multiple contacts between postpartum women and healthcare providers at health facilities, modern contraceptive use during postpartum period remains low even among women with intentions to limit or delay childbearing. We estimated postpartum modern contraceptive use, unmet need and factors associated with modern contraceptive use among HIV positive women attending mother-baby HIV care points. Methods: We conducted a cross-sectional study, between April and May 2016, among HIV positive women attending postpartum care at six health facilities in Kabarole district, Uganda. Health facilities were stratified by level prior to selecting participants using systematic sampling. We administered structured questionnaires to women who had delivered within the last two to 18 months. Women who reported current use of a modern method were categorized as modern contraceptive users. Women not using but wanted to stop childbearing or space childbirth by at least 2 years were considered to have unmet need for modern contraception. We estimated a modified Poisson regression model to examine variations in the use of modern methods by various characteristics of participants. Results: We interviewed 369 women. Forty percent of them were using a modern method, with injectables being the most widely used. A third (33%) of the women had unmet need for modern methods, with unmet need for spacing (24%) being higher than for limiting births (9%). Modern contraceptive use was significantly higher among women who had delivered seven or more months earlier (Adj.PR = 2.02; CI: 1.49, 2.74); women who were counseled on family planning during antenatal care (Adj.PR = 1.53; CI: 1.07, 2.18); those who obtained methods through the care points (Adj.PR =2.27; CI: 1.32, 3.90); and those who jointly made decisions regarding childbearing with their partners (Adj.PR = 1.49; CI: 1.02, 2.17). Conclusion: Use of modern contraceptives was low while unmet need was high among postpartum women living with HIV. The findings suggest that there are gaps which indicate the need to strengthen contraceptive service delivery at these care-points. Providing family planning counseling early would improve uptake of contraception upon resumption of menses and sexual activity.publishedVersio

Contraceptive Uptake Among Married Women in Uganda: Does Empowerment Matter?

Although contraceptive prevalence increased from 24% to 30% between 2006 and 2011, this uptake is still below global level of 62% and low levels of women empowerment could be a factor. Data was extracted from 2011 UDHS to examine associations between women’s empowerment and contraceptive uptake. We developed four empowerment indices symbolising economic and social empowerment, established associations between them and contraceptive use. Most women (83%) were from the rural areas and 61% were married for 10+ years. Most (59%) scored low on power over earnings and domestic violence indices. All indices independently were positively associated with contraceptive use, but only the reproductive health rights index was significant before (OR 2.13, 95% CI; 1.52-2.98) and after adjusting for background characteristics (AOR 1.72, 95% CI; 1.07-2.73). Empowered women were more likely to use contraceptives. More efforts in sensitisation of women about their sexual and reproductive health rights as well as ensuring more control over their earnings.

Low-level viraemia: An emerging concern among people living with HIV in Uganda and across sub-Saharan Africa.

Attaining viral load (VL) suppression for over 95% of the people living with HIV on antiretroviral therapy is a fundamental step in enabling Uganda and other sub-Saharan African countries to achieve global Sustainable Development Goal targets to end the HIV/AIDS epidemic by 2030. In line with the 2013 World Health Organization recommendations, several sub-Saharan African countries, including Uganda, use a threshold of 1000 HIV viral RNA copies/mL to determine HIV viral non-suppression. The United States Centers for Disease Control and Prevention and the International Association of Providers of AIDS Care deem this threshold very high, and hence recommend using 200 copies/mL to determine viral non-suppression. Using 1000 copies/mL as a threshold ignores people living with HIV who have low-level viraemia (LLV; HIV VL of at least 50 copies/mL but less than 1000 copies/mL). Despite the 2021 World Health Organization recommendations of using intensive adherence counselling for people living with HIV with LLV, several sub-Saharan African countries have no interventions to address LLV. However, recent studies have associated LLV with increased risks of HIV drug resistance, virologic failure and transmission. The purpose of this narrative review is to provide insights on the emerging concern of LLV among people living with HIV receiving antiretroviral therapy in sub-Saharan Africa. The review also provides guidance for Uganda and other sub-Saharan African countries to implement immediate appropriate interventions like intensive adherence counselling, reducing VL thresholds for non-suppression and conducting more research to manage LLV which threatens progress towards ending HIV by 2030

Prototype Positive Control Wells for Malaria Rapid Diagnostic Tests: Prospective Evaluation of Implementation Among Health Workers in Lao People's Democratic Republic and Uganda.

Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis, but lack of quality control at point of care restricts trust in test results. Prototype positive control wells (PCW) containing recombinant malaria antigens have been developed to identify poor-quality RDT lots. This study assessed community and facility health workers' (HW) ability to use PCWs to detect degraded RDTs, the impact of PCW availability on RDT use and prescribing, and preferred strategies for implementation in Lao People's Democratic Republic (Laos) and Uganda. A total of 557 HWs participated in Laos (267) and Uganda (290). After training, most (88% to ≥ 99%) participants correctly performed the six key individual PCW steps; performance was generally maintained during the 6-month study period. Nearly all (97%) reported a correct action based on PCW use at routine work sites. In Uganda, where data for 127,775 individual patients were available, PCW introduction in health facilities was followed by a decrease in antimalarial prescribing for RDT-negative patients ≥ 5 years of age (4.7-1.9%); among community-based HWs, the decrease was 12.2% (P < 0.05) for all patients. Qualitative data revealed PCWs as a way to confirm RDT quality and restore confidence in RDT results. HWs in malaria-endemic areas are able to use prototype PCWs for quality control of malaria RDTs. PCW availability can improve HWs' confidence in RDT results, and benefit malaria diagnostic programs. Lessons learned from this study may be valuable for introduction of other point-of-care diagnostic and quality-control tools. Future work should evaluate longer term impacts of PCWs on patient management

Prototype positive control wells for malaria rapid diagnostic tests: Prospective evaluation of implementation among health workers in Lao People's Democratic Republic and Uganda

Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis, but lack of quality control at point of care restricts trust in test results. Prototype positive control wells (PCW) containing recombinant malaria antigens have been developed to identify poor-quality RDT lots. This study assessed community and facility health workers' (HW) ability to use PCWs to detect degraded RDTs, the impact of PCW availability on RDT use and prescribing, and preferred strategies for implementation in Lao People's Democratic Republic (Laos) and Uganda. A total of 557 HWs participated in Laos (267) and Uganda (290). After training, most (88% to ≥ 99%) participants correctly performed the six key individual PCW steps; performance was generally maintained during the 6-month study period. Nearly all (97%) reported a correct action based on PCW use at routine work sites. In Uganda, where data for 127,775 individual patients were available, PCW introduction in health facilities was followed by a decrease in antimalarial prescribing for RDT-negative patients ≥ 5 years of age (4.7–1.9%); among community-based HWs, the decrease was 12.2% (P < 0.05) for all patients. Qualitative data revealed PCWs as a way to confirm RDT quality and restore confidence in RDT results. HWs in malaria-endemic areas are able to use prototype PCWs for quality control of malaria RDTs. PCW availability can improve HWs' confidence in RDT results, and benefit malaria diagnostic programs. Lessons learned from this study may be valuable for introduction of other point-of-care diagnostic and quality-control tools. Future work should evaluate longer term impacts of PCWs on patient management

Male circumcision, sexual risk behaviour and HIV infection in Uganda. A mixed methods study among men age 15-59 years

