Treatment Outcomes for Tuberculosis Infection and Disease Among Persons Deprived of Liberty, Uganda, 2020.

We report that unsuccessful treatment outcomes were 11.8% for tuberculosis (TB) disease and 21.8% for TB infection among persons deprived of liberty in Uganda Prisons Service facilities. Remedial efforts should include enhancing referral networks to ensure treatment continuity, strengthening data systems for complete outcome documentation, and prioritizing short-course treatment regimens.

Tuberculosis Preventive Therapy among Persons Living with HIV, Uganda, 2016-2022.

During October 2016-March 2022, Uganda increased tuberculosis (TB) preventive therapy coverage among persons living with HIV from 0.6% to 88.8%. TB notification rates increased from 881.1 to 972.5 per 100,000 persons living with HIV. Timely TB screening, diagnosis, and earlier treatment should remain high priorities for TB/HIV prevention programming.

Integrating interferon-gamma release assay testing into provision of tuberculosis preventive therapy is feasible in a tuberculosis high burden resource-limited setting: A mixed methods study.

The World Health Organization recommends the scale-up of tuberculosis preventive therapy (TPT) for persons at risk of developing active tuberculosis (TB) as a key component to end the global TB epidemic. We sought to determine the feasibility of integrating testing for latent TB infection (LTBI) using interferon-gamma release assays (IGRAs) into the provision of TPT in a resource-limited high TB burden setting. We conducted a parallel convergent mixed methods study at four tertiary referral hospitals. We abstracted details of patients with bacteriologically confirmed pulmonary tuberculosis (PBC TB). We line-listed household contacts (HHCs) of these patients and carried out home visits where we collected demographic data from HHCs, and tested them for both HIV and LTBI. We performed multi-level Poisson regression with robust standard errors to determine the associations between the presence of LTBI and characteristics of HHCs. Qualitative data was collected from health workers and analyzed using inductive thematic analysis. From February to December 2020 we identified 355 HHCs of 86 index TB patients. Among these HHCs, uptake for the IGRA test was 352/355 (99%) while acceptability was 337/352 (95.7%). Of the 352 HHCs that were tested with IGRA, the median age was 18 years (IQR 10-32), 191 (54%) were female and 11 (3%) were HIV positive. A total of 115/352 (32.7%) had a positive IGRA result. Among HHCs who tested negative on IGRA at the initial visit, 146 were retested after 9 months and 5 (3.4%) of these tested positive for LTBI. At multivariable analysis, being aged ≥ 45 years [PR 2.28 (95% CI 1.02, 5.08)], being employed as a casual labourer [PR 1.38 (95% CI 1.19, 1.61)], spending time with the index TB patient every day [PR 2.14 (95% CI 1.51, 3.04)], being a parent/sibling to the index TB patients [PR 1.39 (95% CI 1.21, 1.60)] and sharing the same room with the index TB patients [PR 1.98 (95% CI 1.52, 2.58)] were associated with LTBI. Implementation challenges included high levels of TB stigma and difficulties in following strict protocols for blood sample storage and transportation. Integrating home-based IGRA testing for LTBI into provision of TB preventive therapy in routine care settings was feasible and resulted in high uptake and acceptability of IGRA tests.

Screening tuberculosis patients for diabetes mellitus in a routine program setting in Kampala, Uganda: a cross-sectional study.

Background: Uganda is located in East Africa and is among the countries with the lowest income globally. The ten health centres in this project serve populations in the under-privileged communities of Kampala. The objective of the study was to implement diabetes mellitus (DM) screening among tuberculosis (TB) patients in a routine program setting with limited resources and high human immunodeficiency virus (HIV) prevalence. Methods: A descriptive cross-sectional observational study was conducted in ten health centres in Kampala, Uganda. As part of a project to implement DM screening in a routine setting, TB patients were screened for DM by trained health workers. A fasting blood glucose (FBG) value ≥7.0mmol/l was considered to indicate DM. For this study, aggregate data was collected and analysed using SPSS for Windows, version 13.0. Results:  Among 4,590 TB patients registered, 4,016 (88.0%) were screened with random blood glucose (RBG). Of those with RBG ≥6.1mmol/l, 1,093 (83.3%) were screened with FBG. In total, 92 (2.3%) patients were diagnosed with DM and 66 (71.8%) of them were newly diagnosed. The proportion of TB patients screened with FBG in the health centres varied from 58.2% to 100%. The proportion of patients screened with FBG and the prevalence of DM were significantly higher in private health centres compared with public health centres. The health centres in peri-urban areas screened more patients with RBG than those in urban areas. Health centres without DM services screened a larger number of patients with RBG and FBG than those with DM services. Conclusions: It appears feasible to implement screening TB patients for DM in routine program settings with limited resources and high HIV prevalence. Its introduction requires close collaboration between TB and DM services. The challenges identified need government attention and certain institutional and service-related factors need to be better managed at times.

