Decompensated cirrhosis-related admissions in a large urban hospital in Uganda: prevalence, clinical and laboratory features and implications for planning patient management.

BACKGROUND: Cirrhosis-related complications are a major cause of morbidity and mortality in areas where its risk factors are endemic. OBJECTIVE: We determined the prevalence of decompensated cirrhosis among patients on the gastroenterology service of Mulago Hospital and described the clinical and laboratory features of these patients. METHODS: All patients admitted to the unit were assessed and their diagnosis documented. Patients with cirrhosis had clinical features of decompensation recorded. History of alcohol consumption was taken and testing for hepatitis B surface antigen (HBsAg) and hepatitis C antibody (anti-HCV) performed. RESULTS: Between September 2010 and January 2011, we enrolled 482 patients. The majority (53.7%) were male, overall median age 38 years. Decompensated cirrhosis was diagnosed in 85 (17.6%) patients. Of the 85 patients, 47 (55.3%) gave a history of alcohol intake, HBsAg was positive in 23 (27.1%) and anti-HCV in 3 (3.5%). Decompensation was defined by ascites among 81 (95.3%) patients, variceal bleeding in 31 (36.5%), encephalopathy in 20 (23.5%). CONCLUSION: Cirrhosis is common in Mulago hospital presenting mainly with ascites and variceal bleeding. Aside from controlling causes of liver diseases, especially alcohol and hepatitis B virus infection, in the interim it is necessary to manage complications in patients who already have cirrhosis.

Religiosity for HIV prevention in Uganda: a case study among Christian youth in Wakiso district.

BACKGROUND: Utilization of religious institutions is one of the strategies for HIV prevention in Uganda. There is limited data on the association between religiosity and HIV infection rates. OBJECTIVE: To determine the association between religiosity and HIV prevalence rates among Christians. METHODS: An unmatched case-control study was done. Data from 106 HIV positive cases and 424 HIV negative controls between 15- 24 years were analyzed. RESULTS: Lower religiosity was associated with higher HIV infection rates when the following dimensions were analyzed: feeling guided by God in daily activities (odds ratio 1.90, 95%CI 1.03-3.50, p=0.035), feeling thankful for God's blessings (odds ratio 1.76, 95%CI 1.01-3.11, p=0.042), praying privately (odds ratio 2.02, 95%CI 1.30-3.11, p=0.001), trying hard to be patient in life (odds ratio1.74, 95%CI 1.07-2.84, p=0.024) and trying hard to love God (odds ratio 1.57, 95%CI 1.01-2.42, p=0.039). Higher HIV infection rates were associated with having multiple life-time sexual partners (odds ratio 5.37, 95%CI 1.86-15.47, p<0.001), ever drinking alcohol (odds ratio 2.28, 95%CI 1.43-3.65, p<0.001) and ever using narcotics for recreation (odds ratio 2.49, 95%CI 1.14-5.44, p=0.018). CONCLUSION: Lower levels of several dimensions religiosity are significantly associated with higher HIV infection rates. This data supports strengthening religiosity in HIV prevention strategies.

Evidence-based monitoring and evaluation of the faith-based approach to HIV prevention among Christian and Muslim youth in Wakiso district in Uganda.

BACKGROUND: The Islamic Medical Association of Uganda, has been implementing the faith-based approach to HIV prevention without baseline data on expected positive outcomes. OBJECTIVES: To establish evidence-based baseline data on expected positive outcomes of the faith-based approach to HIV prevention. METHODS: A cross-sectional study of 15-24 year-old youths was analyzed for significant associations between HIV infections, risky behaviors, and religiosity RESULTS: HIV prevalence was 3.6% among Christians and 2.4% among Muslims. Abstaining from sex among teenagers was at 54% for Christians and 58% for Muslims. Being faithful in marriage among males was at 41% for Christians and 34% for Muslims and among females it was 65% for Christians and 69% for Muslims. Praying privately was associated with lower HIV infections and was observed among 60% of Christians. Sujda, the hyperpigmented marker of regular prayers on the forehead of Muslims was associated with lower HIV infections and observed in 42% of them. Ever drank alcohol was associated with higher HIV prevalence and observed in 52% of Christians and 17% of Muslims. Male circumcision rates were 15% for Christians and 98% for Muslims. CONCLUSION: A sero-behavioral-religiosity survey can provide evidence-based data for monitoring and evaluation of the faith-based approach to HIV prevention.

