Stigma and Associated Sex Disparities Among Patients with Tuberculosis in Uganda: A Cross-Sectional Study.

Background: Tuberculosis (TB) is one of the leading causes of death from a single infectious agent globally. Stigma associated with TB encompassing self-, anticipated-, and public-stigma has significant negative effects on treatment adherence. In Uganda, limited data exist on the prevalence of stigma and its relationship with sex among patients with TB. We evaluate prevalence of three types of stigma and their relationship with the sex of patients undergoing TB treatment. Methods: This cross-sectional study was conducted between July 2020 to March 2021 at selected TB clinics in Kampala, Uganda. Eligible participants were aged 18-65 with confirmed TB and starting their prescribed treatment. We collected data on socio-demographics and used 13 items to capture the self-, anticipated-, and public-stigma from which we composed the dependent variables. The primary independent variable was sex. We employed multivariable logistic regression analysis to evaluate the association between sex and the three stigma types. Additionally, we considered potential confounders such as age, HIV, and employment status. Statistical significance was defined as p<0.05. Results: In this study we enrolled 144 participants with a mean age of 35.8 years (standard deviation = 12). Half of the participants (50%, n=72) were female, 44% had a secondary education, 37.5% were unemployed, and 32.6% were co-infected with HIV. The prevalence of self-stigma was 71.1%, anticipated stigma was 75.7%, and public stigma was 41.7%. Significant factors were associated with self-stigma were female sex (adjusted odds ratio (AOR): 2.35 95% CI: 1.02-5.74) and unemployment (AOR: 2.95 95% CI: 1.16-8.58). HIV-positive status was significantly associated with anticipated stigma (AOR: 3.58 95% CI: 1.38-11.23). However, none of the variables we evaluated showed a significant association with public stigma. Conclusions: Our study showed a high prevalence of self, anticipated and public stigma among TB patients. Notably, females and unemployed individuals were at a higher risk of self-stigma, while those with HIV/AIDS and TB were more likely to report anticipated stigma. To combat stigma effectively, interventions should be tailored to cater to sex-specific needs and persons living with HIV. Future research should delve further in determinants of TB-related stigma in high-burden settings.

Developing strategies to address barriers for tuberculosis case finding and retention in care among refugees in slums in Kampala, Uganda: a qualitative study using the COM-B model.

BACKGROUND: Globally, displaced populations face an increased burden of tuberculosis (TB). Uganda is currently hosting unprecedented big numbers of refugees from the East African region. Recent evidence shows increased spread of multi-drug resistant TB (MDR-TB) across East Africa as a result of migrants from Somalia- a high MDR-TB prevalent country, calling for urgent identification and management of cases for the countries in the region. One of the strategies recommended is optimization of diagnosis, treatment and prevention of TB in refugees. This study aimed at exploring the barriers to and facilitators for TB case finding and retention in care among urban slum refugees and suggestions on how to improve. This was to guide the development of interventions to improve TB case finding and retention in care among the said population. METHODS: A cross-sectional study utilizing qualitative methods was conducted among refugees in an urban slum in Kampala City, Uganda. Key informant interviews with health care workers and community leaders and in-depths interviews with refugee TB patients and care takers of TB patients were conducted (30 interviews in total). Interview questions were based on constructs from the COMB-B model (Capability, Opportunity and Motivation Model of Behaviour change). Manual content analysis was performed and identified targeted intervention strategies guided by the related Behavior Change Wheel implementation framework. RESULTS: Key barriers included; physical capability (availability of and easily accessible private facilities in the community with no capacity to diagnose and treat TB), psychological capability (lack of knowledge about TB among refugees), social opportunity (wide spread TB stigma and language barrier), physical opportunity (poor living conditions, mobility of refugees), reflective motivation (lack of facilitation for health workers), automatic motivation (discrimination and rejection of TB patients). Facilitators were; physical capability (availability of free TB services in the public health facilities), social opportunity (availability of translators). We identified education, incentivization, training, enablement, and restructuring of the service environment as relevant intervention functions with potential to address barriers to and enhance facilitators of TB case finding and retention among refugees in urban slums. CONCLUSION: The key barriers to TB control among refugees living urban slums in Kampala- Uganda, included; poor access to health services, limited knowledge about TB, TB stigma, language barrier and lack of facilitation of community health workers. Identified intervention strategies included; education, training, enablement, environmental restructuring and persuasion. The findings could serve as a guide for the design and implementation of interventions for improving the same.

