The PROCESS study: a protocol to evaluate the implementation, mechanisms of effect and context of an intervention to enhance public health centres in Tororo, Uganda.

BACKGROUND: Despite significant investments into health improvement programmes in Uganda, health indicators and access to healthcare remain poor across the country. The PRIME trial aims to evaluate the impact of a complex intervention delivered in public health centres on health outcomes of children and management of malaria in rural Uganda. The intervention consists of four components: Health Centre Management; Fever Case Management; Patient- Centered Services; and support for supplies of malaria diagnostics and antimalarial drugs. METHODS: The PROCESS study will use mixed methods to evaluate the processes, mechanisms of change, and context of the PRIME intervention by addressing five objectives. First, to develop a comprehensive logic model of the intervention, articulating the project's hypothesised pathways to trial outcomes. Second, to evaluate the implementation of the intervention, including health worker training, health centre management tools, and the supply of artemether-lumefantrine (AL) and rapid diagnostic tests (RDTs) for malaria. Third, to understand mechanisms of change of the intervention components, including testing hypotheses and interpreting realities of the intervention, including resistance, in context. Fourth, to develop a contextual record over time of factors that may have affected implementation of the intervention, mechanisms of change, and trial outcomes, including factors at population, health centre and district levels. Fifth, to capture broader expected and unexpected impacts of the intervention and trial activities among community members, health centre workers, and private providers. Methods will include intervention logic mapping, questionnaires, recorded consultations, in-depth interviews, focus group discussions, and contextual data documentation. DISCUSSION: The findings of this PROCESS study will be interpreted alongside the PRIME trial results. This will enable a greater ability to generalise the findings of the main trial. The investigators will attempt to assess which methods are most informative in such evaluations of complex interventions in low-resource settings. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01024426

Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda.

This study explored the intersection of masculinity and HIV care engagement among fishermen and other male fisherfolk on antiretroviral therapy (ART) in Wakiso District, Uganda. We conducted 30 in-depth interviews with men on ART recruited from HIV treatment sites and used a thematic analysis approach. Since HIV diagnosis and ART initiation, men had adopted masculine identities more conducive to HIV care engagement. The masculine roles of worker and provider, husband and sexual partner and the appearance of physical strength were compromised by HIV, but restored by ART's positive effects on health. Peers also emerged as facilitators to HIV care, with men supporting each other to seek testing and treatment. However, structural and occupational barriers to HIV care associated with the masculine role of worker remained a barrier to care engagement. Findings suggest that emphasising the benefits of ART in bolstering men's ability to fulfil the roles important to them may improve the effectiveness of HIV testing and treatment messaging for men. Differentiated care models that address structural-level barriers to care, and community-level gender-transformative programming to help fishermen engage in HIV care, may be beneficial

Does asset ownership influence sexual risk-taking behaviors among women engaged in sex work in Southern Uganda? A mediation analysis

Background  Economic vulnerability influences women engaged in commercial sex work (WESW) to further engage in sexual risk behaviors, as they often have multiple customers and engage in unprotected sex for financial gains. This study examined asset ownership’s direct and indirect impact on sexual risk-taking behaviors among WESW in Southern Uganda, a very vulnerable group of women at high risk for contracting HIV and other STIs. Methodology  We used baseline data from the Kyaterekera study, an NIH-funded study among WESW aged 18–55 across 19 HIV hotspots in Southern Uganda. Structural equation modeling was used to examine the direct, indirect, and total effects of assets—defined as ownership of physical and financial resources—on sexual risk-taking behaviors among WESW. Results  Results showed that asset ownership was associated with a decrease in depression (β =  − 0.096 [95% CI − 0.191, − 0.001], p = 0.050) and increased access to medical care (β = 0.174 [95% CI 0.072, 0.275], p = 0.001).We also found that an increase in access to medical care was associated with decreased sexual risk-taking behaviors (β =  − 0.107 [95% CI − 0.210, − 0.004], p = 0.041). We observed a specific indirect effect between assets and sexual risk-taking behaviors through access to medical care (β =  − 0.019 [95% CI − 0.040, − 0.002], p = 0.05). Mediation contributed 31% of the total effects of asset ownership on sexual risk-taking behaviors. Conclusion  To our knowledge, this is among the few studies to examine the impact of asset ownership on sexual risk-taking behaviors among WESW in Southern Uganda. Findings from this study indicate that increasing access to economic resources may reduce the risk of WESW engaging in unprotected sex for higher income, which limits the spread of HIV among this population. The results also indicate that asset ownership may allow women to access healthcare services