Religiosity for HIV prevention in Uganda: a case study among Muslim youth in Wakiso district.

BACKGROUND: Evidence for the association between religiosity and HIV infections is limited. Sujda, the hyper-pigmented spot on the forehead due to repeated prostration during prayers and fasting to worship, involving abstaining from food, drink and sex during daytime in Ramadhan and other specified days, are measures of religiosity among Muslims OBJECTIVES: To assess the association between religiosity and HIV infections. METHODS: This was an unmatched case-control study with 29 HIV positive cases and 116 HIV negative controls, from 1224 Muslims, 15-24 years. RESULTS: Respondents without Sujda had more HIV infections (odds ratio 2.90, 95% CI 1.07-7.86, p=0.029). Those with Sujda were more likely to abstain from sex (odds ratio 1.69, 95% CI 1.31-2.20, p<0.001) and be faithful in marriage (odds ratio 1.69, 95% CI 1.11-2.57, p=0.012). Respondents without Sujda were more likely to have ever taken alcohol before sex (odds ratio 5.00, 95% CI 1.39-17.95, p=0.006) and to have ever used narcotics (odds ratio 2.12, 95% CI, 1.11-4.05, p=0.019). Respondents who fasted less, had more HIV infections (odds ratio 2.46, 95% CI 1.07-5.67, p=0.028). CONCLUSION: Sujda and fasting were associated with lower HIV infections. Imams should use this information to intensify the Islamic approach to HIV prevention.

Hepatitis B virus and HIV infection among patients with primary hepatocellular carcinoma in Kampala, Uganda.

BACKGROUND: Hepatitis B virus (HBV) is the commonest cause of primary hepatocellular (PHC) carcinoma worldwide. Co-infection with the HIV leads to more rapid progression of liver disease. OBJECTIVES: We described prevalence of HBV and HIV among patients with PHC admitted to Mulago Hospital, Kampala, Uganda. METHODS: We assessed all patients admitted to the gastrointestinal service of Mulago hospital with a diagnosis of PHC for HBV and HIV infection. RESULTS: From March to June 2008, we recruited 15 patients. Nine (60%) were male; the overall median age was 32 years (IQR 15 -67), with median ages for male and female 33 and 36 years respectively. Alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and AFP were all elevated with median values of 57.5 IU/L, 222 IU/L, 392 IU/L and 362 ng/ml respectively (IQR 14-145, 49-393, 165-1294 and 7-480). Eight (53%) patients were from North and Northeastern Uganda. The HBsAg was reactive in 13(87%) patients and HIV in 3(20%), all of whom were also co-infected with HBV. CONCLUSION: There is high prevalence of HBV and HBV/HIV co-infection among patients with PHC in Uganda with high mortality. Reduction in incidence and mortality due to PHC in Uganda will require urgent large scale HBV vaccination.

Hepatotoxicity from first line antiretroviral therapy: an experience from a resource limited setting.

BACKGROUND: Highly active antiretroviral therapy (HAART) has been associated with liver toxicity. The role of monitoring for liver toxicity has not been well studied in resource-limited settings (RLS). OBJECTIVES: To determine the background prevalence and incidence of liver injury and describe the associated signs and symptoms of acute hepatitis after initiating HAART; and to determine the role of liver enzyme tests in monitoring hepatotoxicity. METHODS: In this prospective study, in Mulago Hospital AIDS Clinics, we consecutively enrolled adult patients initiated on one of three first line HAART regimens [Stavudine (d4T)-Lamivudine (3TC) and nevirapine (NVP); Zidovudine (AZT)-3TC and Efavirenz (EFV) or d4T-3TC-EFV]. We monitored ALT (alanine aminotransferase) and clinical evidence of acute hepatitis at baseline, 2(nd), 6(th), 10(th) and 14(th) week of therapy. RESULTS: Two hundred and forty HIV-positive HAART- naïve patients were enrolled in the study. The baseline prevalence of transaminitis was 1.7% with an incidence of 4.2% at 14 weeks. Grade 3-4 hepatotoxicity was documented in 1.3%. Jaundice was seen in grade 2-4 ALT elevations. Being on concurrent HAART and antituberculous drugs was associated with grade 2-4 toxicity compared to those who were only on HAART [OR; 16.0 (95% CI; 2.4-104.2)]. CONCLUSIONS: Incidence of severe hepatotoxicity within three months of first-line antiretroviral therapy was low, suggesting that routine measurement of transaminases may not be necessary in all patients initiating HAART in RLS. Routine measurement may be important in following patients on HAART and concurrent TB treatment as well as those with jaundice to avoid missing hepatotoxicity.

