Factors that influence the satisfaction of people living with HIV with differentiated antiretroviral therapy delivery models in east Central Uganda: a cross-sectional study.

BACKGROUND: The World Health Organization (WHO) and the Uganda Ministry of Health recommend differentiated service delivery models (DSDMs) as patient-centered antiretroviral therapy (ART) mechanisms for people living with HIV/AIDS (PLHIV) with undetectable viral loads. We studied patient satisfaction with ART services, and its associated factors amongst PLHIV enrolled in DSDMs in Uganda. METHODS: This cross-sectional study involved a random sample of PLHIV accessing DSDM-related ART at nine facilities in East Central Uganda. Eligible patients were adult PLHIV (≥18 years), on ART, and enrolled for at least 12 months in one of three DSDMs: Community Client-Led ART Delivery (CCLAD), Community Drug Distribution Points (CDDP), or Fast-Track Drug Refill (FTDR). We collected data from June to July 2019. A validated tool measured satisfaction. General Estimating Equations with modified Poisson regression and exchangeable correlation structures accounted for clustering at health facilities and identified DSDM-related satisfaction factors. RESULTS: Of 842 participants enrolled, 530 (63.5%) accessed HIV care through CDDP, 166 (20.1%) through CCLAD, and 146 (16.3%) through FTDR; 541 (64.2%) were satisfied with DSDM services: 78.7% in CDDP, 42.8% in CCLAD, and 36.3% in FTDR. The delivery and treatment factors positively associated with satisfaction included: being enrolled on CDDP [adjusted prevalence ratio (aPR) = 1.51, 95% CI:1.47-1.56] or FTDR [aPR = 1.47, 95% CI:1.26-1.71] relative to CCLAD and being enrolled in a DSDM for more than 3 years [aPR = 1.28, 95% CI:1.11-1.48]. Poor ART adherence [aPR = 0.33, 95% CI:0.19-0.56] and having a baseline WHO HIV stage of 3 or 4 [aPR = 0.36, 95% CI:0.20-0.64] relative to stages 1 and 2 were negatively associated. Among socioeconomic factors, having lower transport costs (< $1.35) per clinic visit [aPR = 1.34, 95% CI:1.17-1.53], being employed [aPR = 1.61, 95% CI:1.38-1.87], and being single [aPR = 1.10, 95% CI:1.08-1.13] were positively associated with satisfaction; drinking alcohol at least once a week [aPR = 0.77, 95% CI:0.63-0.93] was negatively associated with patient satisfaction. CONCLUSIONS: Results showed that 64.2% of patients were satisfied with DSDM services. HIV service delivery and treatment factors (DSDM type, time in DSDM, WHO stage, ART adherence), plus social factors (employment and marital status, transport costs, alcohol consumption), were associated with patient satisfaction. DSDM implementers should tailor services to address these factors to improve patient satisfaction.

Trends in antenatal care attendance and health facility delivery following community and health facility systems strengthening interventions in Northern Uganda.

BACKGROUND: Maternal morbidity and mortality remains high in Uganda; largely due to inadequate antenatal care (ANC), low skilled deliveries and poor quality of other maternal health services. In order to address both the demand and quality of ANC and skilled deliveries, we introduced community mobilization and health facility capacity strengthening interventions. METHODS: Interventions were introduced between January 2010 and September 2011. These included: training health workers, provision of medical supplies, community mobilization using village health teams, music dance and drama groups and male partner access clubs. These activities were implemented at Kitgum Matidi health center III and its catchment area. Routinely collected health facility data on selected outcomes in the year preceding the interventions and after 21 months of implementation of the interventions was reviewed. Trend analysis was performed using excel and statistical significance testing was performed using EPINFO StatCal option. RESULTS: The number of pregnant women attending the first ANC visit significantly increased from 114 to 150 in the first and fourth quarter of 2010 (OR 1.72; 95% CI 1.39-2.12) and to 202 in the third quarter of 2011(OR 11.41; 95% CI 7.97-16.34). The number of pregnant women counselled, tested and given results for HIV during the first ANC attendance significantly rose from 92 (80.7%) to 146 (97.3%) in the first and fourth quarter of 2010 and then to 201 (99.5%) in the third quarter of 2011. The number of male partners counseled, tested and given results together with their wives at first ANC visit rose from 13 (16.7%) in the fourth quarter of 2009 to 130 (89%) in the fourth quarter of 2010 and to 180 (89.6%) in the third quarter of 2011. There was a significant rise in the number of pregnant women delivering in the health facility with provision of mama-kits (delivery kits), from 74 (55.2%) to 149 (99.3%) in the second and fourth quarter of 2010. CONCLUSIONS: Combined community and facility systems strengthening interventions led to increased first ANC visits by women and their partners, and health facility deliveries. Interventions aimed at increasing uptake of maternal health services should address both the demand and availability of quality services.