Introduction: HIV/AIDS is a significant public health threat, especially in the sub Saharan African region. Enormous global efforts to control and prevent new infections are still needed on top of managing the huge number of over 36 million people living with the virus. Transmission through heterosexual intercourse remains the main contributor to the HIV epidemic in sub Saharan Africa. The WHO in 2007 recommended adoption of safe male circumcision (SMC) as part of the comprehensive HIV prevention interventions. However, like other risk reduction interventions, SMC is prone to challenges when implemented at such large-scale population levels. Behavioural risk compensation and, sociocultural beliefs and misconceptions in the post-circumcision period may affect successful implementation. Therefore, it is prudent to explore the existence of risk compensation and the beliefs that may shape sexual behaviour of men both before and after circumcision, so as to contribute to the success of the SMC programme scale-up. General objective: To estimate the associations of male circumcision with sexual risk behaviour and HIV prevalence before and just after the national scale up of the safe male circumcision (SMC) programme in Uganda, and to understand the sexual behaviour choices among men circumcised under the SMC programme in Wakiso district, Uganda. Methods: A mixed method study was conducted in Uganda that included an analysis of the Uganda AIDS Indicator surveys of 2004 and 2011 (papers I and II), and a qualitative sub study in 2015 and 2016. The two surveys had nationally representative samples and employed a two-stage stratified cluster sampling design. The analysis in paper I is based on data from 14,875 (6,906 in 2004 and 7,969 in 2011) circumcised and uncircumcised men, while paper II includes 5,776 uncircumcised men from the 2011 survey alone. Both samples are of men who reported to ever have had sex and were aged 15-59 years. In paper I, the dependent variables were HIV sero-status obtained from blood sample tests in both surveys, and sexual risk behaviours, while the main independent variable was self-reported circumcision status. In paper II, willingness to be circumcised was the dependent variable while the sexual risk behaviours were the independent variables. In the qualitative sub study, SMC clients were enrolled and followed up after receiving services at health facilities in Wakiso district located in central Uganda (papers III and IV). In 2015 twenty-five participants were purposively selected from health facilities where they reported for voluntarily receive male circumcision. They were interviewed twice, just after circumcision and six months later. Baseline indepth interview topics included discussions of motives for circumcision, influences on the decision, sexual behaviours, experiences with health education received and any known beliefs. Follow-up interview topics included experiences with healing, beliefs and post circumcision sexual behaviours. Results: Circumcised men reported higher prevalence of all sexual risk behaviours than uncircumcised men, except for transactional sex. Use of condoms with the last non-marital sexual partner among circumcised men was lower in the 2011 survey (PR 0.88; 95% CI: 0.79-0.99) compared with the 2004 survey (PR 1.07; 95% CI: 0.98- 1.18), but there were no other statistically significant changes in sexual risk behaviours between the two surveys. Circumcised men were less likely to test HIV positive than the uncircumcised in both surveys, (PR 0.63; 95% CI: 0.48-0.82) in 2004 and (PR 0.62; 95% CI: 0.49-0.80) in 2011 (paper I). Willingness to be circumcised was higher in uncircumcised men reporting multiple partners (PR 1.19; 95% CI: 1.11-1.29), non-marital sex with (PR 1.71; 95% CI: 1.59-1.85) and without a condom (PR 1.47; 95% CI: 1.35-1.59), or transactional sex (PR 1.61; 95% CI: 1.39- 1.87) in the 2011 survey (paper II) compared to those who did not report these risk behaviours. Findings from the qualitative study showed that the important factors influencing men to opt for circumcision were female sexual partners and a perceived need to reduce HIV transmission risk. According to participants’ reports, emphasis was mainly put on the immediate problems of wound care and the surgical procedure during health education for circumcision clients at health facilities, and less on post circumcision sexual behaviour. All the men, however, were aware that circumcision only offers partial risk reduction for HIV infection (paper III). In the baseline interviews, the men talked about beliefs that could influence their sexual behaviour, while in the follow up interviews they discussed how these had indeed shaped their behaviour after circumcision. All men had heard that it was important that the initial sexual intercourse post circumcision was with someone else other than the stable partner. Some of the men strongly believed in this and consequently ended up engaging in one-off sex without using condoms. There was also some misunderstanding of what comprised complete wound healing, and indeed a few men had sex before the completion of the recommended abstinence period. Men also correctly believed that the risk of acquiring HIV remained even after SMC and as a result the majority continued to practice safe sexual behaviour such as maintaining one sexual partner or using condoms with extra marital partners (paper IV). Conclusion: The higher level of willingness to be circumcised among men reporting sexual risk behaviour may suggest that the early adopters of SMC were likely to be those in particular need of this additional HIV protective measure. There was no clear evidence of behavioural risk compensation after circumcision in the 2011 UAIS although sexual risk behaviours were more common among circumcised than uncircumcised men. The qualitative study indicated gaps in health education for clients at health facilities, with no attention being given by health care providers to detrimental beliefs influencing sexual risk behaviour decisions, yet these beliefs were widespread among men who were interviewed