Predictors of mobility among women engaged in commercial sex work in Uganda using generalized estimating equations model

Background: Women engaged in commercial sex work (WESW) are at a higher risk of acquiring and transmitting HIV. WESW are highly mobile, and their mobility may increase their economic status, and increased access to healthcare and other social services. However, it may also facilitate the spread of HIV infection from higher to lower prevalence regions. This study examined the predictors of mobility among WESW in Uganda using a generalized estimating equations model. Methods: We defined and measured mobility as the change in residence by WESW between baseline, 6 months, and 12 months follow-up. Participants who changed places were considered mobile, and those who never changed were nonmobile. We used data from a longitudinal study, which recruited 542 WESW from Southern Uganda aged 18–55 years and constructed a Generalized Estimating Equations Model. Results: Findings show that 19.6% of WESW changed residence between baseline and 6 months of follow-up and 26.2% (cumulative) between baseline and 12 months of follow-up. Older women (OR = 0.966, 95% CI = 0.935, 0.997) were associated with decreased odds of mobility, whereas WESW who were HIV positive (OR = 1.475, 95% CI = 1.078, 2.018) and those from large households (OR = 1.066, 95% CI = 1.001, 1.134) were associated with increased odds of mobility. WESW residing in rural areas (OR = 0.535, 95% CI = 0.351, 0.817) were associated with decreased odds of mobility compared to those from fishing sites. Conclusion: The results indicate risk factors for mobility, further research is needed to determine the directionality of these factors in order to design interventions addressing mobility among WESW

Self-Reported Adherence to Antiretroviral Therapy (ART) Among Women Engaged in Commercial Sex Work in Southern Uganda

We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW

Factors Associated with Consistent Condom Use Among Women Engaged in Sex Work: Lessons From the Kyaterekera Study in Southwestern Uganda

We examined the factors associated with consistent condom use among women engaged in sex work in the Southern parts of Uganda. We used baseline data from a longitudinal study involving WESW from 19 hotspots in Southern Uganda. We conducted hierarchical models to determine the individual, economic, behavioral, and health-related factors associated with consistent condom use. We found that, alcohol use (b=-0.48, 95% CI=-0.77, -0.19), accepting money for condomless sex (b=-0.33, 95% CI=-0.38, -0.28), multiple customers (b=-0.01, 95% CI=-0.01, -0.005), being married (b = 0.50, 95% CI = 0.01, 0.99), owning more assets (b = 0.08, 95% CI = 0.05, 0.13), having another income earner in the household (b = 0.55, 95% CI = 0.27, 0.83), condom use self-efficacy (b = 0.11, 95% CI = 0.03, 0.19), condom use communication (b = 0.06, 95% CI = 0.001, 0.12), and being knowledgeable about HIV/STIs transmission (b = 0.08, 95% CI = 0.01, 0.15) were associated with consistent condom use. Additionally, 29% of the women were consistent condom users. Hence, there is need to implement interventions that promote consistent condom use among WESW

Correlates of Intimate Partner Violence Among Young Women Engaged in Sex Work in Southern Uganda