B-cell differentiation in EBV-positive Burkitt lymphoma is impaired at posttranscriptional level by miRNA-altered expression.

Endemic, sporadic and HIV-associated Burkitt lymphoma (BL) all have a B-cell phenotype and a MYC translocation, but a variable association with the Epstein-Barr virus (EBV). However, there is still no satisfactory explanation of how EBV participates in the pathogenesis of BL. A recent investigation suggested that EBV-positive and EBV-negative BL have different cells of origin. In particular, according to immunoglobulin gene mutation analysis, EBV-negative BLs may originate from early centroblasts, whereas EBV-positive BLs seem to arise from postgerminal center B cells or memory B cells. The appearance of a germinal center phenotype in EBV-positive cells might thus derive from a block in B-cell differentiation. The exit from the germinal center involves a complex series of events, which require the activation of BLIMP-1, and the consequent downregulation of several target genes. Here, we investigated the expression of specific miRNAs predicted to be involved in B-cell differentiation and found that hsa-miR-127 is differentially expressed between EBV-positive and EBV-negative BLs. In particular, it was strongly upregulated only in EBV-positive BL samples, whereas EBV-negative cases showed levels of expression similar to normal controls, including microdissected germinal centers (GC) cells. In addition, we found evidence that hsa-miR-127 is involved in B-cell differentiation process through posttranscriptional regulation of BLIMP1 and XBP1. The overexpression of this miRNA may thus represent a key event in the lymphomagenesis of EBV positive BL, by blocking the B-cell differentiation process.

Action for child survival: elimination of Haemophilus influenzae type b meningitis in Uganda.

OBJECTIVE: To guide immunization policy, we determined the public health benefit of introducing Haemophilus influenzae type b (Hib) vaccine in Uganda and estimated the vaccine effectiveness. METHODS: Surveillance data for acute bacterial meningitis among children aged 0-59 months were reviewed from three hospital sentinel sites, for July 2001 to June 2007, to determine the incidence of Hib meningitis, the effectiveness of Hib vaccine with a case-control design, and the number of vaccine-preventable cases and deaths of Hib disease in Uganda. FINDINGS: Of the 13 978 children from 17 districts with suspected bacterial meningitis, 269 had confirmed Hib meningitis, declining from 69 patients in the prevaccine year (2001-2002) to three in 2006-2007. Hib meningitis incidence dropped from 88 cases per 100,000 children aged < 5 years in the year before vaccine introduction to 13 within 4 years, and to near zero in the fifth year. Vaccine effectiveness for 2 or more doses was 93% (95% confidence interval, CI: 69-99) against confirmed Hib meningitis and 53% (95% CI: 11-68) against purulent meningitis of unknown cause. In Uganda, Hib vaccine prevents an estimated 28 000 cases of pneumonia and meningitis, 5000 deaths and 1000 severe meningitis sequelae each year. CONCLUSION: Infant immunization with Hib vaccine has virtually eliminated Hib meningitis in Uganda within 5 years. Ensuring long-term benefits of Hib vaccine urgently requires sustainable vaccine financing, high-quality ongoing surveillance, and a health sector able to deliver a robust immunization programme.

Differences in hospital admissions for males and females in northern Uganda in the period 1992-2004: a consideration of gender and sex differences in health care use.

To inform our understanding of male and female health care use, we assessed sex differences in hospital admissions by diagnosis and for in-patient mortality using discharge records for 210319 patients admitted to the Lacor Hospital in northern Uganda in the period 1992-2004. These differences were interpreted using a gender framework. The overall number of admissions was similar by sex, yet differences emerged among age groups. In children (0-14 years), malaria was the leading cause of admission, and the distribution of diseases was similar between sexes. Among 15-44 year olds, females had more admissions, overall, and for malaria, cancer and anaemia, in addition to delivery and gynaeco-obstetrical conditions (25.7% of female admissions). Males had more admissions for injuries, liver disease and tuberculosis in the same age group. In older persons (>or=45 years), women had more admissions for cancer, hypertension, malaria and diarrhoea, while, as for the previous age group, males had more admissions for injuries, liver disease and tuberculosis. This study provides insight into sex- and gender-related differences in health. The analysis and documentation of these differences are crucial for improving service delivery and for assessing the achievement of the dual goals of improving health status and reducing health inequalities.