Community drivers of tuberculosis diagnostic delay in Kampala, Uganda: a retrospective cohort study.

BACKGROUND: Recent approaches to TB control have focused on identifying and treating active cases to halt further transmission. Patients with TB symptoms often delay to seek care, get appropriate diagnosis, and initiate effective treatment. These delays are partly influenced by whom the patients contact within their community network. We aimed to evaluate the community drivers of diagnostic delay in an urban setting in Uganda. METHODS: In this study we analyze data from a retrospective cohort of 194 TB patients in Kampala, Uganda. We characterized the patterns of contacts made by patients seeking care for TB symptoms. The main outcome of interest was total community contact delay, defined as the time patients spent seeking care before visiting a provider capable of diagnosing TB. RESULTS: Visits to health providers without access to appropriate diagnostic services accounted for 56% of contacts made by cohort members, and were significantly associated with community contact delay, as were symptoms common to other prevalent illnesses, such as bone and joint pain. CONCLUSIONS: Education programs aimed at primary care providers, as well as other community members, may benefit case identification, by informing them of rarer symptoms of TB, potential for co-infections of TB and other prevalent diseases, and the availability of diagnostic services.

Defining an intermediate category of tuberculin skin test: A mixture model analysis of two high-risk populations from Kampala, Uganda.

One principle of tuberculosis control is to prevent the development of tuberculosis disease by treating individuals with latent tuberculosis infection. The diagnosis of latent infection using the tuberculin skin test is not straightforward because of concerns about immunologic cross reactivity with the Bacille Calmette-Guerin (BCG) vaccine and environmental mycobacteria. To parse the effects of BCG vaccine and environmental mycobacteria on the tuberculin skin test, we estimated the frequency distribution of skin test results in two divisions of Kampala, Uganda, ten years apart. We then used mixture models to estimate parameters for underlying distributions and defined clinically meaningful criteria for latent infection, including an indeterminate category. Using percentiles of two underlying normal distributions, we defined two skin test readings to demarcate three ranges. Values of 10 mm or greater contained 90% of individuals with latent infection; values less than 7.2 mm contained 80% of individuals without infection. Contacts with values between 7.2 and 10 mm fell into an indeterminate zone where it was not possible to assign infection. We conclude that systematic tuberculin skin test surveys within populations at risk, combined with mixture model analysis, may be a reproducible, evidence-based approach to define meaningful criteria for latent tuberculosis infection.

Excess Risk of Tuberculosis Infection Among Extra-household Contacts of Tuberculosis Cases in an African City.

BACKGROUND: Although households of tuberculosis (TB) cases represent a setting for intense transmission of Mycobacterium tuberculosis, household exposure accounts for <20% of transmission within a community. The aim of this study was to estimate excess risk of M. tuberculosis infection among household and extra-household contacts of index cases. METHODS: We performed a cross-sectional study in Kampala, Uganda, to delineate social networks of TB cases and matched controls without TB. We estimated the age-stratified prevalence difference of TB infection between case and control networks, partitioned as household and extra-household contacts. RESULTS: We enrolled 123 index cases, 124 index controls, and 2415 first-degree network contacts. The prevalence of infection was highest among household contacts of cases (61.5%), lowest among household contacts of controls (25.2%), and intermediary among extra-household TB contacts (44.9%) and extra-household control contacts (41.2%). The age-adjusted prevalence difference between extra-household contacts of cases and their controls was 5.4%. The prevalence of infection was similar among the majority of extra-household case contacts and corresponding controls (47%). CONCLUSIONS: Most first-degree social network members of TB cases do not have adequate contact with the index case to experience additional risk for infection, but appear instead to acquire infection through unrecognized exposures with infectious cases in the community.

Video directly observed therapy for supporting and monitoring adherence to tuberculosis treatment in Uganda: a pilot cohort study.