Intimate partner violence (IPV) is a significant global public health problem that results in high social and economic costs to individuals and communities. Compared to women in the general population, women engaged in sex work (WESW) are more likely to experience physical, emotional, and sexual IPV. This study examines the correlates of IPV among young WESW with their intimate partners in Southern Uganda. We used baseline data from the Kyaterekera project, a 5 year NIH-funded longitudinal study aimed at reducing HIV risks among 542 WESW in Southern Uganda. To examine the factors associated with IPV, we fitted three separate multi-level Poisson regression models for physical, emotional, and sexual IPV, respectively. Average age was 31.4 years, and 54% of the women reported being victims of at least one form of IPV from their intimate partners. Model one assessed correlates of sexual IPV. Being married women (β = .71, 95% CI [0.24, 1.17]), divorced/separated/widowed (β = .52, [0.02, 1.02]), depressed (β = .04, [0.02, 0.05]), and having any sexually transmitted infections (STIs) (β = .58, [0.14, 1.01]) were associated with sexual IPV. Model two assessed correlates of physical IPV. Experience of childhood sexual abuse (β = .12, [0.04, 0.19]) was associated with an increase in physical IPV, and increasing age reduced its occurrence (β = −.02, [−0.04, −0.001]). Finally, model three assessed emotional IPV. Women with higher education (β = .49, [0.14, 0.85]) and symptoms of depression (β = .02, [0.001, 0.04]) had higher risks for emotional IPV. For WESW, IPV presents an additional potential pathway for HIV and STIs acquisition and transmission through a lack of negotiating power for safe sex. Efforts to reduce violence against WESW should be prioritized as a strategy for enhancing the well-being of WESW

High-resolution African HLA resource uncovers HLA-DRB1 expression effects underlying vaccine response

How human genetic variation contributes to vaccine effectiveness in infants is unclear, and data are limited on these relationships in populations with African ancestries. We undertook genetic analyses of vaccine antibody responses in infants from Uganda (n = 1391), Burkina Faso (n = 353) and South Africa (n = 755), identifying associations between human leukocyte antigen (HLA) and antibody response for five of eight tested antigens spanning pertussis, diphtheria and hepatitis B vaccines. In addition, through HLA typing 1,702 individuals from 11 populations of African ancestry derived predominantly from the 1000 Genomes Project, we constructed an imputation resource, fine-mapping class II HLA-DR and DQ associations explaining up to 10% of antibody response variance in our infant cohorts. We observed differences in the genetic architecture of pertussis antibody response between the cohorts with African ancestries and an independent cohort with European ancestry, but found no in silico evidence of differences in HLA peptide binding affinity or breadth. Using immune cell expression quantitative trait loci datasets derived from African-ancestry samples from the 1000 Genomes Project, we found evidence of differential HLA-DRB1 expression correlating with inferred protection from pertussis following vaccination. This work suggests that HLA-DRB1 expression may play a role in vaccine response and should be considered alongside peptide selection to improve vaccine design

Trends and spatial distribution of Human African Trypanosomiasis (HAT), Uganda, 2005 – 2015: A descriptive analysis of surveillance data

Background: Human African Trypanosomiasis (HAT), commonly referred to as sleeping sickness, is a neglected tropical disease endemic in Sub-Saharan Africa. It is caused by Trypanosoma brucei (T.b.) sub-species: rhodesiense (Rhodesian HAT) and gambiense (Gambian HAT) parasites. The World Health Organization (WHO) targeted HAT for elimination as a public health problem by 2020 (annual incidence ≤1/10,000, and early diagnosis for all cases). We evaluated progress towards HAT elimination in Uganda and described its epidemiological characteristics. Methods: We analysed data reported from sleeping sickness treatment centres (SSTCs) to the Uganda National Sleeping Sickness Control Program during 2005–2015. A HAT case was defined as identification of T.b. rhodesiense or T.b. gambiense parasites in the blood (early-stage) or cerebrospinal fluid (late-stage) of patients at a SSTC. We analysed the cases’ distribution by person, time, and place. We used projected population data from 2002 and 2014 censuses, and linear regression to evaluate temporal trends. Results: During 2005–2015, SSTCs reported 2,032 HAT cases, (55% Rhodesian and 45% Gambian). The number of districts reporting AT reduced from 18 in 2005 to three districts in 2015. The average annual incidence rate (/10,000) during 2005–2015 was similar between males (Gambian=0.1, Rhodesian=0.76) and females (Gambian=0.09, Rhodesian=0.74). Gambian AT incidence declined annually by 24% (IRR=0.76; CI: 0.74-0.78) while Rhodesian AT declined annually by 13% (IRR=0.87; CI: 0.85-0.89). However, for both diseases more than 50% of cases were diagnosed in the late stage. Conclusion: Uganda has achieved the WHO 2020 elimination target for AT incidence. However, many cases are still diagnosed late. We recommend sustaining efforts to achieve eradication, emphasizing early case detection and diagnosis and follow up of all AT cases to ensure good treatment success