Modern contraceptive use among postpartum women living with HIV attending mother baby care points in Kabarole District, Uganda

Background: Preventing unintended pregnancies among women living with HIV is important for improving maternal and child health outcomes. Despite multiple contacts between postpartum women and healthcare providers at health facilities, modern contraceptive use during postpartum period remains low even among women with intentions to limit or delay childbearing. We estimated postpartum modern contraceptive use, unmet need and factors associated with modern contraceptive use among HIV positive women attending mother-baby HIV care points. Methods: We conducted a cross-sectional study, between April and May 2016, among HIV positive women attending postpartum care at six health facilities in Kabarole district, Uganda. Health facilities were stratified by level prior to selecting participants using systematic sampling. We administered structured questionnaires to women who had delivered within the last two to 18 months. Women who reported current use of a modern method were categorized as modern contraceptive users. Women not using but wanted to stop childbearing or space childbirth by at least 2 years were considered to have unmet need for modern contraception. We estimated a modified Poisson regression model to examine variations in the use of modern methods by various characteristics of participants. Results: We interviewed 369 women. Forty percent of them were using a modern method, with injectables being the most widely used. A third (33%) of the women had unmet need for modern methods, with unmet need for spacing (24%) being higher than for limiting births (9%). Modern contraceptive use was significantly higher among women who had delivered seven or more months earlier (Adj.PR = 2.02; CI: 1.49, 2.74); women who were counseled on family planning during antenatal care (Adj.PR = 1.53; CI: 1.07, 2.18); those who obtained methods through the care points (Adj.PR =2.27; CI: 1.32, 3.90); and those who jointly made decisions regarding childbearing with their partners (Adj.PR = 1.49; CI: 1.02, 2.17). Conclusion: Use of modern contraceptives was low while unmet need was high among postpartum women living with HIV. The findings suggest that there are gaps which indicate the need to strengthen contraceptive service delivery at these care-points. Providing family planning counseling early would improve uptake of contraception upon resumption of menses and sexual activity

Perceptions, Practices, and Mother’s Willingness to Provide Meconium for Use in the Assessment of Environmental Exposures among Children in Mukono and Pallisa Districts, Uganda

Presence of biomarkers or metabolites is assessed in various human biospecimens including meconium in the investigation of exposures to environmental contaminants. This study gathered data on the perceptions and practices of mothers in two rural districts of Uganda concerning meconium and their willingness to provide meconium from their babies for research purposes. The study reveals a wide range of perceptions and beliefs around meconium as well as a number of associated taboos and practices. Many participants noted that meconium could be used to detect ailments among newborns based on its appearance. Practices and beliefs included using it to prevent stomach discomfort and other ailments of newborns, as a means to confirm paternity and initiate the child into the clan as well as facilitating father-child bonding that included ingestion of meconium by the fathers. Most mothers indicated scepticism in accepting to provide meconium for research purposes and had fears of unscrupulous people disguising as researchers and using meconium to harm their children. However, some were willing to provide meconium, if it helped to detect ailments among their children. These perceptions and practices may negatively influence mothers’ willingness to participate in meconium study. However, through provision of educational and behaviour change interventions, mothers’ willingness to participate in a meconium study can be improved