INTRODUCTION: Nonadherence to treatment remains an obstacle to tuberculosis (TB) control worldwide. The aim of this study was to evaluate the feasibility of using video directly observed therapy (VDOT) for supporting TB treatment adherence in Uganda. METHODS: From May to December 2018, we conducted a pilot cohort study at a TB clinic in Kampala City. We enrolled patients aged 18-65 years with ≥3 months remaining of their TB treatment. Participants were trained to use a smartphone app to record videos of medication intake and submit them to a secured system. Trained health workers logged into the system to watch the submitted videos. The primary outcome was adherence measured as the fraction of expected doses observed (FEDO). In a secondary analysis, we examined differences in FEDO by sex, age, phone ownership, duration of follow-up, reasons for missed videos and patients' satisfaction at study exit. RESULTS: Of 52 patients enrolled, 50 were analysed. 28 (56%) were male, the mean age was 31 years (range 19-50 years) and 35 (70%) owned smartphones. Of the 5150 videos expected, 4231 (82.2%) were received. The median FEDO was 85% (interquartile range 66%-94%) and this significantly differed by follow-up duration. Phone malfunction, uncharged battery and VDOT app malfunctions were the commonest reasons for missed videos. 92% of patients reported being very satisfied with using VDOT. CONCLUSION: VDOT was feasible and acceptable for monitoring and supporting TB treatment. It resulted in high levels of adherence, suggesting that digital technology holds promise in improving patient monitoring in Uganda.

There's no such thing as a free TB diagnosis: Catastrophic TB costs in Urban Uganda.

Identifying and reducing TB-related costs is necessary for achieving the End TB Strategy's goal that no family is burdened with catastrophic costs. This study explores costs during the pre-diagnosis period and assesses the potential for using coping costs as a proxy indicator for catastrophic costs when comprehensive surveys are not feasible. Detailed interviews about TB-related costs and productivity losses were conducted with 196 pulmonary TB patients in Kampala, Uganda. The threshold for catastrophic costs was defined as 20% of household income. Multivariable regression analyses were used to assess the influence of patient characteristics on economic burden, and the positive predictive value (PPV) of coping costs was estimated. Over 40% of patients experienced catastrophic costs, with average (median) pre-diagnosis costs making up 30.6% (14.1%) of household income. Low-income status (AOR = 2.91, 95% CI = 1.29, 6.72), hospitalisation (AOR = 8.66, 95% CI = 2.60; 39.54), and coping costs (AOR = 3.84, 95% CI = 1.81; 8.40) were significantly associated with the experience of catastrophic costs. The PPV of coping costs as an indicator for catastrophic costs was estimated to be 73% (95% CI = 58%, 84%). TB patients endure a substantial economic burden during the pre-diagnosis period, and identifying households that experience coping costs may be a useful proxy measure for identifying catastrophic costs.

High parity predicts use of long-acting reversible contraceptives in the extended postpartum period among women in rural Uganda.

BACKGROUND: The use of implants and Intra-uterine devices (IUD) during the post-partum period is very low in Uganda especially in rural settings. Long-acting reversible contraceptives (LARC) are known to be the most cost-effective for prevention of unintended pregnancy and unsafe abortions. This study aimed at determining the factors associated with long-acting reversible contraceptive use among women in the extended postpartum period in rural Uganda. METHODS: We conducted a household-based, cross-sectional study among 400 women in two rural communities in Mityana district, central Uganda. Eligible women were aged 15 to 45 years who had childbirth within 12 months of study enrollment in September 2014. The outcome variable was self-reported use of a LARC method, either IUD or implants in the extended postpartum period. The main independent variables were previous childbirths (parity), fertility desire, willingness to use modern contraception, duration of postpartum period and previous pregnancies (gravidity). A logistic regression model was run in STATA v12.0 to compute adjusted odds ratios (AOR) for factors that predicted LARC use statistically significant at p < 0.05. RESULTS: Four hundred respondents had a mean age of 27 years (SD = 12) and only 8.5% reported using a LARC method. Use of IUD and implant was 1.8% and 10.4% respectively. Most women using LARC (44.1%) had five or more childbirths (p = 0.01), 70.8% of non-LARC users were willing to use modern contraceptives (p = 0.07) and 2.5% ever had an induced abortion. Having five or more childbirths was independently associated with LARC use in the extended postpartum period (AOR = 4.07, 95%CI 1.08-15.4). Willingness to use modern contraception, desire for more children and postpartum duration had no significant association with LARC use in the extended postpartum period. CONCLUSION: This study revealed low use of LARC within twelve months of child birth despite women's willingness to use them. High parity (≥5 childbirths) predicted LARC use. The next logical step is to identify barriers to using LARC in the extended postpartum period and design appropriate interventions to increase access and use especially in multi-parous women.

Low Prevalence of Tuberculin Skin Test Boosting among Community Residents in Uganda.

Boosted tuberculin skin test (TST) reactions can be misclassified as new latent tuberculosis (TB) infection. To our knowledge, no study has evaluated the prevalence of TST boosting in a population-based sample in high TB burden settings. We determined the prevalence of TST boosting among urban residents in Uganda. We evaluated 99 participants with initial TST < 5 mm and repeated a skin test after 2 weeks. We found that only 2% had boosted TST reactions suggesting that most TST conversions could represent new TB infections in this high-burden setting.

