Patient attitudes towards community-based tuberculosis DOT and adherence to treatment in an urban setting; Kampala, Uganda

Introduction: High Tuberculosis treatment default rate (17%) and sub-optimal treatment completion rates (45%) has burdened Kampala. Nevertheless, there are observable increase in the number of patients on TB DOT; from 6% to 29% in two consecutive annual reports. The main objective was to determine the association of TB patient attitudes towards community-based observers on the TB drug adherence on directly observed treatment for TB in Kampala.Methods: A cross-sectional study was carried out in Lubaga division, Kampala. A total of 201 patients in continuation phase of treatment for Pulmonary TB (i.e. 8 to 20 weeks of TB treatment) were included in the study. Patient attitudes were measured using a 4-point Likert scale aggregated into a binary outcome with ''agree'' and ''disagree'' responses. Poisson regression model using a forward fitting approach in STATA v12 was used to determine the association between patient attitude towards CB-DOTs observers and adherence to TB treatment.Results: Among the 201 patients, 66% reported their treatment was being observed by someone. Relatives were the commonest (82%) treatment observers, 26% were non adherent to their TB treatment. Perceiving ''no need for a treatment observer'' and ''people rejecting TB patients'' were predictors of non-adherence to TB treatment (IRR=1.6,95%CI 1.00-2.57;p=0.048) and (IRR=0.6, 95%CI 0.35-0.95; p=0.019) respectively.Conclusion: Patient's perceived attitude and stigma towards treatment observers contribute to non-adherence on TB treatment. For improved local TB control, more emphasis is needed to build a friendly environment between treatment supporters and patients during the course of TB treatment.Keywords: Tuberculosis, pulmonary tuberculosis, tuberculosis directly observed treatment, community-based, treatment supporter

Willingness by people living with HIV/AIDS to utilize HIV services provided by Village Health team workers in Kalungu district, central Uganda.

BACKGROUND: Less than one quarter of people in need have access to HIV services in Uganda. This study assessed willingness of people living with HIV/AIDS (PLWHAs) to utilize HIV services provided by Village Health Teams (VHTs) in Kalungu district, central Uganda. METHODS: A cross-sectional study conducted in two health facilities providing anti-retroviral therapy enrolled 312 PLWHAs. Pre-tested semi-structured questionnaires were administered to participants at household level. A forward fitting logistic regression model computed the predictors of willingness of PLWHAs to utilize services provided by VHTs. RESULTS: Overall, 49% were willing to utilize HIV services provided by VHTs increasing to 75.6% if the VHT member was HIV positive. PLWHAs who resided in urban areas were more likely to utilize HIV services provided by VHTs (AOR 0.24, 95%CI 0.06-0.87). Barriers to utilizing HIV services provided by VHTs were: income level > 40 USD (AOR 6.43 95%CI 1.19-34.68), being a business person (AOR 8.71 95%CI 1.23-61.72), peasant (AOR 7.95 95%CI 1.37-46.19), lack of encouragement from: peers (AOR 6.33 95%CI 1.43-28.09), spouses (AOR 4.93 95%CI 1.23-19.82) and community leader (AOR 9.67 95%CI 3.35-27.92). CONCLUSION: Social support could improve willingness by PLWHAs to utilize HIV services provided by VHTs for increased access to HIV services by PLWHA

Willingness by people living with HIV/AIDS to utilize HIV services provided by Village Health team workers in Kalungu district, central Uganda

Background: Less than one quarter of people in need have access to HIV services in Uganda. This study assessed willingness of people living with HIV/AIDS (PLWHAs) to utilize HIV services provided by Village Health Teams (VHTs) in Kalungu district, central Uganda. Methods: A cross-sectional study conducted in two health facilities providing anti-retroviral therapy enrolled 312 PLWHAs. Pre-tested semi-structured questionnaires were administered to participants at household level. A forward fitting logistic regression model computed the predictors of willingness of PLWHAs to utilize services provided by VHTs. Results: Overall, 49% were willing to utilize HIV services provided by VHTs increasing to 75.6% if the VHT member was HIV positive. PLWHAs who resided in urban areas were more likely to utilize HIV services provided by VHTs (AOR 0.24, 95%CI 0.06-0.87). Barriers to utilizing HIV services provided by VHTs were: income level > 40 USD (AOR 6.43 95%CI 1.19-34.68), being a business person (AOR 8.71 95%CI 1.23-61.72), peasant (AOR 7.95 95%CI 1.37-46.19), lack of encouragement from: peers (AOR 6.33 95%CI 1.43-28.09), spouses (AOR 4.93 95%CI 1.23-19.82) and community leader (AOR 9.67 95%CI 3.35-27.92). Conclusion: Social support could improve willingness by PLWHAs to utilize HIV services provided by VHTs for increased access to HIV services by PLWHA

