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

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

Schistosomiasis infection in pre-school aged children in Uganda: a qualitative descriptive study to identify routes of exposure

Abstract Background Prevalence of schistosomiasis is high among children under five years in Uganda. Schistosomiasis control efforts over time have included periodic mass treatments in endemic areas for adults and school going children aged 5 years and above. This study explores behaviour practices of children age 2–4 years that increase the risk of schistosomiasis infection in this age group. Methods A qualitative descriptive study was conducted using in-depth interviews with 30 caregivers of children aged 2–4 years who tested positive for schistosomiasis in a national prevalence survey in 2017. Observations were done at water bodies where young children go with caretakers or other older children. The study was conducted in three Ugandan sub-regions of West Nile and East-central, and South-western with high, and low prevalence of schistosomiasis, respectively. Data were thematically analysed. Anonymised supporting photos from observations are also presented. Results Knowledge about schistosomiasis transmission was poor among caregivers, who concurrently had mixed right and wrong information. Reported avenues for contracting schistosomiasis included both correct: contact activities with infested water, and incorrect modes: contact with dirty water, sharing bathrooms, witchcraft, polluted air and contaminated food. The children in this study could have contracted schistosomiasis through the contact with infested water during activities such as bathing and playing, while their caregivers washed clothes, collected snail shells for poultry feeds, fetched water at the water bodies. These activities were reported by caregivers and observed in all study areas. Evidence of open defecation and urination in and near water bodies by adults and children was also observed. Conclusions Pre-school children age 2–4 years are at a high risk of exposure to schistosomiasis while caretakers conduct activities in infested water bodies. There is need for prevention interventions to target children in their early stages of life to control schistosomiasis in this vulnerable population

A comparison of sexual risk behaviours and HIV seroprevalence among circumcised and uncircumcised men before and after implementation of the safe male circumcision programme in Uganda

Background: Although male circumcision reduces the heterosexual HIV transmission risk, its effect may be attenuated if circumcised men increase sexual risk behaviours (SRB) due to perceived low risk. In Uganda information about the protective effects of circumcision has been publicly disseminated since 2007. If increased awareness of the protection increases SRB among circumcised men, it is likely that differences in prevalence of SRB among circumcised versus uncircumcised men will change over time. This study aimed at comparing SRBs and HIV sero-status of circumcised and uncircumcised men before and after the launch of the safe male circumcision programme. Methods: Data from the 2004 and 2011 Uganda AIDS Indicator Surveys (UAIS) were used. The analyses were based on generalized linear models, obtaining prevalence ratios (PR) as measures of association between circumcision status and multiple sexual partners, transactional sex, sex with non-marital partners, condom use at last non-marital sex, and HIV infection. In addition we conducted multivariate analyses adjusted for sociodemographic characteristics, and the multivariate models for HIV status were also adjusted for SRB. Results: Twenty six percent of men were circumcised in 2004 and 28 % in 2011. Prevalence of SRB was higher among circumcised men in both surveys. In the unadjusted analysis, circumcision was associated with having multiple sexual partners and non-marital partners. Condom use was not associated with circumcision in 2004, but in 2011 circumcised men were less likely to report condom use with the last non-marital partner. The associations between the other sexual risk behaviours and circumcision status were stable across the two surveys.” In both surveys, circumcised men were less likely to be HIV positive (Adj PR 0.55; CI: 0.41–0.73 in 2004 and Adj PR 0.64; CI: 0.49–0.83 in 2011). Conclusions: There was higher prevalence of SRBs among circumcised men in both surveys, but the only significant change from 2004 to 2011 was a lower prevalence of condom use among the circumcised. Nevertheless, HIV prevalence was lower among circumcised men. Targeted messages for circumcised men and their sexual partners to continue using condoms even after circumcision should be enhanced to avoid risk compensation

Uvula infections and traditional uvulectomy: Beliefs and practices in Luwero district, central Uganda.

Uvulitis is the inflammation and swelling of the uvula, usually associated with infection of nearby structures. Uvulitis can be treated symptomatically, using medication or in some cases with uvulectomy, the uvula surgical removal or shortening. Traditional uvulectomy by traditional practitioners has been practiced in Africa for ages, associated with adverse outcomes. Although there is no empirical evidence for the association between adverse outcomes and traditional uvulectomy in Uganda, anecdotal findings showed incidents of uvula infections following uvulectomy in central Uganda. While these findings also indicate that traditional uvulectomy is common, the community understanding of uvulitis, the beliefs and practices are not well understood. This qualitative study sought to understand beliefs and practices using interviews with community health workers, traditional uvulectomy clients, and traditional surgeons, and focus group discussions with community members. Transcribed data were analysed in Atlas.ti 9 using thematic analysis steps. The findings show that uvula infection, locally known as "Akamiro" and the associated traditional uvulectomy are common in Luwero and beyond. "Akamiro" was described as larger than the normal, the size of a chicken heart or a big pimple, visible when a child cries, with unknown causes. Symptoms included persistent cough, diarrhoea, vomiting, loss of appetite, inability to swallow and ultimately weight loss, swollen stomach, saliva overflow, fever, breathing and speech difficulty. Diagnosis was confirmed after seeking care from health workers or in consultation with significant others and finally the traditional surgeon; in a hierarchical pattern. Uvulectomy was conducted by traditional surgeons, with surgery lasting a few minutes, in the morning or after sun-set. Tools used were razor blades, reeds, strings, wires, sickle knives and spoons. Payment was flexible; cash or in-kind. Surgeons had immense community trust, including community health workers. Interventions to support persons with uvula infections need to address the health system weaknesses, and health education

Investigating the early impact of the Trump Administration's Global Gag Rule on sexual and reproductive health service delivery in Uganda.

BACKGROUND:The Global Gag Rule (GGR), reinstated by President Trump in January 2017, makes non-U.S. non-governmental organizations ineligible for U.S. foreign assistance if they provide access to or information about abortion. While evidence suggests previous iterations of the GGR negatively impacted sexual and reproductive health outcomes, no studies have quantitatively assessed the impacts of the Trump administration's GGR. METHODS:We constructed a panel dataset of facilities (76% public) using 2017/2018 Performance Monitoring and Accountability 2020 service delivery point (SDP) surveys in Uganda. Based on information from stakeholder meetings, we classified districts as more or less exposed to the GGR; 45% (N = 34) of study districts were classified as "more exposed", which corresponded to 145 "more exposed" and 142 "less exposed" health facilities in our sample. We assessed changes in provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, engagement with community health workers (CHWs), service integration, and quality of care from 2017 (pre-GGR) to 2018 (post-GGR). Multivariable regression models were estimated, and difference-in-differences impact estimators were determined by calculating predicted probabilities from interaction terms for exposure and survey round. FINDINGS:We observed no immediate impact of the GGR on the provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, service integration, or quality of care. We did observe a significant impact of the policy on the average number of CHWs, with "more exposed" facilities engaging 3.8 fewer CHWs post-GGR (95% CI:-7.31,-0.32). CONCLUSIONS:The reduction in CHWs could reduce contraceptive use and increase unintended pregnancies in Uganda. The lack of other significant findings may not be surprising given the short post-GGR observation window. Rapid organizational responses and stopgap funding from foreign governments may have mitigated any immediate impacts on service delivery in the short term. The true impact may not be felt for many years, as stopgap funding potentially ebbs and service providers adapt to new funding environments

Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys.

Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda