HiSTEP: A Single-Arm Pilot Study of a Technology-Assisted HIV Self-testing Intervention in Kampala, Uganda.

We developed and pilot tested a 3-month HIV self-testing intervention called HiSTEP ("HIV Self-testing Engagement Project") among 95 adult (18+ years) at-risk (condomless sex < 3 months) adults in Kampala, Uganda. HiSTEP leverages theoretically-grounded (in the Information-Motivation-Behavioral Skills model) text messages, a telehealth centre with live support, and "last-mile" HIV self-testing kit delivery to a location chosen by the participant. Nearly 94% of participants were retained at month 3. HIV self-testing was highly acceptable across age and gender groups (94% very satisfied), although older women had slightly lower acceptability ratings (92% very satisfied). Only 13% of participants used HIV self-testing prior to enrollment. Over the 3-month study period, 86% of participants ordered a total of 169 HIV self-testing kits (69% for participant use; 31% for use by others). Findings show that the intervention approach taken in HiSTEP may be particularly valuable for engaging at-risk Ugandan adults in HIV self-testing using a novel technology-assisted promotion and delivery method.

Chest X-ray interpretation does not complement Xpert MTB/RIF in diagnosis of smear-negative pulmonary tuberculosis among TB-HIV co-infected adults in a resource-limited setting.

BACKGROUND: Chest X-ray (CXR) interpretation remains a central component of the current World Health Organization recommendations as an adjuvant test in diagnosis of smear-negative tuberculosis (TB). With its low specificity, high maintenance and operational costs, utility of CXR in diagnosis of smear-negative TB in high HIV/TB burden settings in the Xpert MTB/RIF era remains unpredictable. We evaluated accuracy and additive value of CXR to Xpert MTB/RIF in the diagnosis of TB among HIV-positive smear-negative presumptive TB patients. METHODS: HIV co-infected presumptive TB patients were recruited from the Infectious Diseases Institute outpatient clinic and in-patient medical wards of Mulago Hospital, Uganda. CXR films were reviewed by two independent radiologists using a standardized evaluation form. CXR interpretation with regard to TB was either positive (consistent with TB) or negative (normal or unlikely TB). Sensitivity, specificity and predictive values of CXR and CXR combined with Xpert MTB/RIF for diagnosis of smear-negative TB in HIV-positive patients were calculated using sputum and/or blood mycobacterial culture as reference standard. RESULTS: Three hundred sixty-six HIV co-infected smear-negative participants (female, 63.4%; hospitalized, 68.3%) had technically interpretable CXR. Median (IQR) age was 32 (28-39) years and CD4 count 112 (23-308) cells/mm3. Overall, 22% (81/366) were positive for Mycobacterium tuberculosis (Mtb) on culture; 187/366 (51.1%) had CXR interpreted as consistent with TB, of which 55 (29.4%) had culture-confirmed TB. Sensitivity and specificity of CXR interpretation in diagnosis of culture-positive TB were 67.9% (95%CI 56.6-77.8) and 53.7% (95%CI 47.7-59.6) respectively, while Xpert MTB/RIF sensitivity and specificity were 65.4% (95%CI 54.0-75.7) and 95.8% (95%CI 92.8-97.8) respectively. Addition of CXR to Xpert MTB/RIF had overall sensitivity and specificity of 87.7% (95%CI 78.5-93.9) and 51.6% (95%CI 45.6-57.5) respectively; 86.2% (95%CI 75.3-93.5) and 48.1% (95%CI 40.7-55.6) among inpatients and 93.8% (95%CI 69.8-99.8) and 58.0% (95%CI 47.7-67.8) among outpatients respectively. CONCLUSION: In this high prevalence TB/HIV setting, CXR interpretation added sensitivity to Xpert MTB/RIF test at the expense of specificity in the diagnosis of culture-positive TB in HIV-positive individuals presenting with TB symptoms and negative smear. CXR interpretation may not add diagnostic value in settings where Xpert MTB/RIF is available as a TB diagnostic tool.

Disruption in Essential Health Service Delivery: A Qualitative Study on Access to Family Planning Information and Service Utilization During the First Wave of COVID-19 Pandemic in Uganda.