#Globalhealth Twitter Conversations on #Malaria, #HIV, #TB, #NCDS, and #NTDS: a Cross-Sectional Analysis.

BACKGROUND: Advocates use the hashtag #GlobalHealth on Twitter to draw users' attention to prominent themes on global health, to harness their support, and to advocate for change. OBJECTIVES: We aimed to describe #GlobalHealth tweets pertinent to given major health issues. METHODS: Tweets containing the hashtag #GlobalHealth (N = 157,951) from January 1, 2014, to April 30, 2015, were purchased from GNIP Inc. We extracted 5 subcorpora of tweets, each with 1 of 5 co-occurring disease-specific hashtags (#Malaria, #HIV, #TB, #NCDS, and #NTDS) for further analysis. Unsupervised machine learning was applied to each subcorpus to categorize the tweets by their underlying topics and obtain the representative tweets of each topic. The topics were grouped into 1 of 4 themes (advocacy; epidemiological information; prevention, control, and treatment; societal impact) or miscellaneous. Manual categorization of most frequent users was performed. Time zones of users were analyzed. FINDINGS: In the entire #GlobalHealth corpus (N = 157,951), there were 40,266 unique users, 85,168 retweets, and 13,107 unique co-occurring hashtags. Of the 13,087 tweets across the 5 subcorpora with co-occurring hashtag #malaria (n = 3640), #HIV (n = 3557), #NCDS (noncommunicable diseases; n = 2373), #TB (tuberculosis; n = 1781), and #NTDS (neglected tropical diseases; n = 1736), the most prevalent theme was prevention, control, and treatment (4339, 33.16%), followed by advocacy (3706, 28.32%), epidemiological information (1803, 13.78%), and societal impact (1617, 12.36%). Among the top 10 users who tweeted the highest number of tweets in the #GlobalHealth corpus, 5 were individual professionals, 3 were news media, and 2 were organizations advocating for global health. The most common users' time zone was Eastern Time (United States and Canada). CONCLUSIONS: This study highlighted the specific #GlobalHealth Twitter conversations pertinent to malaria, HIV, tuberculosis, noncommunicable diseases, and neglected tropical diseases. These conversations reflect the priorities of advocates, funders, policymakers, and practitioners of global health on these high-burden diseases as they presented their views and information on Twitter to their followers.

Delays and Pathways to Final Tuberculosis Diagnosis in Patients from a Referral Hospital in Urban China.

AbstractChina is among the countries with the largest epidemic of drug susceptible and resistant tuberculosis globally. We investigated the locations tuberculosis patients visited before being diagnosed, total diagnostic delay, and risk factors associated with total delay from a large tuberculosis referral hospital in Nanjing, China. We conducted a retrospective cohort study among tuberculosis patients who initiated anti-tuberculosis treatment within 3 months prior to the study date. Patient information regarding time and locations visited while seeking care for tuberculosis-related symptoms was collected through face-to-face interviews. Crude and adjusted Cox proportional hazard ratios of factors associated with time to diagnosis were calculated. Of 179 bacteriologically confirmed patients, 37% were women and median age was 41 (interquartile range [IQR], 26-62). Public hospitals were the most commonly visited health-care institution and repeated visits to them were common. The mean days to tuberculosis diagnosis were 50.3. Female patients (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.04-1.48) or patients who contacted a health-care provider 2 weeks after becoming symptomatic (HR, 1.59; 95% CI, 1.43-1.70) were significantly less likely to have a timely diagnosis. In a referral hospital in urban China, we found that female tuberculosis patients took significantly more time to reach diagnosis than males and patients often cycled in public hospitals for multiple visits before reaching final diagnosis. Health professionals at public hospitals in Nanjing should be encouraged to refer potential tuberculosis patients as soon as possible to avoid nosocomial transmission.

The conduct of maternal and perinatal death reviews in Oyam District, Uganda: a descriptive cross-sectional study.