Performance of the new WHO diagnostic algorithm for smear-negative pulmonary tuberculosis in HIV prevalent settings: a multisite study in Uganda.

OBJECTIVE: To compare the performance of the new WHO (2007) diagnostic algorithm for pulmonary tuberculosis (PTB) in high HIV prevalent settings (WHO07) to the WHO 2003 guidelines used by the Ugandan National Tuberculosis Program (UgWHO03). METHODS: A prospective observational cohort design was used at Reach Out Mbuya Parish HIV/AIDS Initiative, an urban slum community-based AIDS Service Organisation (ASO) and Kayunga Rural District Government Hospital. Newly diagnosed and enrolled HIV-infected patients were assessed for PTB. Research staff interviewed patients and staff and observed operational constraints. RESULTS: WHO07 reduced the time to diagnosis of smear-negative PTB with increased sensitivity compared with the UgWHO03 at both sites. Time to diagnosis of smear-negative PTB was significantly shorter at the urban ASO than at the rural ASO (12.4 vs. 28.5 days, P = 0.003). Diagnostic specificity and sensitivity [95% confidence intervals (CIs)] for smear-negative PTB were higher at the rural hospital compared with the urban ASO: [98% (93-100%) vs. 86% (77-92%), P = 0.001] and [95% (72-100%) vs. 90% (54-99%), P > 0.05], respectively. Common barriers to implementation of algorithms included failure by patients to attend follow-up appointments and poor adherence by healthcare workers to algorithms. CONCLUSION: At both sites, WHO07 expedited diagnosis of smear-negative PTB with increased diagnostic accuracy compared with the UgWHO03. The WHO07 expedited diagnosis more at the urban ASO but with more diagnostic accuracy at the rural hospital. Barriers to implementation should be taken into account when operationalising these guidelines for TB diagnosis in resource-limited settings.

Validation in Uganda of the new WHO diagnostic algorithm for smear-negative pulmonary tuberculosis in HIV prevalent settings.

BACKGROUND: We compared the effectiveness of the new WHO 2007 diagnostic algorithm for pulmonary tuberculosis (PTB) for HIV prevalent settings (WHO07) to the WHO 2003 guidelines used by the Ugandan National Tuberculosis Program (UgWHO03) and most other countries for the diagnosis of smear-negative PTB. METHODS: A prospective observational cohort design was employed under routine operational conditions at a District Hospital in Uganda. Newly diagnosed patients with HIV and enrolled to the outpatient HIV clinic were assessed for possible PTB. The study was in 2 phases with evaluation of the UgWHO03 and WHO07 over the first and second phases, respectively. RESULTS: One hundred forty-seven enrolled onto the UgWHO03 and 166 onto WHO07. There were significant reductions in the geometric mean days (11.0 vs. 21.2, P < 0.05) and number of health facility visits (1.7 vs. 2.8, P < 0.001) from presentation to diagnosis of all PTB for the WHO07 compared with the UgWHO03. For smear-negative PTB, the geometric mean days (28.5 vs. 34.1, P > 0.05) and number of health facility visits (2.5 vs. 2.6, P > 0.05) from presentation to diagnosis were nonsignificantly reduced. Diagnostic sensitivity (95% confidence intervals) for smear-negative PTB increased nonsignificantly from 63% (27% to 90%) to 95% (72% to 100%) for the WHO07, with specificity (95% confidence interval) remaining high at 99% (92% to 100%) and 98% (93% to 100%). CONCLUSIONS: Implementing the new WHO07 is likely to reduce the number of days and increase sensitivity for diagnosis of smear-negative cases of PTB. We identified many barriers to implementing both guidelines in HIV prevalent resource-poor settings.

Improving clinic attendance and adherence to antiretroviral therapy through a treatment supporter intervention in Uganda: a randomized controlled trial.

