Molecular characteristics of HIV-1 subtype C and its impact on therapeutic outcome in Ethiopia

HIV-1 is characterized by a high genetic diversity which poses several challenges and implications with regard to disease progression, drug resistance and outcome of antiretroviral therapy (ART). HIV-1 subtype C (HIV-1C) is the most rapidly expanding subtype accounting for half of the global disease and nearly all infections in Ethiopia, Southern Africa and India which are the regions with the highest burden of HIV-1 infection. Molecular characteristics of the virus in such epidemic success need to be explored to better understand this subtype. In the thesis, we analysed plasma samples and patient data collected during 2009-2011 in a large country-wide cohort, Advanced Clinical Monitoring of ART (ACM) which was established to evaluate the longitudinal effectiveness of ART as practiced in real life in Ethiopia. The overall aim was to investigate the molecular characteristics of HIV-1C and its impact on first line ART outcome in Ethiopia. Both genotypic and phenotypic molecular techniques were employed to characterize different regions of the viral genome. In papers I and II, population sequencing (PBSS) of the V3 loop of the HIV-1 envelope from therapy naïve, patients failing therapy, as well as HIV-1C sequences from Ethiopia dated 1984-2003 was used to assess the molecular epidemiology of HIV-1C in different geographic regions and the trend of viral tropism over the last decades. We also investigated the utility of different genotypic tropism prediction tools and the impact of the predicted viral co-receptor tropism on the outcome of standard first line ART. Our results showed that the Ethiopian epidemic is still monophylogenetic, exclusively dominated by HIV-1C, CCR5 tropic viruses. Furthermore, baseline tropism had an impact on outcome of standard first line ART. While each tool predicted tropism with comparable frequency, there was yet a large discordance between the tools. We elucidated this discordance further in paper III by employing an in-house phenotypic tropism method compared with the prediction by bioinformatics tools used in paper II as well as in vitro sensitivity of HIV-1CEth strains for the co-receptor antagonist maraviroc. The results showed underestimation of R5 co-receptor usage by bioinformatics tools and effectiveness of maraviroc in HIV-1C. Expanding the exploration further to pol gene, we employed PBSS and next generation sequencing (NGS) to assess the prevalence of surveillance drug resistance mutations (sDRM) to reverse transcriptase- and protease-inhibitors as well as occurrence of DRM by NGS to the novel category of integrase strand inhibitors. The results in paper IV showed that NGS detected sDRM associated with RT- and PI- inhibitors more often than PBSS and major INSTI DRMs were found in minor viral variants. Furthermore, DRM identified before treatment was associated with a poorer treatment outcome. In conclusion, viral tropism and drug resistance mutations at baseline have an impact on subsequent treatment outcome. Currently available genotypic tropism prediction tools need further improvement for use in HIV-1C. The Ethiopian epidemic remains uniquely dominated by R5 tropic HIV-1C since its introduction. Further investigations should be done to delineate associated molecular and epidemiological factors contributing to its uniqueness

Challenges of the Strength of Evidences Presented to Ethiopian Courts in Rape Cases among Children below 14 Years Old: The Case of West Shoa High Court

Ethiopia is estimated to have one of the highest rates of violence against women in the world. The Criminal Code of Ethiopia provides heavy penalties for rape cases and especial provisions for sexual outrages committed on children. The purpose of this study was to explore the strength of evidences presented to West Shoa High Court in rape cases among children below 14 years old in Ambo town, Oromia region, Ethiopia. A retrospective review of court documents for rape was conducted from February to March 2015 at West Shoa High Court and additional data were collected using a semi-structured interview among judges and public prosecutors. Findings indicated testimony of the victim, eyewitness and medical report as the types of evidences presented to court in rape cases, among them testimony of the victim is the main source of evidence. The challenges in evaluating these evidences were lack of standard of proof and especial procedures for children rape cases, backward investigation methods, the hidden nature of the crime and cultural issues. Consequently, judgments given based on such weak evidences make the justice system unpredictable and unreliable, and the justice not to be served. The proper balanced view of courts to do justice to the society, to the victim and to the perpetrators increases awareness of the community on how to handle the rape cases, and establishing standard of proof for rape cases are recommended

Prevalence and factors associated with exclusive breastfeeding among rural mothers of infants less than six months of age in Southern Nations, Nationalities, Peoples (SNNP) and Tigray regions, Ethiopia: a cross-sectional study.