BACKGROUND: Uganda like many developing countries still experiences high levels of maternal and perinatal deaths despite a decade of maternal and perinatal death review (MPDR) program. Oyam district has been implementing MPDR since 2008 with varying successes among the health facilities. This paper presents the factors that influence the conduct of maternal and perinatal death reviews in Oyam District, Uganda. METHODS: This was a cross-sectional study where both qualitative and quantitative data were collected. Semi-structured interviews were administered to 66 health workers and ten key informants (KIs) to assess the factors influencing the conduct of MPDR. Univariate and Bivariate analysis of quantitative data was done using SPSS version 17.0. A Pearson Chi-Square test was done to determine factors associated with conduct of MPDR. Factors with a p-value < 0.05 were considered statistically significant. Qualitative data was analyzed using content analysis. RESULTS: Only 34.8 % of the health workers had ever participated in MPDR. The factors that influenced conduct of MPDR were existence of MPDR committees (p < 0.001), attendance of review meetings (p < 0.001) and knowledge of objectives of MPDR (p < 0.001), implementation of MPDR recommendations (p < 0.001), observed improvement in maternal and newborn care (p < 0.001) and provision of feedback (p < 0.001). Hindrance to conduct of MPDR was obtained from KIs: the health workers were not made aware of the MPDR process, committee formation and training of MPDR committee members was not effectively done, inadequate support supervision, and lack of financial motivation of MPDR committee members. Challenges to MPDR included: heavy workload to health workers, high number of perinatal deaths, and non-implementation of recommendations. CONCLUSION: The proportion of maternal and perinatal death reviews conducted in Oyam was low. This was due to poor initiation of the review process and a lack of support supervision. The district and Ministry of Health needs to put more emphasis on monitoring the conduct of maternal and perinatal death reviews by: forming and training MPDR committees and ensuring they are financially supported, providing overall coordination, and ensuring effective support supervision.

Psychosocial adjustment in perinatally human immunodeficiency virus infected or exposed children - a Retrospective Cohort Study.

OBJECTIVE: To determine whether perinatal HIV infection and exposure adversely affected psychosocial adjustment (PA) between 6 and 18 years of life (i.e. during school-age and adolescence). METHODS: We enrolled 58 perinatally HIV-infected, 56 HIV-exposed uninfected and 54 unexposed controls from Kampala, Uganda. Perinatal HIV status was determined by 18 months of age using a DNA-polymerase chain-reaction test and was confirmed via HIV rapid diagnostic test at psychosocial testing when the children were 6 to 18 years old. Five indicators of PA (depressive symptoms, distress, hopelessness, positive future orientation and esteem) were measured using validated, culturally adapted and translated instruments. Multivariable linear regression analyses estimated HIV-status-related percent differences (ß) in PA indicators and corresponding 95% confidence intervals (CIs). RESULTS: During school-age and adolescence, positive outlook (ß=-3.8, 95% CI: -7.2, -0.1) and self-esteem (ß=-4.3, 95% CI: -6.7, -1.8) scores were significantly lower, whereas depressive (ß=11.4, 95% CI: 3.3, 19.5) and distress (ß=12.3, 95% CI: 5.9, 18.7) symptoms were elevated for perinatally HIV-infected, compared to unexposed controls and exposed uninfected children. Similarly, positive outlook (ß=-4.3, 95% CI: -7.3, -1.2) and self-esteem were lower for exposed controls versus HIV-unexposed children. Hopelessness was similar by perinatal HIV status. Likewise, the distress and depressive symptom levels were comparable for HIV-exposed uninfected and HIV-unexposed children. CONCLUSIONS: Perinatal HIV infection predicted higher distress and depressive symptoms, while HIV-affected status (infection/exposure) predicted low self-esteem and diminished positive outlook in the long term. However, HIV-affected status had no impact on hopelessness, suggesting that psychosocial interventions as an integral component of HIV care for infected children or primary care exposed uninfected children may improve PA and quality of life in these vulnerable groups.

Infectiousness of HIV-Seropositive Patients with Tuberculosis in a High-Burden African Setting.

