An observational study in an urban Ugandan clinic comparing virological outcomes of patients switched from first-line antiretroviral regimens to second-line regimens containing ritonavir-boosted atazanavir or ritonavir-boosted lopinavir.

BACKGROUND: The World Health Organisation approved boosted atazanavir as a preferred second line protease inhibitor in 2010. This is as an alternative to the current boosted lopinavir. Atazanavir has a lower genetic barrier than lopinavir. We compared the virological outcomes of patients during the roll out of routine viral load monitoring, who had switched to boosted second- line regimens of either atazanavir or lopinavir. METHODS: This was a cross-sectional study involving adult patients at the Infectious Diseases Institute Kampala, Uganda started on a standard WHO recommended second-line regimen containing either boosted atazanavir or boosted lopinavir between 1 Dec 2014 and 31 July 2015.. Mantel -Haenszel chi square was used to test for the statistical significance of the odds of being suppressed (VL < 400 copies/ml) when on boosted atazanavir compared to boosted lopinavir after stratifying by duration on antiretroviral therapy (ART). Multivariate logistic regression analysis used to determine if the type of boosted protease inhibitor (bPI) was associated with virological outcome. RESULTS: Ninety (90) % on ATV/r and 83% on LPV/r had a VL less than 1000 copies/ml. The odds of being suppressed using the same viral load cut-off while on boosted atazanavir compared to boosted lopinavir was not statistically significant after stratifying for duration on ART (p = 0.09). In a multivariate analysis the type of bPI used was not a predictor of virological outcome (p = 0.60). CONCLUSIONS: Patients using the WHO recommended second-line of boosted atazanavir have comparable virological suppression to those on boosted lopinavir

Cryptococcal Antigenemia in Human Immunodeficiency Virus Antiretroviral Therapy-Experienced Ugandans With Virologic Failure.

BACKGROUND: Detectable serum or plasma cryptococcal antigen (CrAg) precedes symptomatic cryptococcal meningitis. The World Health Organization recommends CrAg screening for human immunodeficiency virus-positive persons with CD4 count <100 cells/μL initiating antiretroviral therapy (ART). However, an increasing proportion of patients with cryptococcosis are now ART experienced. Whether CrAg screening is cost-effective in those with virologic failure is unknown. METHODS: We retrospectively performed nationwide plasma CrAg testing among ART-experienced Ugandan adults with virologic failure (≥1000 copies/mL) using leftover plasma after viral load testing during September 2017-January 2018. For those who were CrAg positive, we obtained ART history, meningitis occurrence, and 6-month survival via medical records review. RESULTS: Among 1186 subjects with virologic failure, 35 (3.0%) were CrAg positive with median ART duration of 41 months (interquartile range, 10-84 months). Among 25 subjects with 6-month outcomes, 16 (64%) survived, 7 (28%) died, and 2 (8%) were lost. One survivor had suffered cryptococcal meningitis 2 years prior. Two others developed cryptococcal meningitis and survived. Five survivors were known to have received fluconazole. Thus, meningitis-free survival at 6 months was 61% (14/23). Overall, 91% (32/35) of CrAg-positive persons had viral load ≥5000 copies/mL compared with 64% (735/1151) of CrAg-negative persons (odds ratio, 6.0 [95% confidence interval, 1.8-19.8]; P = .001). CrAg prevalence was 4.2% (32/768) among those with viral loads ≥5000 copies/mL and 0.7% (3/419) among those with viral loads <5000 copies/mL. CONCLUSIONS: In addition to the CD4 threshold of <100 cells/μL, reflexive CrAg screening should be considered in persons failing ART in Uganda with viral loads ≥5000 copies/mL

Willingness to pay for an mHealth anti-retroviral therapy adherence and information tool: Transitioning to sustainability, Call for life randomised study experience in Uganda.