BACKGROUND: Exclusive breastfeeding (EBF) is the global recommended nutrition for infants less than 6 months of age. The prevalence of exclusive breastfeeding in Ethiopia is much lower than the recommendations of World Health Organization (WHO). This study aimed to assess the prevalence and associated factors of EBF among rural mothers of infants less than 6 months of age in two regions, Southern Nations, Nationalities and Peoples (SNNP) and Tigray Regions, of Ethiopia. METHODS: The research was based on the secondary data analysis of community-based cross-sectional study conducted in 56 rural woredas (districts) in two regions of Ethiopia for impact evaluation of Alive & Thrive multi-year project. The 24-h recall dietary data were collected from 600 mother-infant dyads where the infant was less than 6 month of age, using multistage cluster sampling technique and 584 dyads were found eligible for analysis. Bivariate and multivariable logistic regressions were applied to identify the associated factors of exclusive breastfeeding. RESULTS: The prevalence of EBF of infants less than 6 months of age was 88.0% (95% CI 84.9, 90.4%). The odds of practicing EBF were significantly higher among infants less than 2 months of age (AOR 4.47, 95% CI 2.41, 8.27), married mothers (AOR 4.35, 95% CI 1.50, 12.67), mothers who gave birth in health facilities (AOR 2.07, 95% CI 1.15, 3.73) and mothers who received breastfeeding counseling during pregnancy (AOR 2.23, 95% CI 1.26, 3.96). CONCLUSIONS: The prevalence of EBF was relatively high when compared with previous studies in Ethiopia but close to the WHO recommendations of 90 %. Infant age, marital status of mothers, delivery place and breastfeeding counseling during pregnancy were identified as factors associated with EBF practices in 24 h preceding the survey. Devising appropriate strategies on breastfeeding messaging/counseling and support in addressing poor breastfeeding practices through existing government-led health intervention packages are recommended

Predictors of undesirable treatment outcomes of severe acute malnutrition among inpatient children in Addis Ababa, Ethiopia: a retrospective cohort study.

BACKGROUND: In 2018, malnutrition contributed to 45% of all global cause of child death. These early child deaths were due to conditions that could either be prevented or treated with basic interventions. Hence, this study intended to provide a quantitative estimate of factors associated with undesirable treatment outcomes of severe acute malnutrition (SAM). METHODS: We studied a retrospective cohort of 304 children aged 6-59 months with complicated SAM admitted to Yekatit 12 Hospital Medical College from 2013 to 2016. We extracted data from hospital records on nutritional status, socio-demographic factors and medical conditions during admission. The analysis was carried out using SPSS version 20. The Kaplan-Meier estimator was employed to analyze the recovery rate of the children treated for SAM and multivariable Cox regression was used to determine factors that predict inpatient undesirable treatment outcomes. RESULT: From a total of 304 children 6-59 months with SAM, 133 (51.4%) were boys. Marasmus was the most common type (132 (51%)) of severe acute malnutrition. The recovery, death and defaulter rate were 70.4, 12.2 and 8.2% respectively. The main predictors of undesirable treatment outcomes were found to be the presence of HIV antibody (AHR = 3.208; 95% CI: [1.045-9.846]) and sepsis (AHR = 7.677, 95% CI: [2.320-25.404]). CONCLUSION: The study revealed that the overall treatment outcomes were below the SPHERE standard recommendation. The main predictors of undesirable treatment outcomes among inpatient children treated for SAM were HIV and sepsis. Intervention to reduce undesirable treatment outcomes should focus on comorbidities, especially HIV and sepsis