RATIONALE: Policy recommendations on contact investigation of HIV-seropositive patients with tuberculosis have changed several times. Current epidemiologic evidence informing these recommendations is considered low quality, and few large studies investigating the infectiousness of HIV-seropositive and -seronegative index cases have been performed in sub-Saharan Africa. OBJECTIVES: We assessed the infectiousness of HIV-seropositive and -seronegative patients with tuberculosis to their household contacts and examined potential modifiers of this relationship. METHODS: Adults suffering from their first episode of pulmonary tuberculosis were identified in Kampala, Uganda. Field workers visited index households and enrolled consenting household contacts. Latent tuberculosis infection was measured through tuberculin skin testing, and relative risks were calculated using modified Poisson regression models. Standard assessments of interaction between latent tuberculosis infection, the HIV serostatus of index cases, and other variables were performed. MEASUREMENTS AND MAIN RESULTS: Latent tuberculosis infection was found in 577 of 878 (65.7%) and 717 of 974 (73.6%) household contacts of HIV-seropositive and -seronegative tuberculosis cases (relative risk, 0.89; 95% confidence interval, 0.82-0.97). On further stratification, cavitary lung disease (P < 0.0001 for interaction) and smear status (P = 0.02 for interaction) of tuberculosis cases modified the infectiousness of HIV-seropositive indexes. Cough duration of index cases did not display interaction (P = 0.499 for interaction). CONCLUSIONS: This study suggests that HIV-seropositive tuberculosis cases may be less infectious than HIV-seronegative patients only when they are smear-negative or lack cavitary lung disease. These results may explain heterogeneity between prior studies and provide evidence suggesting that tuberculosis contact investigation should include HIV-seropositive index cases in high disease burden settings.

Perinatal HIV Status and Executive Function During School-Age and Adolescence: A Comparative Study of Long-Term Cognitive Capacity Among Children From a High HIV Prevalence Setting.

The aim of this study was to determine whether perinatal HIV infection (PHIV), HIV-exposed uninfected (PHEU) versus HIV-unexposed (PHU) status predicted long-term executive function (EF) deficit in school-aged Ugandan children.Perinatal HIV status was determined by 18 months via DNA polymerase chain reaction test and confirmed at cognitive assessment between 6 and 18 years using HIV rapid-diagnostic test. Primary outcome is child EF measured using behavior-rating inventory of executive function questionnaire across 8 subscales summed to derive the global executive composite (GEC). EF was proxy-reported by caregivers and self-reported by children 11 years or older. Descriptive analyses by perinatal HIV status included derivation of mean, standard deviations (SD), number, and percent (%) of children with EF deficits warranting clinical vigilance. Raw scores were internally standardized by age and sex adjustment. EF scores warranting clinical vigilance were defined as ≥ mean + 1.5SD. t Tests for mean score differences by perinatal HIV status and linear-regression models were implemented in SAS version 9.4 to derive HIV status-related EF deficits (ß) and 95% confidence intervals (CIs).Proxy-reported and self-reported EF were assessed in 166 and 82 children, respectively. GEC deficit was highest for PHIV (mean = 121.9, SD = 29.9), intermediate for PHEU (mean = 107.5, SD = 26.8), and lowest for PHU (mean = 103.4, SD = 20.7; P-trend < 0.01). GEC deficit levels warranting clinical vigilance occurred in 9 (15.8%), 5 (9.3%) and 0 (0%) PHIV, PHEU, and PHU children, respectively (P-trend = 0.01). Nineteen percent (n = 32) children had deficits requiring clinical vigilance in ≥2 proxy-reported EF subscales. Of these, multisubscale deficits occurred in 35.1%, 13.0%, and 9.3% of PHIV, PHEU, and PHU respectively (P-trend = 0.001). Multivariable analyses find significantly higher GEC deficits for PHIV compared with PHU and PHEU children regardless of respondent (all P values <0.01). Proxy-reported EF performance was similar for PHEU compared with PHU; however, child self-reported GEC scores were elevated by 12.8 units (95% CI: 5.4-25.5) for PHEU compared with PHU.PHIV had long-term EF deficits compared with other groups. Furthermore, PHEU ≥11 years may have long-term EF deficits compared with PHU, but future studies are needed to clarify this relationship. Cognitive remediation interventions with emphasis on EF may translate to improvements in long-term functional survival in HIV-affected children from sub-Saharan Africa.

Contraceptive use, knowledge, attitude, perceptions and sexual behavior among female University students in Uganda: a cross-sectional survey.