Validity of the rapid strip assay test for detecting HBsAg in patients admitted to hospital in Uganda.

Commercially available rapid strip assays (RSAs) for hepatitis B surface antigen (HBsAg) are used for most routine clinical testing in sub-Saharan Africa. This study evaluated the validity of RSA and a more sophisticated enzyme immunoassay (EIA) with confirmation by nucleic acid testing (NAT) in hospitalized patients in Uganda. Sera from 380 consecutive patients collected and tested for HBsAg and anti-HIV in Kampala, Uganda by RSA were sent frozen to Dallas for EIA including HBsAg, total anti-hepatitis B core, hepatitis B e antigen, and anti-HIV. NAT was performed on all HBsAg-positives and on a random sample of 102 patients that were HBsAg-negative by both assays. Overall, 31 (8%) were HBsAg positive by RSA while 50 (13%) were HBsAg-positive by EIA; 26 were concordant between the two assays. Of 55 HBsAg-positive patients, nearly all showed detectable serum hepatitis B virus (HBV) DNA by bDNA (46) or PCR (4) assay. The 26 patients who were HBsAg positive by both EIA and RSA had significantly higher median serum HBV DNA levels than the 24 patients who were HBsAg positive by EIA alone. An additional 12/102 (12%) HBsAg negative patients had very low serum HBV DNA levels by NAT. Several differences in expected results of serologic testing were observed in this large series of African patients. RSA HBsAg testing is less sensitive than EIA; even EIA failed to detect all HBV DNA positive sera. A more complex testing protocol than RSA alone will be needed in Africa to improve patient care.

Poor performance of hepatitis C antibody tests in hospital patients in Uganda.

Most hepatitis C testing in Uganda is performed using commercial rapid strip assays (RSA) to detect antibodies to hepatitis C virus (anti-HCV), rather than enzyme immunoassays (EIA). The prevalence of hepatitis C antibodies in a Ugandan hospital population was determined using both methods to test their accuracy using nucleic acid testing (NAT) as a reference. Sera from 380 consecutive hospitalized Ugandan patients were tested for anti-HCV using an RSA in Uganda, with subsequent automated third-generation EIA testing in the United States, followed by NAT. Recombinant immunoblot assays (RIBA) were used as a supplementary test to detect anti-HCV epitopes. Overall, anti-HCV was detected in 48/380 (13%) by one or both antibody tests. Anti-HCV was detected in 19 (5.0%) patients by RSA and in 33 (8.7%) patients by EIA; only four patients were anti-HCV positive by both methods. Fourteen of the 48 anti-HCV positive patients had detectable serum HCV RNA, 7 each by bDNA assay or by PCR. RSA detected only 7 of 14 HCV RNA positive sera. Of 29 RNA negative but anti-HCV positive patients tested by RIBA, only two were anti-HCV positive; 27 were anti-HCV negative or indeterminate. Anti-HCV testing by RSA and/or EIA was neither sensitive nor specific for detection of ongoing HCV infection in hospitalized Ugandan patients. Our findings underscore the importance of confirmatory nucleic acid testing, which, despite its increased cost, appears essential to manage African patients with HCV.

Screening for hepatitis C among HIV positive patients at Mulago hospital in Uganda.

BACKGROUND: In industrialized countries with more resources, it is recommended that HIV infected patients should be screened for hepatitis C virus (HCV) on entry into the health care system. Implementation of these guidelines in a country like Uganda with limited resources requires some modification after taking into account the prevailing circumstances. These include the prevalence of HCV in HIV positive patients and the cost of HCV testing. OBJECTIVE: The objective of the study was to estimate the prevalence of HCV in HIV positive patients. METHODS: This was a cross sectional study among HIV positive outpatients in Mulago hospital. HCV screening was done using anti-HCV Enzyme Immuno Assay (Roche Diagnostics) RESULTS: Between October 2003 and February 2004, one hundred and twenty two HIV positive patients were enrolled into the study with a mean age of 33.9 years. There were more females 81 (66.4%) than males. Only 4 patients had anti-HCV, giving an estimated HCV prevalence of 3.3%. CONCLUSION: In view of the low HCV prevalence found in our study and similar studies and considering the high cost of HCV screening, routine HCV testing cannot be recommended among all HIV positive patients in our health care settings with limited resources. We recommend that HCV screening be limited to investigating HIV positive patients with features suggestive of liver disease in order to identify HCV as a possible cause.

Who should be screened to reduce the endoscopy workload in Mulago Hospital?

A retrospective study of 330 patients who had been endoscoped in Mulago hospital was done. It was found that of these 119 (36.1) were normal endoscopically. Normal endoscopy was significantly associated with patients presenting with dyspepsia. Dyspepsia was common in the age group 13-45 years compared to the age group 46-85 years. The older age group; 46-85 years; had a singificantly higher prevalence of serious disease. It is concluded that it is the younger patients with dyspepsia who should be screened to reduce the endoscopy workload. Published guidelines should be used to assist in the screening process

Hepatitis B virus and hiv infections among patients in Mulago hospital.

OBJECTIVE: To compare the frequency of exposure to hepatitis B infection among HIV seropositive and HIV seronegative medical outpatients. DESIGN: Case control study. SETTING: Mulago hospital medical outpatient clinics. PATIENTS: One hundred and twenty nine consecutive HIV seropositive patients and one hundred and twenty nine HIV seronegative control patients. RESULTS: The frequency of anti-HBc among the HIV seropositive patients was 65.1% compared to 41.9% in the HIV seronegative patients (95% confidence interval: 1.51-4.45; p-value: 0.0002). Of the 84 HIV positive patients with anti-HBc, 52 (61.9%) had more than five lifetime sexual partners. In comparison, of the 45 HIV positive patients with no anti-HBc, only 18 (40%) had more than five lifetime sexual partners (95% confidence interval: 1.04-1.80; p-value: 0.028). There was no significant difference in the frequency of HBsAg and HBeAg among the HIV seropositives and HIV seronegatives. CONCLUSION: The frequency of previous exposure to hepatitis B infection was higher among HIV seropositive patients compared with HIV seronegative patients and was associated with a greater number of lifetime sexual partners. Safe sexual behaviour and reduction in the number of sexual partners should continue to be promoted in the community including HIV positive patients, because it is likely to have the added advantage of reducing coincident exposure to HBV infection. This is especially important for the immunocompromised HIV positive patients who are more likely to develop a chronic infectious carrier state and among whom HBV control by vaccination is less effective than in the immunocompetent individuals.

Evaluation of the effectiveness of AIDS health education interventions in the Muslim community in Uganda.

In 1992 the Islamic Medical Association of Uganda designed an AIDS prevention project and conducted a baseline survey prior to community level activities. Results of that baseline were previously reported in this journal. During 2 years of prevention activities in local Muslim communities, 23 trainers educated over 3,000 religious leaders and their assistants, who in turn educated their communities on AIDS during home visits and at religious gatherings. After 2 years, there was a significant increase in correct knowledge of HIV transmission, methods of preventing HIV infection and the risk associated with ablution of the dead and unsterile circumcision (p < 0.001). There was a significant reduction in self-reported sexual partners among the young respondents less than 45 years. In addition there was a significant increase in self-reported condom use among males in urban areas (p < 0.001). Collaboration between health professionals and religious leaders can be achieved and can contribute to the success of AIDS prevention efforts.

PIP: In 1992, the Islamic Medical Association of Uganda designed an AIDS prevention project based on recognition of the role of the imam (mosque leader) as the teacher of family behavior and sexual values. Over a 2-year period, 23 trainers educated more than 3000 religious leaders and their assistants, who in turn educated their communities on AIDS during home visits and at religious gatherings. Almost 600,000 family contacts occurred. Comparison of findings of a baseline survey (n = 1907) with interviews conducted after 2 years of program implementation with both exposed (n = 1260) and nonexposed (n = 566) community members revealed significant increases in correct knowledge of transmission of HIV, vertical transmission, and the risk of unsterile skin-piercing instruments. Also recorded were significant increases in awareness of risks entailed in use of a common razor blade when a number of male infants are circumcised and ablution of the dead. Concurrent focus group discussions indicated weakened support for polygamy. There was a significant difference in condom use, number of sexual partners, and the incidence of extramarital sex reported at baseline compared with follow-up and between those exposed and not exposed to the project. The adoption of risk reduction behaviors was most marked among respondents under 45 years of age. The success of this intervention is attributed to its use of the Islamic religious organizational structure as a vehicle for HIV/AIDS education. This project demonstrates that positive collaboration between health professionals and religious leaders can be achieved and will enhance the success of community AIDS prevention efforts.