Systemic and cerebrospinal fluid immune and complement activation in Ugandan children and adolescents with long‐standing nodding syndrome: a case‐control study

Objective Nodding syndrome is a poorly understood epileptic encephalopathy characterized by a unique seizure type— head nodding— and associated with Onchocerca volvulus infection. We hypothesized that altered immune activation in the cerebrospinal fluid (CSF) and plasma of children with nodding syndrome may yield insights into the pathophysiology and progression of this seizure disorder. Method We conducted a case‐control study of 154 children (8 years or older) with long‐standing nodding syndrome and 154 healthy age‐matched community controls in 3 districts of northern Uganda affected by nodding syndrome. Control CSF samples were obtained from Ugandan children in remission from haematological malignancy during routine follow‐up. Markers of immune activation and inflammation (cytokines and chemokines) and complement activation (C5a) were measured in plasma and CSF using ELISA or Multiplex Luminex assays. O. volvulus infection was assessed by serology for anti‐Ov16 IgG levels. Results The mean (SD) age of the population was 15.1 (SD 1.9) years and the mean duration of nodding syndrome from diagnosis to enrolment was 8.3 (SD 2.7) years. Majority with nodding syndrome had been exposed to O. volvulus 147/154 (95.4%) compared to community children 86/154 (55.8%), OR 17.04 (95% CI 7.33, 45.58), p<0.001. C5a was elevated in CSF of children with nodding syndrome compared to controls, (p<0.0001). The levels of other CSF markers tested were comparable between cases and controls after adjusting for multiple comparisons. Children with nodding syndrome had lower plasma levels of IL10, APRIL, CCL5 (RANTES), CCL2, CXCL13, MMP‐9 compared to community controls (p<0.05 for all; multiple comparisons). Plasma CRP was elevated in children with nodding syndrome compared to community children and correlated with disease severity. Significance Nodding syndrome is associated with exposure to O. volvulus. Compared to controls, children with long‐standing symptoms of nodding syndrome show evidence of complement activation in CSF and altered immune activation in plasma

Doxycycline for the treatment of nodding syndrome (DONS); the study protocol of a phase II randomised controlled trial.

BACKGROUND: Nodding syndrome is a poorly understood neurological disorder of unknown aetiology, affecting several thousand children in Africa. There has been a consistent epidemiological association with infection by the filarial parasite, Onchocerca volvulus and antibodies to leiomodin and DJ-1, cross-reacting with O.volvulus proteins, have been reported. We hypothesized that nodding syndrome is a neuro-inflammatory disorder, induced by antibodies to O.volvulus or its symbiont, Wolbachia, cross-reacting with human neuron proteins and that doxycycline, which kills Onchocerca through effects on Wolbachia, may be used as treatment. METHODS: This will be a two-arm, double-blind, placebo-controlled, randomised phase II trial of doxycycline 100 mg daily for six weeks in 230 participants. Participants will be patients' ages≥8 years with nodding syndrome. They will receive standard of care supportive treatment. All will be hospitalised for 1-2 weeks during which time baseline measurements including clinical assessments, EEG, cognitive and laboratory testing will be performed and antiepileptic drug doses rationalised. Participants will then be randomised to either oral doxycycline (Azudox®, Kampala Pharmaceutical Industries) 100 mg daily or placebo. Treatment will be initiated in hospital and continued at home. Participants will be visited at home at 2, 4 and 6 weeks for adherence monitoring. Study outcomes will be assessed at 6, 12, 18 and 24-month visits. Analysis will be by intention to treat. The primary efficacy outcome measure will be the proportion of patients testing positive and the levels or titires of antibodies to host neuron proteins (HNPs) and/or leiomodin at 24 months. Secondary outcome measures will include effect of the intervention on seizure control, inflammatory markers, cognitive function, disease severity and quality of life. DISCUSSION: This trial postulates that targeting O.volvulus through drugs which kill Wolbachia can modify the pathogenic processes in nodding syndrome and improve outcomes. Findings from this study are expected to substantially improve the understanding and treatment of nodding syndrome. TRIAL REGISTRATION: Registered with clinicaltrials.gov ID: NCT02850913 on 1st August, 2016

High parity predicts use of long-acting reversible contraceptives in the extended postpartum period among women in rural Uganda