BACKGROUND: In Uganda, the risk of unintended pregnancies and unsafe abortions remains high due to relatively low contraceptive use. There is paucity of data on knowledge, attitudes, perceptions and practices towards modern contraceptives and, sexual and reproductive health especially among the young female university students. METHODS: A survey was conducted at Makerere University main campus in Kampala, Uganda during April 2014. A team of well-trained and experienced research assistants interviewed female undergraduate students who provided data on socio-demographic characteristics, knowledge, perceptions and attitudes and use of contraceptives, as well as other sexual and reproductive health practices. Users of any contraceptive method in the past 12 months were coded as '1' and none users as '0'. The prevalence of contraceptive use was determined as the number of users divided by all female participants. Prevalence ratios (PRs) with their corresponding 95 % confidence intervals were used as measures of association between contraceptive use and associated factors. The PRs were obtained via a modified Poisson regression model using a generalized linear model with Poisson as family and a log link without an offset but including robust standard errors. All analyses were conducted with Stata version 13. RESULTS: A total of 1,008 females responded to the survey; median (IQR) age was 21(20, 21) years, 38.6% in year 2 of study, and nearly three quarters (72.3%) were of Christian faith. Knowledge of any contraceptives was almost universal (99.6%) but only 22.1% knew about female condoms. Perceived acceptability of contraceptive use at the university (93%) or being beneficial to male partners too (97.8%) were high. Nearly 70% had ever engaged in sexual intercourse and 62.1% reported sexual intercourse in the past 12 months. Overall, 46.6% reported current contraceptive use, with male condoms (34.5%) being the commonest methods. Factors associated with higher contraceptive use were being in year 2, consensual union or perception that contraceptives are for females only. However, being evangelical/SDA or perception that contraceptive use is wrong was associated with lower contraceptive use. Overall, 9% reported ever being pregnant, 2% were pregnant at the time of the survey and a third (33.8%) knew of a pregnant friend. About 40% of ever pregnant respondents reported ever trying to terminate the pregnancy. CONCLUSIONS: Knowledge, perceived acceptability and benefits of contraceptive use were nearly universal, but contraceptive use was suboptimal in this setting. Ever trying to terminate a pregnancy was common and a clear indicator of unintended pregnancies.

Four Degrees of Separation: Social Contacts and Health Providers Influence the Steps to Final Diagnosis of Active Tuberculosis Patients in Urban Uganda.

BACKGROUND: Delay in tuberculosis (TB) diagnosis adversely affects patients' outcomes and prolongs transmission in the community. The influence of social contacts on steps taken by active pulmonary TB patients to seek a diagnosis has not been well examined. METHODS: A retrospective study design was use to enroll TB patients on treatment for 3 months or less and aged ≥18 years from 3 public clinics in Kampala, Uganda, from March to July 2014. Social network analysis was used to collect information about social contacts and health providers visited by patients to measure the number of steps and time between onset of symptoms and final diagnosis of TB. RESULTS: Of 294 TB patients, 58 % were male and median age was 30 (IQR: 24-38) years. The median number of steps was 4 (IQR: 3, 7) corresponding to 70 (IQR: 28,140) days to diagnosis. New patients had more steps and time to diagnosis compared retreatment patients (5 vs. 3, P < 0.0001; 84 vs. 46 days P < 0.0001). Fifty-eight percent of patients first contacted persons in their social network. The first step to initiate seeking care accounted for 41 % of the patients' time to diagnosis while visits to non-TB providers and TB providers (without a TB diagnosis) accounted for 34 % and 11 % respectively. New TB patients vs. retreatment (HR: 0.66, 95 % CI; 1.11, 1.99), those who first contacted a non-TB health provider vs. contacting social network (HR: 0.72 95 % CI; 0.55, 0.95) and HIV seronegative vs. seropositive patients (HR: 0.70, 95 % CI; 0.53, 0.92) had a significantly lower likelihood of a timely final diagnosis. CONCLUSIONS: There were four degrees of separation between the onset of symptoms in a TB patient and a final diagnosis. Both social and provider networks of patients influenced the diagnostic pathways. Most delays occurred in the first step which represents decisions to seek help, and through interactions with non-TB health providers. TB control programs should strengthen education and active screening in the community and in health care settings to ensure timely diagnosis of TB.

Age, sex, and nutritional status modify the CD4+ T-cell recovery rate in HIV-tuberculosis co-infected patients on combination antiretroviral therapy.

BACKGROUND: Baseline age and combination antiretroviral therapy (cART) were examined as determinants of CD4+ T-cell recovery during 6 months of tuberculosis (TB) therapy with/without cART. It was determined whether this association was modified by patient sex and nutritional status. METHODS: This longitudinal analysis included 208 immune-competent, non-pregnant, ART-naive HIV-positive patients from Uganda with a first episode of pulmonary TB. CD4+ T-cell counts were measured using flow cytometry. Age was defined as ≤24, 25-29, 30-34, and 35-39 vs. ≥40 years. Nutritional status was defined as normal (>18.5kg/m(2)) vs. underweight (≤18.5kg/m(2)) using the body mass index (BMI). Multivariate random effects linear mixed models were fitted to estimate differences in CD4+ T-cell recovery in relation to specified determinants. RESULTS: cART was associated with a monthly rise of 15.7 cells/µl (p<0.001). Overall, age was not associated with CD4+ T-cell recovery during TB therapy (p = 0.655). However, among patients on cART, the age-associated CD4+ T-cell recovery rate varied by sex and nutritional status, such that age <40 vs. ≥40 years predicted superior absolute CD4+ T-cell recovery among females (p=0.006) and among patients with a BMI ≥18.5kg/m(2) (p<0.001). CONCLUSIONS: TB-infected HIV-positive patients aged ≥40 years have a slower rate of immune restoration given cART, particularly if BMI is >18.5kg/m(2) or they are female. These patients may benefit from increased monitoring and nutritional support during cART.

