CD4 cell count and viral load monitoring in patients undergoing antiretroviral therapy in Uganda: cost effectiveness study

Objective To examine the cost and cost effectiveness of quarterly CD4 cell count and viral load monitoring among patients taking antiretroviral therapy (ART)

Utility of routine viral load, CD4 cell count, and clinical monitoring among adults with HIV receiving antiretroviral therapy in Uganda: randomised trial

Objective To evaluate the use of routine laboratory monitoring in terms of clinical outcomes among patients receiving antiretroviral therapy (ART) in Uganda

A Comparison of Tools Used for Tuberculosis Diagnosis in Resource-Limited Settings: A Case Study at Mubende Referral Hospital, Uganda

This study compared TB diagnostic tools and estimated levels of misdiagnosis in a resource-limited setting. Furthermore, we estimated the diagnostic utility of three-TB-associated predictors in an algorithm with and without Direct Ziehl-Neelsen (DZM).Data was obtained from a cross-sectional study in 2011 conducted at Mubende regional referral hospital in Uganda. An individual was included if they presented with a two weeks persistent cough and or lymphadenitis/abscess. 344 samples were analyzed on DZM in Mubende and compared to duplicates analyzed on direct fluorescent microscopy (DFM), growth on solid and liquid media at Makerere University. Clinical variables from a questionnaire and DZM were used to predict TB status in multivariable logistic and Cox proportional hazard models, while optimization and visualization was done with receiver operating characteristics curve and algorithm-charts in Stata, R and Lucid-Charts respectively.DZM had a sensitivity and specificity of 36.4% (95% CI = 24.9-49.1) and 97.1%(95% CI = 94.4-98.7) compared to DFM which had a sensitivity and specificity of 80.3%(95% CI = 68.7-89.1) and 97.1%(95% CI = 94.4-98.7) respectively. DZM false negative results were associated with patient's HIV status, tobacco smoking and extra-pulmonary tuberculosis. One of the false negative cases was infected with multi drug resistant TB (MDR). The three-predictor screening algorithm with and without DZM classified 50% and 33% of the true cases respectively, while the adjusted algorithm with DZM classified 78% of the true cases.The study supports the concern that using DZM alone risks missing majority of TB cases, in this case we found nearly 60%, of who one was an MDR case. Although adopting DFM would reduce this proportion to 19%, the use of a three-predictor screening algorithm together with DZM was almost as good as DFM alone. It's utility is whoever subject to HIV screening all TB suspects

EFFECT OF STEREOTYPE ON EMPLOYMENT OPPORTUNITIES FOR PEOPLE LIVING WITH DISABILITIES IN SELECTED UNIVERSITIES IN KENYA

All over the world, reports from different organizations say that people living with disabilities (PLWDs) are underemployed. In Kenya besides many organizations lobbying for the increased employment of PLWDs, amplified by the constitution that at least 5% elective positions must be spared for (PLWDs) there is lower rate of employment. For example the entire cabinet and parastatal secretaries of about twenty six people only one is disabled. The empirical review has pointed out that education has affected negatively on people with disability employment; the employer stereotype also has made it difficult for PLWDs to attain jobs. The literature revealed that the organizational culture is of dare consequences as it may work against the advantage of the disabled, also inaccessibility inhibit Disabled employees from accessing organizational facilities. The employer perception in the literature shows that employers view people living with disabilities as costly. The objective of the study investigated the challenges facing employment opportunities for PLWDs while the specific objectives investigated; the effect of education on employment opportunities for People Living With Disability, to find out the effect of organizational culture on employment opportunities for People Living With Disability, to investigate the effect of employer stereotype on employment opportunities for People Living With Disability, and to investigate the effect of employer perception on employment opportunities for People Living With Disability. The target population was all People Living with Disability employees in selected Universities in Kenya and associations of People Living with Disabilities in Kenya. The sample size was all employees living with Disabilities and all members of the association of People Living with Disabilities in Murang’a County. The findings were presented in tabular form. Both Descriptive statistics i.e. mean standard deviation, skewness, kurtosis and inferential statistics i.e. Correlation, Regression, ANOVA models were used to analyze the findings. The findings showed that People Living with Disabilities do not secure employment opportunities due to: lack of required Skills; lack of available accessible organizational facilities; stringent organizational culture; negative employee stereotype; and negative employer perception towards employees. The study recommended that for people living with disabilities to increase their employment opportunities, their educational level, working experience have to be enhanced. The organizational facilities have to be made available and accessible to PLWDs. The organizational culture has to be changed to embrace acceptable performance not high performance, be less bureaucratic, and equal measures in performance have to be changed to favor customized to individual nature of being