Abstract Background The use of implants and Intra-uterine devices (IUD) during the post-partum period is very low in Uganda especially in rural settings. Long-acting reversible contraceptives (LARC) are known to be the most cost-effective for prevention of unintended pregnancy and unsafe abortions. This study aimed at determining the factors associated with long-acting reversible contraceptive use among women in the extended postpartum period in rural Uganda. Methods We conducted a household-based, cross-sectional study among 400 women in two rural communities in Mityana district, central Uganda. Eligible women were aged 15 to 45 years who had childbirth within 12 months of study enrollment in September 2014. The outcome variable was self-reported use of a LARC method, either IUD or implants in the extended postpartum period. The main independent variables were previous childbirths (parity), fertility desire, willingness to use modern contraception, duration of postpartum period and previous pregnancies (gravidity). A logistic regression model was run in STATA v12.0 to compute adjusted odds ratios (AOR) for factors that predicted LARC use statistically significant at p < 0.05. Results Four hundred respondents had a mean age of 27 years (SD = 12) and only 8.5% reported using a LARC method. Use of IUD and implant was 1.8% and 10.4% respectively. Most women using LARC (44.1%) had five or more childbirths (p = 0.01), 70.8% of non-LARC users were willing to use modern contraceptives (p = 0.07) and 2.5% ever had an induced abortion. Having five or more childbirths was independently associated with LARC use in the extended postpartum period (AOR = 4.07, 95%CI 1.08–15.4). Willingness to use modern contraception, desire for more children and postpartum duration had no significant association with LARC use in the extended postpartum period. Conclusion This study revealed low use of LARC within twelve months of child birth despite women’s willingness to use them. High parity (≥5 childbirths) predicted LARC use. The next logical step is to identify barriers to using LARC in the extended postpartum period and design appropriate interventions to increase access and use especially in multi-parous women

DATASET_SMC.xlsx

Safe Male Circumcision dataset and questionnair

Development of an evidence-based model for predicting patient, provider, and appointment factors that influence no-shows in a rural healthcare system

Abstract Background No-show appointments pose a significant challenge for healthcare providers, particularly in rural areas. In this study, we developed an evidence-based predictive model for patient no-shows at the Marshfield Clinic Health System (MCHS) rural provider network in Wisconsin, with the aim of improving overbooking approaches in outpatient settings and reducing the negative impact of no-shows in our underserved rural patient populations. Methods Retrospective data (2021) were obtained from the MCHS scheduling system, which included 1,260,083 total appointments from 263,464 patients, as well as their demographic, appointment, and insurance information. We used descriptive statistics to associate variables with show or no-show status, logistic regression, and random forests utilized, and eXtreme Gradient Boosting (XGBoost) was chosen to develop the final model, determine cut-offs, and evaluate performance. We also used the model to predict future no-shows for appointments from 2022 and onwards. Results The no-show rate was 6.0% in both the train and test datasets. The train and test datasets both yielded 5.98. Appointments scheduled further in advance (> 60 days of lead time) had a higher (7.7%) no-show rate. Appointments for patients aged 21–30 had the highest no-show rate (11.8%), and those for patients over 60 years of age had the lowest (2.9%). The model predictions yielded an Area Under Curve (AUC) of 0.84 for the train set and 0.83 for the test set. With the cut-off set to 0.4, the sensitivity was 0.71 and the positive predictive value was 0.18. Model results were used to recommend 1 overbook for every 6 at-risk appointments per provider per day. Conclusions Our findings demonstrate the feasibility of developing a predictive model based on administrative data from a predominantly rural healthcare system. Our new model distinguished between show and no-show appointments with high performance, and 1 overbook was advised for every 6 at-risk appointments. This data-driven approach to mitigating the impact of no-shows increases treatment availability in rural areas by overbooking appointment slots on days with an elevated risk of no-shows

Injection and sexual risk among people who use or inject drugs in Kampala, Uganda: An exploratory qualitative study.

BackgroundCountries in Sub-Saharan Africa (SSA) have seen rapid increases in injection drug use since 2008. In Uganda, the Global Sate of Harm report and studies conducted by Makerere University Crane Surveys have estimated HIV prevalence among people who inject drugs (PWID) at approximately 17%. The objective of the research was to document injection and other drug-related risks among people who use drugs in Uganda to develop comprehensive HIV/HCV prevention interventions.MethodsBetween August and September 2018, we conducted qualitative interviews among male and female people who use drugs. Interview topics included the availability and accessibility of clean syringes, injection risks, overdose, sexual-risk behaviors, and the availability and accessibility of harm reduction and drug treatment services.ResultsParticipants reported several injection-related risks including sharing and reusing syringes, pooling and mixing drugs in the same container, measuring drugs using syringes, getting prefilled injections from dealers, being injected by other people who inject drugs, and using contaminated water or blood to dilute drugs. Participants reported a scarcity of harm reduction services, although a few appear to have participated in the syringe exchange pilot conducted by the Uganda Harm Reduction Network (UHRN). Even fewer reported knowing organizations that helped people who use drugs abstain from or reduce their use. Medication assisted therapy (MAT) and naloxone to reverse overdoses are not currently available.ConclusionsComprehensive prevention and treatment services are needed in Uganda and should include expanded syringe exchange programs, social network HIV testing, HCV testing, provision of naloxone and MAT, and linkage to and retention in HIV care