Effect of a low-cost food on the recovery and death rate of malnourished children.

OBJECTIVES: Nutritional rehabilitation in Africa relies mainly on imported skim milk enriched with a sugar and salt mixture. We evaluated whether milk plus porridge made from local ingredients improves the outcome of childhood nutritional rehabilitation versus milk alone. PATIENTS AND METHODS: This study was conducted in a nutritional unit in Lacor (Northern Uganda). The porridge, made from cheap locally available ingredients (maize flour, dried fish or meat, peanut butter and oil) supplemented with proteins and fats, provides 1.1 energy units, 4.4 kJ/g. We randomly sampled the files of 100 cases discharged in October, November and December 2001 (preintervention), in 2002 (soon after intervention onset) and in 2003 (more than 1 year after intervention onset). We recorded the average hospital days and average oedema-free weight gain at discharge in the 3 groups. RESULTS: Average oedema-free weight gain increased from 21 g/d (95% confidence interval [CI], 12-29) in 2001 to 35 g/d (95% CI, 25-45) in 2002 and reached 59 g/d (95% CI, 51-65) in 2003. Mortality decreased from 22% to 7.8%, and nutritional failures (insufficient weight gain) decreased by greater than 50%. CONCLUSIONS: The low-cost porridge supplement (2640 euros/yr per 100 children) was effective in treating malnutrition. Widespread use of the porridge, which resulted in better outcomes than milk alone, could produce a savings in the medium- to long-term, thereby releasing resources for other uses. A high-energy porridge that is made from locally available ingredients and does not require imported foods seems to be appropriate for supplementary feeding after mother's milk in this setting.

Availability of Human Immunodeficiency Virus Prevention Services in Secondary Schools in Kabarole District, Uganda.

The aim of this study was to assess the level of availability of HIV prevention strategies in secondary schools in Kabarole district, Uganda in order to inform the design of interventions to strengthen HIV Prevention and psychosocial support. Quantitative and qualitative research methods were used in eight secondary schools in Kabarole district to establish available HIV prevention and psychosocial support services. Questionnaires were administered to 355 students 12-24 years old. In addition, 20 Key Informant interviews were held with education service providers. Quantitative data was analyzed using Epi-data and qualitative data were analyzed by thematic content analysis. Seven of the eight schools had at least one HIV prevention strategy. Two teachers in each of the five schools had been trained in HIV prevention. No school had a nurse trained in HIV prevention, care and support. Education service providers had limited knowledge of HIV prevention support and care of students living with HIV. We found out that students had knowledge on how one can acquire HIV. HIV prevention services reported by students in schools included: talks from teachers and guests (19%), drama with HIV prevention related messages (16%), peer education clubs (15%), workshops and seminars on HIV (8%), sensitization about HIV/AIDS (7%), guidance and counseling (6%), talking compounds- (5%), abstinence talks (6%), keeping students busy in sports (4%), straight talk (4%). Sixty three percent reported receiving HIV reading materials from various sources. Preventing HIV infection among students in schools is still demanding with limited interventions for students. Efforts to support school interventions should focus on including HIV Prevention in the school curriculum, working with peer educators as well as education service providers who spend much of the time with the students while at school.

The burden of traditional practices, ebino and tea-tea, on child health in Northern Uganda.

Traditional medical practices persist today in Northern Uganda; for example, the operations of ebino and tea-tea are frequently performed in childhood. Ebino, or "false teeth", refers to gingival swellings during the eruption of the primary canine teeth in infants, and consists of the extraction of deciduous canine tooth buds. Tea-tea consists of systematic cuts made on the chest wall when the child has difficulty in breathing. The objectives of this study are to describe the morbidity and mortality related to complications arising from the ebino and tea-tea procedures among children admitted to the paediatric ward of St. Mary's Hospital Lacor in 1999, and to estimate the prevalence of ebino and tea-tea among children aged 0-4 years attending, for any cause, the child welfare department (CWD) of the hospital. The prevalence survey consisted of the examination of 1,995 children attending CWD during a four-week period in 1999 to look for missing primary canine teeth (ebino), and for "therapeutic" cuts on the chest wall (tea-tea). In the difficult context of war and social disruption prevailing in Northern Uganda, sustainable methods of data collection and analysis should be utilised to support evidence-based decision-making.