EFFECT OF EDUCATIONAL ON EMPLOYMENT OPPORTUNITIES FOR PEOPLE LIVING WITH DISABILITIES IN SELECTED UNIVERSITIES IN KENYA

All over the world, reports from different organizations say that people living with disabilities (PLWDs) are underemployed. In Kenya besides many organizations lobbying for the increased employment of PLWDs, amplified by the constitution that at least 5% elective positions must be spared for (PLWDs) there is lower rate of employment. For example the entire cabinet and parastatal secretaries of about twenty six people only one is disabled. The empirical review has pointed out that education has affected negatively on people with disability employment; the employer stereotype also has made it difficult for PLWDs to attain jobs. The literature revealed that the organizational culture is of dare consequences as it may work against the advantage of the disabled, also inaccessibility inhibit Disabled employees from accessing organizational facilities. The employer perception in the literature shows that employers view people living with disabilities as costly. The objective of the study investigated the challenges facing employment opportunities for PLWDs while the specific objective investigated; the effect of education on employment opportunities for People Living With Disability. The target population was all People Living with Disability employees in selected Universities in Kenya and associations of People Living with Disabilities in Kenya. The sample size was all employees living with Disabilities and all members of the association of People Living with Disabilities in Murang’a County. The findings were presented in tabular form. Both Descriptive statistics i.e. mean standard deviation, skewness, kurtosis and inferential statistics i.e. Correlation, Regression, ANOVA models were used to analyze the findings. The findings showed that People Living with Disabilities do not secure employment opportunities due to: lack of required Education and Skills. The study recommended that for people living with disabilities to increase their employment opportunities, their Educational level, working experience have to be enhance

Coming back from the dead: living with HIV as a chronic condition in rural Africa.

Scaling-up of anti-retroviral therapy (ART) in resource-poor settings has dramatically reduced mortality and morbidity for those with access, but considerable challenges remain for people who are trying to live with HIV as a manageable chronic condition. A return to 'normal life' for people on ART depends on the assurance of an uninterrupted, affordable and accessible supply of medication. However, many poor people also require economic support to re-establish their livelihoods, particularly where productive and financial assets have been depleted because of long-term illness. ART programmes need to seek convergence with economic programmes that have expertise in livelihood support and promotion, and with social protection initiatives. The future for those on ART depends not only on the provision of medicine but also on economic and social support for rebuilding lives and livelihoods

Population-Based Hematologic and Immunologic Reference Values for a Healthy Ugandan Population

To assess the validity of the reference values for hematologic and immunologic indices currently used in Africa, we evaluated blood samples from 3,311 human immunodeficiency virus (HIV)-negative Ugandans aged 1 week to 92 years. Erythrocyte, hemoglobin, and hematocrit levels and mean corpuscular volume all significantly increased with age (P < 0.001) and were independent of gender until the age of 13 years, after which the levels were higher in males than in females (P < 0.001). White blood cell, neutrophil, lymphocyte, basophil, and monocyte counts significantly declined with age until the age of 13 years (P < 0.001), with no differences by gender, while platelet counts declined with age (P < 0.001) and showed differences by gender only among adults older than age 24 years. CD4(+)- and CD8(+)-cell counts declined with age until the age of 18 years; thereafter, females had higher counts than males. The absolute values for many of these parameters differed from those reported for populations outside Africa, suggesting that it may be necessary to develop tables of reference values for hematologic and immunologic indices specific for the African population. This may be particularly important with regard to CD4(+)-cell counts among children because significant differences in absolute and percent CD4(+)-cell counts exist between the values for Western populations and the values for the population evaluated in our study. These differences could influence the decision to initiate antiretroviral therapy among children infected with HIV