Disability Vis-a-Vis Micro and Small Scale Enterprises The Case of Menbere-Mariam Saving and Credit Association, Debrebirhan, Ethiopia

Though micro and small scale enterprises are energetic and vibrant economic sectors which have the largest potential for job creation, access of vocational training, and hiring of persons with disabilities in these enterprises is low. The study examined the challenges of access to training and employment of persons with disabilities in micro and small scale enterprises in Debrebirhan town in the case of Menbere-Mariam saving and credit association. To realize the objective, data collection methods like in-depth interviews, focus group discussions and key informants interviews were used. Purposive sampling method was applied for the study.  The study employed the qualitative method of analysis. Document analysis was used to examine various aspects of the association’s experience of disability. The results of the study reveal that despite the wide range of protection under international, regional, and national laws, vocational training and employment access of persons with disabilities is a problem in the study area. Among the challenges they face are: absence of vocational training, attitudinal related challenges, institutional related barriers, employers related problems, guarantee related problems, barriers linked to project area and shop booths, lose of profit and health problems and problem with provision of infrastructure. Keywords: Disability, Employment, Micro and Small Scale, Enterprises, Vocational Training

Food Insecurity and Mental Distress among Mothers in Rural Tigray and SNNP Regions, Ethiopia.

Access to safe and adequate food is a basic human right under Article 25 of the Universal Declaration of Human Rights. Globally, more than 870 million people consume less calories than they require, which can lead to disabling physical and mental health outcomes. This study was designed to investigate the association between household food insecurity and mental distress among mothers in the Tigray and SNNP regions of Ethiopia. A community based cross-sectional survey was completed on a total of 2,992 households. A linear multiple regression model was used to study the association between food insecurity and mental distress. More than half of the study participants, 57.9%, were experiencing food insecurity. The prevalence of mental distress among the mothers was 39%. Food insecurity was significantly associated with mental distress after controlling for socioeconomic covariates. Integrating screening and management of mental distress would result in a better health status of the mothers and those under their care

Prevalence and associated factors of undernutrition among adult tuberculosis patients in some selected public health facilities of Addis Ababa, Ethiopia: a cross-sectional study

BACKGROUND: The prevalence of undernutrition among adult tuberculosis patients is high in developing countries. However it has not been well explored in Ethiopian situation. Therefore the aim of this study was to determine the prevalence of undernutrition and its associated factors among adult TB patients in some selected public health facilities of Addis Ababa. METHODS: An institution based cross-sectional study was conducted. The total sample size of the study was 360. The sample size was allocated to the selected health facilities proportional to their size and study subjects were consecutively enrolled to the study during the study period. Data were collected using a pretested structured questionnaire. The data were entered and cleaned by using EPI info version 3.6.1 and transferred to SPSS version 20 for analysis. Bivariate and multivariate logistic regression analyses were done to identify factors that are associated with undernutrition. RESULTS: The prevalence of undernutrition was 39.7 % (23.6 % mild, 8.6 % moderate and 7.2 % severe undernutrition). Functional status of the patients (AOR = 2.57; 95 % CI = 1.42, 4.68) and dietary counselling (AOR = 1.79; 95 % CI = 1.03, 3.12) were factors independently associated with undernutrition among adult TB patients. CONCLUSION: The prevalence of undernutrition was found to be very high. Regular nutritional assessment and dietary counselling should be part of the routine care of adult TB patients

Client Satisfaction with Delivery Care Service and Associated Factors in the Public Health Facilities of Gamo Gofa Zone, Southwest Ethiopia: In a Resource Limited Setting