Background: Coronavirus disease 2019 (COVID-19) remains a challenge to public health with profound impact on people's lives. With several mitigation measures implemented to curb the spread of COVID-19, these impacted on access and utilization of general health services including family planning (FP) services. The objective of the study was to understand the extent to which COVID-19 interrupted access and utilization of FP services as well as highlight the challenges faced during the lockdown in Uganda. Methods: A qualitative study was carried out in August and September 2020 across the country. A total of 21 key informant interviews among researchers, policy makers, funding agencies, district family planning focal persons, district health officers and service providers with implementing partners were conducted. These were conducted using face to face (7), phone calls (11) and zoom (3) meetings. All interviews were audio recorded and transcribed verbatim. Transcripts were used to identify and generate codes, sub themes and themes. Analysis was done using the thematic framework analysis and results presented in themes. Results: Five themes were identified in this study which included; (i) financial and psychosocial needs, (ii) mobility hindrances, (iii) disrupted service delivery, (iv) responsive reproductive health services. The financial and psychosocial needs themes included: household and individual financial constraints, unpredictable future and community acceptance, loss of employment and unemployment, misconceptions and unintended pregnancies; while mobility hindrances included; restricted movement, high transport costs, and difficulty in finding transport. Conclusion: Results showed that the pandemic had immediate and significant long-term effects on family planning service accessibility, utilization and delivery. The study recommends implementation of telehealth services, country-wide sensitization on use of long-term contraceptive methods, empowering village health teams and making family planning services mandatory and free to all private facilities in order to lower any disruptions during pandemics.

Continuity of health service delivery during the COVID-19 pandemic: the role of digital health technologies in Uganda.

In response to coronavirus disease-2019 pandemic (COVID-19), the government of Uganda instituted movement restrictions to curb disease spread. However, this affected accessibility to medical services in a setting where the healthcare system is not equipped to handle most healthcare needs of the populace outside hospital premises. This gap led to the prominence and unprecedented rise in the use of digital health technologies to deliver health information and services at a distance (telehealth) during the COVID-19 outbreak. The use of telehealth modalities including tele-consultation, tele-psychiatry, call centers and mobile phone health information dissemination increased. The COVID-19 pandemic augmented the rising role of digital health technologies as a much needed aspect of medical service delivery in our times. However, the efficacy and impact on clinical outcomes across various healthcare thematic areas need to be explored further and more evidence generated.

Clinical predictors and accuracy of empiric tuberculosis treatment among sputum smear-negative HIV-infected adult TB suspects in Uganda.

INTRODUCTION: The existing diagnostic algorithms for sputum smear-negative tuberculosis (TB) are complicated, time-consuming, and often difficult to implement. The decision to initiate TB treatment in resource-limited countries is often largely based on clinical predictors. We sought to determine the clinical predictors and accuracy of empiric TB treatment initiation in HIV-infected sputum smear-negative TB suspects using sputum culture as a reference standard. SETTING: Out-patient HIV-TB integrated urban clinic in Kampala, Uganda. METHODS: HIV-infected TB suspects were screened using sputum smear microscopy, and mycobacterial sputum liquid and solid cultures were performed. Smear results were made available to the clinician who made a clinical decision on empiric TB treatment initiation for sputum smear-negative patients. Clinic records were reviewed for patients whose sputum smears were negative to collect data on socio-demographics, TB symptomatology, chest X-ray findings, CD4 cell counts and TB treatment initiation. RESULTS: Of 253 smear-negative TB suspects, 56% (142/253) were females, median age 38 IQR (31-44) years, with a median CD4 cell count of 291 IQR (150-482) cells/mm(3). Of the 85 (33.6%) smear-negative patients empirically initiated on TB treatment, 35.3% (n = 30) were sputum culture positive compared to only 18 (10.7%) of the 168 untreated patients (p<0.001). Abnormal chest X-ray [aOR 10.18, 95% CI (3.14-33.00), p<0.001] and advanced HIV clinical stage [aOR 3.92, 95% CI (1.20-12.85), p = 0.024] were significantly associated with empiric TB treatment initiation. The sensitivity and specificity of empiric TB treatment initiation in the diagnosis of TB in HIV-infected patients after negative smear microscopy was 62.5% and 73.7% respectively. CONCLUSION: In resource-limited settings, clinically advanced HIV and abnormal chest X-ray significantly predict a clinical decision to empirically initiate TB treatment in smear-negative HIV-infected patients. Empiric TB treatment initiation correlates poorly with TB cultures. Affordable, accurate and rapid point-of-care diagnostics are needed in resource-limited settings to more accurately determine which HIV-infected TB suspects have smear-negative TB.