We assessed the effectiveness of the treatment supporter initiative as an intervention in improving clinic attendance for antiretroviral (ARV) drug refills and adherence to antiretroviral therapy (ART) in a cohort of HIV-infected adults. This two-arm randomized controlled trial was undertaken at an HIV clinic in a district hospital in Uganda. A total of 174 adult patients on ART were randomized 1:1 to a standard adherence intervention package plus a treatment supporter intervention (TS arm) or to a standard adherence intervention package (non-TS arm) alone. Clinic attendance for refills and adherence measurements using monthly clinic-based pill counts were monitored for both arms for 28 weeks. Baseline characteristics were similar for both arms. There was a non-significant difference in mean adherence between the TS and non-TS groups at end of follow-up [99.1% (95% CI: 98.3-99.9% vs. 96.3% (95% CI: 94.2-98.3%), P > 0.05]. TS participants had more than four times the odds of achieving optimal adherence (≥95%) [Odds ratio (OR) = 4.51, 95% CI: 1.22-16.62, exact P = 0.027]. TS participants were also more likely to be on time for their clinic appointments: 91.6 vs. 90.1% for TS and non-TS, respectively (OR = 1.19, 95% CI: 0.74-1.91, P > 0.05). Use of patient-selected treatment supporters may be an effective intervention to improve ARV treatment outcomes in resource-constrained settings.

Using mobile phones to improve clinic attendance amongst an antiretroviral treatment cohort in rural Uganda: a cross-sectional and prospective study.

We aimed to assess the patterns and dynamics of mobile phone usage amongst an antiretroviral treatment (ART) cohort in rural Uganda and ascertain its feasibility for improving clinic attendance. A cross-sectional study of clients on ART exploring their access to mobile phones and patterns of use was employed. Clinic attendances for antiretroviral drug refills were then monitored prospectively over 28 weeks in 176 patients identified in the cross-sectional survey who had access to mobile phones and had given consent to be contacted. Patients were contacted via voice calls or text messages to remind them about their missed clinic appointments. Of the 276 patients surveyed, 177 (64%) had access to mobile phones with all but one were willing to be contacted for missed visits reminders. Of the 560 total scheduled clinic appointments, 62 (11%) were missed visits. In 79% of episodes in which visits were missed, patients presented for treatment within a mean duration of 2.2 days (SD = 1.2 days) after mobile phone recall. Access to mobile phones was high in this setting. Privacy and confidentiality issues were not considered deterrents. Mobile phones have a potential for use in resource-constrained settings to substantially improve the clinical management of HIV/AIDS.

Ascertaining baseline levels of antiretroviral therapy adherence in Uganda: a multimethod approach.

BACKGROUND: Many antiretroviral treatment (ART) adherence measurement methods have been employed by different studies, but no single method has been found to be appropriate for all settings. This study aimed to determine baseline levels of adherence using 2 measures of adherence. METHODS: Levels of adherence in 967 patients continuing to receive ART in 4 health facilities were assessed over a 28-week period using a clinic-based pill count method and a patient self-report questionnaire. Factors associated with adherence were also determined. RESULTS: Mean adherence (95% confidence interval) was 97.3% (96.8% to 97.9%) and 98.4% (97.9% to 98.8%) for the clinic-based pill count and patient self-report methods, respectively. Proportion of clients achieving optimal adherence (≥ 95%) was 89.9% by pill count and 94.2% by self-report. The 2 adherence measures were closely correlated with each other (r = 0.87, P = 0.000). Adherence increased with age (P = 0.014) with patients aged 40 years and below being less likely to achieve optimal adherence [odds ratio = 0.55; 95% confidence interval (0.34 to 0.89)]. CONCLUSIONS: There is a very high level of optimal adherence among patients still on treatment. The combined use of these 2 replicable and reliable methods of measuring adherence is vital to ART programs in resource-constrained settings.

Clinic Attendance for Medication Refills and Medication Adherence amongst an Antiretroviral Treatment Cohort in Uganda: A Prospective Study.

Background. Regular clinic attendance for antiretroviral (ARV) drug refills is important for successful clinical outcomes in HIV management. Methods. Clinic attendance for ARV drug refills and medication adherence using a clinic-based pill count in 392 adult patients receiving antiretroviral therapy (ART) in a district hospital in Uganda were prospectively monitored over a 28-week period. Results. Of the 2267 total scheduled clinic visits, 40 (1.8%) were missed visits. Among the 392 clients, 361 (92%) attended all appointments for their refills (regular attendance). Clinic attendance for refills was statistically significantly associated with medication adherence with regular attendant clients having about fourfold greater odds of achieving optimal (≥95%) medication adherence [odds ratio (OR) = 3.89, 95% CI: 1.48 to 10.25, exact P = .013]. In multivariate analysis, clients in age category 35 years and below were less likely to achieve regular clinic attendance. Conclusion. Monitoring of clinic attendance may be an objective and effective measure and could be a useful adjunct to an adherence measure such as pill counting in resource-constrained settings. Where human resource constraints do not allow pill counts or other time-consuming measures, then monitoring clinic attendance and acting on missed appointments may be an effective proxy measure.