HIV prevalence among children admitted with severe acute malnutrition and associated factors with mother-to-child HIV transmission at Mulago Hospital, Uganda: A mixed methods study.

BACKGROUND: Despite global efforts to eliminate mother-to-child-transmission of HIV (MTCT), many children continue to become infected. We determined the prevalence of HIV among children with severe acute malnutrition (SAM) and that of their mothers, at admission to Mwanamugimu Nutrition Unit, Mulago Hospital, Uganda. We also assessed child factors associated with HIV-infection, and explored factors leading to HIV-infection among a subset of the mother-child dyads that tested positive. METHODOLOGY: We conducted a cross-sectional evaluation within the REDMOTHIV (Reduce mortality in HIV) clinical trial that investigated strategies to reduce mortality among HIV-infected and HIV-exposed children admitted with SAM at the Nutrition Unit. From June 2021 to December 2022, we consecutively tested children aged 1 month to 5 years with SAM for HIV, and the mothers who were available, using rapid antibody testing upon admission to the unit. HIV-antibody positive children under 18 months of age had a confirmatory HIV-DNA PCR test done. In-depth interviews (IDIs) were conducted with mothers of HIV positive dyads, to explore the individual, relationship, social and structural factors associated with MTCT, until data saturation. Quantitative data was analyzed using descriptive statistics and logistic regression in STATAv14, while a content thematic approach was used to analyze qualitative data. RESULTS: Of 797 children tested, 463(58.1%) were male and 630(79.1%) were ≤18months of age; 76 (9.5%) tested positive. Of 709 mothers, median (IQR) age 26 (22, 30) years, 188(26.5%) were HIV positive. Sixty six of the 188 mother-infant pairs with HIV exposure tested positive for HIV, an MTCT rate of 35.1% (66/188). Child age >18 months was marginally associated with HIV-infection (crude OR = 1.87,95% CI: 1.11-3.12, p-value = 0.02; adjusted OR = 1.72, 95% CI: 0.96, 3.09, p-value = 0.068). The IDIs from 16 mothers revealed associated factors with HIV transmission at multiple levels. Individual level factors: inadequate information regarding prevention of MTCT(PMTCT), limited perception of HIV risk, and fear of antiretroviral drugs (ARVs). Relationship level factors: lack of family support and unfaithfulness (infidelity) among sexual partners. Health facility level factors: negative attitude of health workers and missed opportunities for HIV testing. Community level factors: poverty and health service disruptions due to the COVID-19 pandemic. CONCLUSION: In this era of universal antiretroviral therapy for PMTCT, a 10% HIV prevalence among severely malnourished children is substantially high. To eliminate vertical HIV transmission, more efforts are needed to address challenges mothers living with HIV face intrinsically and within their families, communities and at health facilities.

Deploying machine learning with messy, real world data in low- and middle-income countries: Developing a global health use case.

The rapid emergence of machine learning in the form of large-scale computational statistics and accumulation of data offers global health implementing partners an opportunity to adopt, adapt, and apply these techniques and technologies to low- and middle-income country (LMIC) contexts where we work. These benefits reside just out of the reach of many implementing partners because they lack the experience and specific skills to use them. Yet the growth of available analytical systems and exponential growth of data require the global digital health community to become conversant in this technology to continue to make contributions to help fulfill our missions. In this community case study, we describe the approach we took at IntraHealth International to inform the use case for machine learning in global health and development. We found that the data needed to take advantage of machine learning were plentiful and that an international, interdisciplinary team can be formed to collect, clean, and analyze the data at hand using cloud-based (e.g., Dropbox, Google Drive) and open source tools (e.g., R). We organized our work as a "sprint" lasting roughly 10 weeks in length so that we could rapidly prototype these approaches in order to achieve institutional buy in. Our initial sprint resulted in two requests in subsequent workplans for analytics using the data we compiled and directly impacted program implementation.

Motivators of couple HIV counseling and testing (CHCT) uptake in a rural setting in Uganda.

BACKGROUND: Couple HIV Counseling and Testing (CHCT) is one of the key preventive strategies used to reduce the spread of HIV. In Uganda, HIV prevalence among married/living together is 7.2% among women and 7.6% among men. CHCT can help ease disclosure of HIV-positive status, which in turn may help increase opportunities to get social support and reduce new infections. The uptake of CHCT among attendees of health facilities in rural Uganda is as high as 34%. The purpose of this study was to explore the motivators of CHCT uptake in Mukono district, a rural setting in Uganda. METHODS: The study was conducted in two sub-counties in a rural district (Mukono district) about 28 km east of the capital Kampala, using a descriptive and explorative qualitative research design. Specifically, we conducted focus group discussions and key informant interviews with HIV focal persons, village health team (VHT) members, religious leaders and political leaders. We also interviewed persons in couple relationships. Data was analysed using NVivo 8 software. Ethical clearance was received from the Mengo Hospital Research Review Board and from the Uganda National Council of Science and Technology. RESULTS: The study was conducted from June 2013 to July 2013 We conducted 4 focus group discussions, 10 key informant interviews and interviewed 53 persons in couple relationships. None of the participants were a couple. The women were 68% (36/53) and 49% (26/53) of them were above 29 years old. The motivators of CHCT uptake were; perceived benefit of HIV testing, sickness of a partner or child in the family and suspicion of infidelity. Other important motivators were men involvement in antenatal care (ANC) attendance and preparation for marriage. CONCLUSION: The motivators for CHCT uptake included the perceived benefit of HIV testing, sickness of a partner or child, preparation for marriage, lack of trust among couples and men involvement in antenatal care. Greater attention to enhancers of CHCT programming is needed in trying to strengthen its uptake.

Changes in the timing of antiretroviral therapy initiation in HIV-infected patients with tuberculosis in Uganda: a study of the diffusion of evidence into practice in the global response to HIV/AIDS.

BACKGROUND: We aimed to determine the extent to which emerging evidence and changing guidelines regarding timing of antiretroviral therapy (ART) among human immunodeficiency virus (HIV)-infected patients with tuberculosis influenced "real-world" clinical practice in Uganda. METHODS: We evaluated ART-naive, HIV-infected adults starting tuberculosis therapy at 2 HIV clinics in Uganda between 26 August 2006 and 29 September 2012. We used multivariate regression to calculate associations between 4 calendar periods reflecting publication of seminal clinical studies or changes in guidelines and timing of ART after tuberculosis therapy initiation. RESULTS: For patients with CD4 counts <50 cells/µL, the fraction starting ART within 14 and 30 days of initiating tuberculosis therapy increased from 7% to 14% and from 14% to 86% over the period of observation. The fraction of patients with CD4 counts >50 cells/µL starting ART within 60 days increased from 16% to 28%. After adjustment for sociodemographic factors, when comparing the most recent with the earliest calendar period, the rate of ART initiation increased by 4.57-fold (95% confidence interval [CI], 1.76-fold to 11.86-fold) among patients with baseline CD4 counts ≤ 50 cells/µL and by 5.43-fold (95% CI, 3.16- fold to 9.31-fold) among those with baseline CD4 counts >50 cells/µL. CONCLUSIONS: We observed large changes in clinical practice during a period of emerging data and changing guidelines among HIV-infected patients with tuberculosis. Nonetheless, a significant proportion of individuals with higher CD4 cell counts do not start ART within recommended time frames. Targeted dissemination and implementation efforts are still needed to achieve target levels in practice.