Funder: Johnson & Johnson Corporate Citizenship TrustINTRODUCTION: Evidence shows benefit of digital technology for people living with human immunodeficiency virus on antiretroviral therapy adherence and retention in care, however, scalability and sustainability have scarcely been evaluated. We assessed participants' willingness to pay a fee for mHealth "Call for life Uganda" support, a mobile-phone based tool with the objective to assess sustainability and scalability. METHODS: "Call for Life study", approved by Makerere University, School of Public Health research & ethics committee, at 2 sites in Uganda, evaluated a MoTech based software "CONNECT FOR LIFE™" mHealth tool termed "Call for life Uganda". It provides short messages service or Interactive Voice Response functionalities, with a web-based interface, allows a computer to interact with humans through use of voice and tones input via keypad. Participants were randomized at 1:1 ratio to Standard of Care or standard of care plus Call for life Uganda. This sends pill reminders, visit reminders, voice messages and self-reported symptom support. At study visits 18 and 24 months, through mixed method approach we assessed mHealth sustainability and scalability. Participants were interviewed on desire to have or continue adherence support and willingness to pay a nominal fee for tool. We computed proportions willing to pay (± 95% confidence interval), stratified by study arm and predictors of willingness to continue and to pay using multivariate logistic regression model backed up by themes from qualitative interviews. RESULTS: 95% of participants were willing to continue using C4LU with 77.8% willing to pay for the service. Persons receiving care at the peri-urban clinic (OR 3.12, 95% CI 1.43-9.11.86) and those with exposure to the C4LU intervention (OR 4.2, 95% CI 1.55-11.84) were more likely to continue and pay for the service. Qualitative interviews revealed mixed feelings regarding amounts to pay, those willing to pay, argued that since they have been paying for personal phone calls/messages, they should not fail to pay for Call for life. CONCLUSIONS: Payment for the service offers opportunities to scale up and sustain mHealth interventions which may not be priorities for government funding. A co-pay model could be acceptable to PLHIV to access mHealth services in low resource settings. Clinical Trial Number NCT02953080

Effects of rural–urban residence and education on intimate partner violence among women in Sub-Saharan Africa : a meta-analysis of health survey data

BACKGROUND: Intimate Partner Violence (IPV) against women is a major public health and human rights problem worldwide. Sub-Saharan Africa (SSA) has one of the highest prevalence of IPV against women in the world. This study used meta-analysis to obtain pooled rural–urban and education attainment differences in the prevalence of IPV among ever-partnered women in SSA, and assessed whether the differences in IPV depended on the SSA region or period or women’s age. METHODS: We analysed IPV data on 233,585 ever-partnered women aged 15–49 years from 44 demographic and health surveys conducted between 2000 and 2018 in 29 SSA countries. Random-effects meta-analyses were used to estimate overall rural–urban residence and educational differences in IPV rates among the women in SSA. Subgroup analyses were also done to investigate the sources of heterogeneity in the overall meta-analysis findings. RESULTS: The pooled prevalence of intimate partner violence was estimated to be 41.3% (37.4–45.2%). Regionally, the highest prevalence of IPV was in Middle Africa (49. 3%; 40.32–58.45), followed by East Africa (44.13%; 36.62–51.67), Southern Africa (39.36%; 34.23–44.49), and West Africa (34.30%; 27.38–41.22). The risks of experiencing IPV were significantly higher if the women had less than secondary education (RR=1.12; 95% CI 1.07–1.22) compared to those with at least a secondary education. Generally, women who resided in a rural area had their risks of experiencing IPV increased (RR=1.02; CI 0.96–1.06) compared to those who resided in urban areas, but the IPV increases were only significant in East Africa (RR=1.13; CI 1.07–1.22). CONCLUSION: In sub-Saharan Africa, intimate partner violence against women is widespread, but the levels are much higher among women with lower levels of education and residing in rural areas. Our findings have provided additional support to policies aimed at achieving SDG goals on the elimination of all forms of violence against women and girls in sub-Saharan Africa. For example, policies that advocate improved educational attainment, especially among women and communities in rural areas.Additional file 1: Figure A1: Prevalence of any IPV among women aged 15–49 years according to women’s residence type in each country and year. Figure A2: Prevalence of any IPV among women aged 15–49 years according to women’s level of education in each country and year.Additional file 2: Figure B1: Prevalence of any IPV among women aged 15–24 years in each country and year by region of Africa. Figure B2: Prevalence of any IPV among women aged 25–49 years in each country and year by region of Africa. Figure B3: Prevalence of any IPV among women aged 15–24 years in each country and year by the period of DHS survey. Figure B4: Prevalence of any IPV among women aged 25–49 years in each country and year by the period of DHS surveyhttp://www.biomedcentral.com/bmcwomenshealthpm2021Statistic