Prevalence of latent tuberculosis infection and associated risk factors in an urban African setting.

BACKGROUND: Nearly one third of the world is infected with latent tuberculosis infection (LTBI) and a vast pool of individuals with LTBI persists in developing countries, posing a major barrier to global TB control. The aim of the present study was to determine the prevalence of LTBI and the associated risk factors among adults in Kampala, Uganda. METHODS: We performed a secondary analysis from a door-to-door cross-sectional survey of chronic cough conducted from January 2008 to June 2009. Urban residents of Rubaga community in Kampala aged 15 years and older who had received Tuberculin skin testing (TST) were included in the analysis. The primary outcome was LTBI defined as a TST with induration 10 mm or greater. Multivariable logistic regression analyses were used to assess the risk factors associated with LTBI. RESULTS: A total of 290 participants were tested with TST, 283 had their tests read and 7 didn't have the TST read because of failure to trace them within 48-72 hours. Of the participants with TST results, 68% were female, 75% were 15-34 years, 83% had attained at least 13 years of education, 12% were smokers, 50% were currently married, 57% left home for school or employment, 21% were HIV positive and 65% reported chronic cough of 2 weeks or longer. The overall prevalence of LTBI was 49% [95% CI 44-55] with some age-and sex-specific differences. On multivariable analysis, leaving home for school or employment, aOR = 1.72; [95%CI: 1.05, 2.81] and age 25-34, aOR = 1.94; [95%CI: 1.12, 3.38]; 35 years and older, aOR = 3.12; [95%CI: 1.65, 5.88] were significant risk factors of LTBI. CONCLUSION: The prevalence of LTBI was high in this urban African setting. Leaving home for school or employment and older age were factors significantly associated with LTBI in this setting. This suggests a potential role of expansion of one's social network outside the home and cumulative risk of exposure to TB with age in the acquisition of LTBI. Our results provide support for LTBI screening and preventive treatment programs of these sub-groups in order to enhance TB control.

Cost-effectiveness analysis of community active case finding and household contact investigation for tuberculosis case detection in urban Africa.

INTRODUCTION: Case detection by passive case finding (PCF) strategy alone is inadequate for detecting all tuberculosis (TB) cases in high burden settings especially Sub-Saharan Africa. Alternative case detection strategies such as community Active Case Finding (ACF) and Household Contact Investigations (HCI) are effective but empirical evidence of their cost-effectiveness is sparse. The objective of this study was to determine whether adding ACF or HCI compared with standard PCF alone represent cost-effective alternative TB case detection strategies in urban Africa. METHODS: A static decision modeling framework was used to examine the costs and effectiveness of three TB case detection strategies: PCF alone, PCF+ACF, and PCF+HCI. Probability and cost estimates were obtained from National TB program data, primary studies conducted in Uganda, published literature and expert opinions. The analysis was performed from the societal and provider perspectives over a 1.5 year time-frame. The main effectiveness measure was the number of true TB cases detected and the outcome was incremental cost-effectiveness ratios (ICERs) expressed as cost in 2013 US$ per additional true TB case detected. RESULTS: Compared to PCF alone, the PCF+HCI strategy was cost-effective at US$443.62 per additional TB case detected. However, PCF+ACF was not cost-effective at US$1492.95 per additional TB case detected. Sensitivity analyses showed that PCF+ACF would be cost-effective if the prevalence of chronic cough in the population screened by ACF increased 10-fold from 4% to 40% and if the program costs for ACF were reduced by 50%. CONCLUSIONS: Under our baseline assumptions, the addition of HCI to an existing PCF program presented a more cost-effective strategy than the addition of ACF in the context of an African city. Therefore, implementation of household contact investigations as a part of the recommended TB control strategy should be prioritized.