Background. Ensuring patient satisfaction is an important means of secondary prevention of maternal mortality. This study presents findings from a multidimensional study of client satisfaction from the Gamo Gofa Zone in Southwest Ethiopia. Methods. A facility based cross-sectional study using exit interviews was conducted from 2014. Client satisfaction was measured using a survey adopted from the Donabedian quality assessment framework. Thirteen health institutions were randomly sampled of 66 institutions in Gamo Gofa Zone. Logistic regression was used to determine predictors of client satisfaction. Results. The overall satisfaction level of the clients in this study was 79.1% with (95% CI; 75–82). Women attending health centres were more likely satisfied than women attending hospitals (χ2=83.7, df=12, P<0.001). The proportion of women who complained about an unfriendly attitude or unresentful care from health workers was higher in the hospitals (χ2=27.4, df=1, P<0.001). The presence of support persons during child birth improved client satisfaction (AOR = 6.23 95% CI; 2.75–14.1) and women who delivered with caesarean section are four times more likely satisfied than those who deliver vaginally (AOR 3.6 95% CI; 1.44–9.06). Client satisfaction was reduced if the women had to pay for the services (AOR = 0.27 95% CI; 0.09–81). Conclusions. The study shows that overall satisfaction level is good. More emphasis should be put on giving women friendly care, particularly at the hospitals

An integrated community-based outpatient therapeutic feeding programme for severe acute malnutrition in rural Southern Ethiopia: Recovery, fatality, and nutritional status after discharge.

A scaled up and integrated outpatient therapeutic feeding programme (OTP) brings the treatment of severely malnourished children closer to the community. This study assessed recovery from severe acute malnutrition (SAM), fatality, and acute malnutrition up to 14 weeks after admission to a programme integrated in the primary health care system. In this cohort study, 1,048 children admitted to 94 OTPs in Southern Ethiopia were followed for 14 weeks. Independent anthropometric measurements and information on treatment outcome were collected at four home visits. Only 32.7% (248/759) of children with SAM on admission fulfilled the programme recovery criteria at the time of discharge (i.e., gained 15% in weight, or oedema, if present at admission, was resolved at discharge). Of all children admitted to the programme for whom nutritional assessment was done 14 weeks later, 34.6% (321/928) were severely malnourished, and 37.5% (348/928) were moderately malnourished; thus, 72.1% were acutely malnourished. Of the children, 27/982 (2.7%) had died by 14 weeks, of whom all but one had SAM on admission. Children with severe oedema on admission had the highest fatality rate (12.0%, 9/75). The median length of admission to the programme was 6.6 weeks (interquartile range: 5.3, 8.4 weeks). Despite children participating for the recommended duration of the programme, many children with SAM were discharged still acutely malnourished and without reaching programme criteria for recovery. For better outcome of OTP, constraints in service provision by the health system as well as challenges of service utilization by the beneficiaries should be identified and addressed

Observed changes in extremes of daily rainfall and temperature in Jemma Sub-Basin, Upper Blue Nile Basin, Ethiopia

Climate variability has been a threat to the socio-economic development of Ethiopia. This paper examined the changes in rainfall, minimum, and maximum temperature extremes of Jemma Sub-Basin of the Upper Blue Nile Basin for the period of 1981 to 2014. The nonparametric Mann-Kendall, seasonal Mann-Kendall, and Sen’s slope estimator were used to estimate annual trends. Ten rainfall and 12 temperature indices were used to study changes in rainfall and temperature extremes. The results showed an increasing trend of annual and summer rainfall in more than 78% of the stations and a decreasing trend of spring rainfall in most of the stations. An increase in rainfall extreme events was detected in the majority of the stations. Several rainfall extreme indices showed wetting trends in the sub-basin, whereas limited indices indicated dryness in most of the stations. Annual maximum and minimum temperature and extreme temperature indices showed warming trend in the sub-basin. Presence of extreme rainfall and a warming trend of extreme temperature indices may suggest signs of climate change in the Jemma Sub-Basin. This study, therefore, recommended the need for exploring climate induced risks and implementing appropriate climate change adaptation and mitigation strategies