The Cost Effectiveness of Home-Based Provision of Antiretroviral Therapy in Rural Uganda

Background: Highly active antiretroviral therapy (HAART) provides dramatic health benefits for HIV-infected individuals in Africa, and widespread implementation of HAART is proceeding rapidly. Little is known about the cost and cost effectiveness of HAART programmes. Objective: To determine the incremental cost effectiveness of a home-based HAART programme in rural Uganda. Methods: A computer-based, deterministic cost-effectiveness model was used to assess a broad range of economic inputs and health outcomes. From the societal perspective, the cost effectiveness of HAART and cotrimoxazole prophylaxis was compared with cotrimoxazole alone, and with the period before either intervention. Data for 24 months were derived from a trial of home-based HAART in 1045 patients in the Tororo District in eastern Uganda. Costs and outcomes were projected out to 15 years. All costs are in year 2004 values. The main outcome measures were HAART programme costs, health benefits accruing to HAART recipients, averted HIV infections in adults and children and the resulting effects on medical care costs. The first-line HAART regimen consisted of standard doses of stavudine, lamivudine, and either nevirapine or, for patients with active tuberculosis, efavirenz. Second-line therapy consisted of tenofovir, didanosine and lopinavir/ritonavir. For children, first-line HAART consisted of zidovudine, lamivudine and nevirapine syrup; second-line therapy was stavudine, didanosine and lopinavir/ritonavir. Results: The HAART programme, standardized for 1000 patients, cost an incremental &dollar;US1.39 million in its first 2 years. Compared with cotrimoxazole prophylaxis alone, the programme reduced mortality by 87%, and averted 6861 incremental disability-adjusted life-years (DALYs). Benefits were accrued from reduced mortality in HIV-infected adults (67.5% of all benefits), prevention of death in HIV-negative children (20.7%), averted HIV infections in adults (9.1%) and children (1.0%), and improved health status (1.7%). The net programme cost, including the medical cost implications of these health benefits, was &dollar;US4.10 million. The net cost per DALY averted was &dollar;US597 compared with cotrimoxazole alone. Many HIV interventions have a cost-effectiveness ratio in the range of &dollar;US1-150 per DALY averted. Conclusions: This study suggests that a home-based HAART programme in rural Africa may be more cost effective than most previous estimates for facility-based HAART programmes, but remains less cost effective than many HIV prevention and care interventions, including cotrimoxazole prophylaxis.

Determining eligibility for antiretroviral therapy in resource-limited settings using total lymphocyte counts, hemoglobin and body mass index

Background. CD4+ T lymphocyte (CD4) cell count testing is the standard method for determining eligibility for antiretroviral therapy (ART), but is not widely available in sub-Saharan Africa. Total lymphocyte counts (TLCs) have not proven sufficiently accurate in identifying subjects with low CD4 counts. We developed clinical algorithms using TLCs, hemoglobin (Hb), and body mass index (BMI) to identify patients who require ART. Methods We conducted a cross-sectional study of HIV-infected adults in Uganda, who presented for assessment for ART-eligibility with WHO clinical stages I, II or III. Two by two tables were constructed to examine TLC thresholds, which maximized sensitivity for CD4 cell counts ≤ 200 cells μL, while minimizing the number offered ART with counts > 350 cells μL. Hb and BMI values were then examined to try to improve model performance. Results 1787 subjects were available for analysis. Median CD4 cell counts and TLCs, were 239 cells/μL and 1830 cells/μL, respectively. Offering ART to all subjects with a TLCs ≤ 2250 cells/μL produced a sensitivity of 0.88 and a false positive ratio of 0.21. Algorithms that treated all patients with a TLC 3000 cells/μL, and used Hb and/or BMI values to determine eligibility for those with TLC values between 2000 and 3000 cells/μL, marginally improved accuracy. Conclusion TLCs appear useful in predicting who would be eligible for ART based on CD4 cell count criteria. Hb and BMI values may be useful in prioritizing patients for ART, but did not improve model accuracy.Medicine, Department ofMedicine, Faculty ofNon UBCReviewedFacult