An observational study in an urban Ugandan clinic comparing virological outcomes of patients switched from first-line antiretroviral regimens to second-line regimens containing ritonavir-boosted atazanavir or ritonavir-boosted lopinavir.

BACKGROUND: The World Health Organisation approved boosted atazanavir as a preferred second line protease inhibitor in 2010. This is as an alternative to the current boosted lopinavir. Atazanavir has a lower genetic barrier than lopinavir. We compared the virological outcomes of patients during the roll out of routine viral load monitoring, who had switched to boosted second- line regimens of either atazanavir or lopinavir. METHODS: This was a cross-sectional study involving adult patients at the Infectious Diseases Institute Kampala, Uganda started on a standard WHO recommended second-line regimen containing either boosted atazanavir or boosted lopinavir between 1 Dec 2014 and 31 July 2015.. Mantel -Haenszel chi square was used to test for the statistical significance of the odds of being suppressed (VL < 400 copies/ml) when on boosted atazanavir compared to boosted lopinavir after stratifying by duration on antiretroviral therapy (ART). Multivariate logistic regression analysis used to determine if the type of boosted protease inhibitor (bPI) was associated with virological outcome. RESULTS: Ninety (90) % on ATV/r and 83% on LPV/r had a VL less than 1000 copies/ml. The odds of being suppressed using the same viral load cut-off while on boosted atazanavir compared to boosted lopinavir was not statistically significant after stratifying for duration on ART (p = 0.09). In a multivariate analysis the type of bPI used was not a predictor of virological outcome (p = 0.60). CONCLUSIONS: Patients using the WHO recommended second-line of boosted atazanavir have comparable virological suppression to those on boosted lopinavir

USING INTERACTIVE VOICE RESPONSE FOR PLHIV ON ART: PATIENT INTERACTION WITH MHEALTH

The WHO recommends use of mobile phone health technologies (mHealth) to support adherence in HIV [1], [2]. Studies on text messages (SMS) show promise in limited rigorous evaluations[3]. Increasing use of mobile phones in Africa provides an opportunity to use mHealth tools to support resource limited health systems. We used Information-Motivation-Behavioural Skills model of Highly Active Antiretroviral Therapy (HAART or ART) adherence theory of change[4] to locally adapt, implement and evaluate an mHealth tool (Call for Life Uganda – C4LU). The tool is designed to support ART adherence in people living with HIV (PLHIV) in Uganda through interactive voice response (IVR) and SMS. We describe the evolution of the C4LU projects and the interaction of patients with the health tip function of the tool.Johnson and Johnson Corporate Citizenship Trus

Perceptions and Attitudes Toward an Interactive Voice Response Tool (Call for Life Uganda) Providing Adherence Support and Health Information to HIV-Positive Ugandans: Qualitative Study.