Who should be screened to reduce the endoscopy workload in Mulago Hospital?

A retrospective study of 330 patients who had been endoscoped in Mulago hospital was done. It was found that of these 119 (36.1%) were normal endoscopically. Normal endoscopy was significantly associated with patients presenting with dyspepsia. Dyspepsia was commoner in the age group 13-45 years compared to the age group 46-85 years. The older age group, 46-85 years, had a significantly higher prevalence of serious disease. It is concluded that it is the younger patients with dyspepsia who should be screened to reduce the endoscopy workload. Published guidelines should be used to assist in the screening process.

Who should be screened to reduce the endoscopy workload in Mulago Hospital?

A retrospective study of 330 patients who had been endoscoped in Mulago Hospital was done. It was found that of these 119(36.1) were normal endoscopically. Normal endoscopy was significantly associated with patients presenting with dyspepsia. Dyspepsia was commoner in the age group 13-45 years compared to the age group 46-85 years. The older age group; 46-85 years; had a significantly higher prevalence of serious disease. It is concluded that it is the younger patients with dyspepsia who should be screened to reduce the endoscopy workload. Published guidelines should be used to assist in the screening process

Planning and evaluating strategies for AIDS health education interventions in the Muslim community in Uganda.

In 1992 the Islamic Medical Association of Uganda designed an AIDS prevention project. A baseline survey was conducted to assess prevailing knowledge, attitudes, and practices among the Muslim communities in two districts. A low rate of incorrect beliefs about HIV transmission was found, although gaps in knowledge remain, particularly regarding vertical transmission and asymptomatic HIV infection. Less than 10% knew that condoms can protect against HIV transmission. Lack of knowledge was documented regarding the risk of HIV transmission associated with practices common in the Islamic community, such as polygamous marriages, circumcision, and ablution of the dead. The AIDS prevention project has incorporated specific messages and interventions as a result of these findings.

PIP: The Islamic Medical Association of Uganda has designed a project known as Family Acquired Immunodeficiency Syndrome (AIDS) Education and Prevention Through Imams. In a 1992 baseline survey, 1096 persons from the pilot project's two target districts--Mpigi and Iganga--were interviewed. Respondents were recruited from mosques in both rural and trade center areas of the districts. The mass media was identified as the main source of information about AIDS by 49.6% of respondents in Iganga and 80% of those in the more urbane Mpigi district. Only 3% of respondents in both communities viewed the imam (mosque leader) as someone with whom they could discuss concerns about AIDS. Although 80% of respondents were aware that the main route of transmission of the AIDS virus is sexual, only 1.2% knew about the possibility of maternal-fetal transmission. 55.4% recognized a condom, but just 9.9% had ever used one. In this culture, condom use is associated with sexual promiscuity and is not used within marriage. The survey identified three risk factors prevalent among Uganda's Muslim minority: polygamous marriage, practiced by about a third of respondents; use of the same cutting instrument for multiple male circumcision procedures without sterilization in between; and ablution of the dead, without the use of protective gloves. These cultural practices will be targeted in the AIDS prevention campaign. In each district, 10 imams will receive intensive training in AIDS and community education skills. Each imam will be provided with a male and female assistant who, in turn, will train indigenous family workers selected by the mosque. These community workers will make monthly home visits to about 15 families in the mosque area.

AIDS Prevention through Community Participation: Lesson Learned from the Islamic Community in Uganda

Objectives: The Islamic Medical Association of Uganda (IMAU) is implementing a pilot project to educate the Muslim minorities in two districts regarding AIDS and prevention of HIV transmission. Methods: Two districts with over 20Muslim minorities were selected for project implementation. Imams and volunteers are trained to encourage behaviour change during repeated family visits. Results: Project staff have been active in soliciting and incorporating community involvement in designing the project and in creating specific messages. Reliance on volunteers ensures that interventions are responsive to the perceived needs of the lack of community. Supervision of volunteers is constrained by the lack of transport. Condom promotion is controversial among religious leaders but the communities are demanding condom education and distribution. Conclusion: Community participation and support has been an essential element in the success of this project to date. Reliance on community participation has enabled the project to include condom education and distribution in response to community demand in spite of continuing ambivalence in the religious leadership. Behaviour change and condom education is enhanced by local participation in the design and implementation of the project