BACKGROUND: The continuing decline in AIDS-related deaths in the African region is largely driven by the steady scale-up of antiretroviral therapy. However, there are challenges to retaining people living with HIV on treatment. Call for Life Uganda (CFLU) is an interactive voice response tool using simple analogue phones. CFLU supports patients with daily pill reminders, preappointment reminders, symptom reporting and management, and weekly health promotion tips. Mobile health tools are being increasingly used in resource-limited settings but are often adopted without rigorous evaluation. OBJECTIVE: This qualitative study conducted at 12 months after enrollment assessed patients' experiences, perceptions, and attitudes regarding CLFU. METHODS: We conducted a qualitative substudy within an open-label randomized controlled trial titled "Improving outcomes in HIV patients using mobile phone based interactive software support." Data were collected through 6 focus group discussions with participants sampled based on proportion of calls responded to-50%-conducted at the Infectious Diseases Institute, Mulago, and the Kasangati Health Centre IV. NVivo (version 11; QSR International) was used in the management of the data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis. RESULTS: There was consensus across all groups that they had more positive than negative experiences with the CFLU system. Participants who responded to >50% of the calls reported more frequent use of the specific elements of the CFLU tool and, consequently, experienced more benefits from the system than those who responded to calls less frequently. Irrespective of calls responded to, participants identified pill reminders as the most important aspect in improved quality of life, followed by health promotion tips. The most common challenge faced was difficulty with the secret personal identification number. CONCLUSIONS: Findings showed participants' appreciation, high willingness, and interest in the intervention, CFLU, that demonstrated great perceived potential to improve their access to health care; adherence to treatment; health awareness; and, consequently, quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT02953080; https://clinicaltrials.gov/ct2/show/NCT02953080

Perceptions and Attitudes Toward an Interactive Voice Response Tool (Call for Life Uganda) Providing Adherence Support and Health Information to HIV-Positive Ugandans: Qualitative Study

BackgroundThe continuing decline in AIDS-related deaths in the African region is largely driven by the steady scale-up of antiretroviral therapy. However, there are challenges to retaining people living with HIV on treatment. Call for Life Uganda (CFLU) is an interactive voice response tool using simple analogue phones. CFLU supports patients with daily pill reminders, preappointment reminders, symptom reporting and management, and weekly health promotion tips. Mobile health tools are being increasingly used in resource-limited settings but are often adopted without rigorous evaluation.ObjectiveThis qualitative study conducted at 12 months after enrollment assessed patients' experiences, perceptions, and attitudes regarding CLFU.MethodsWe conducted a qualitative substudy within an open-label randomized controlled trial titled "Improving outcomes in HIV patients using mobile phone based interactive software support." Data were collected through 6 focus group discussions with participants sampled based on proportion of calls responded to-&lt;25%, between 25% and 50%, and &gt;50%-conducted at the Infectious Diseases Institute, Mulago, and the Kasangati Health Centre IV. NVivo (version 11; QSR International) was used in the management of the data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis.ResultsThere was consensus across all groups that they had more positive than negative experiences with the CFLU system. Participants who responded to &gt;50% of the calls reported more frequent use of the specific elements of the CFLU tool and, consequently, experienced more benefits from the system than those who responded to calls less frequently. Irrespective of calls responded to, participants identified pill reminders as the most important aspect in improved quality of life, followed by health promotion tips. The most common challenge faced was difficulty with the secret personal identification number.ConclusionsFindings showed participants' appreciation, high willingness, and interest in the intervention, CFLU, that demonstrated great perceived potential to improve their access to health care; adherence to treatment; health awareness; and, consequently, quality of life.Trial registrationClinicalTrials.gov NCT02953080; https://clinicaltrials.gov/ct2/show/NCT02953080

Re-engagement in HIV care following a missed visit in rural Uganda

Abstract Objective We conducted a retrospective cohort study to assess the effect of tracking People Living with HIV (PLHIV) after missed clinic visits and factors associated with return to care in rural Uganda. We assessed retention in care among 650 HIV-infected women and men. We used univariable and multivariable generalized linear models to assess demographic and self-reported factors associated with re-engagement in HIV care. Results Of 381 PLHIV who ever missed a scheduled appointment, 68% were female and most (80%) had initiated ART. Most (70%) of those tracked returned to care. Relative to men, women (adjusted risk ratio [ARR] 1.23; 95% confidence interval (CI) 1.05–1.43; p = 0.009) were more likely to return to care after active tracking. PLHIV who missed scheduled visits for other reasons (forgetting, adequate drug supplies, or long distance to clinic) had reduced odds of return to care (ARR 0.41; 95% CI 0.28–0.59; p < 0.001). These data support close monitoring of patient retention in HIV care and active measures to re-engage those who miss an appointment. Furthermore, they highlight the need for targeted interventions to those more resistant to re-engagement such as men