HIV epidemic and cascade of care in 12 east African rural fishing communities: results from a population-based survey in Uganda.

BACKGROUND: In East Africa, fishing communities are considered most-at-risk populations for the acquisition of HIV. We estimated HIV prevalence and assessed progress towards the UNAIDS 90-90-90 targets along the HIV treatment cascade in 12 fishing communities surrounding Lakes Edward and George, Uganda. METHODS: We conducted a cross-sectional household-based survey between September and November 2016. All adults between 15 and 69 years old were eligible to participate. Children below 15 years old were eligible for HIV testing if either parent was HIV-positive. Viral load testing was done for all HIV-infected individuals. Logistic regression models adjusted for sociodemographic-behavioral variables were used to assess the association between occupation and HIV positivity. RESULTS: Overall, 1738 adults (959 women, 779 men) and 148 children were included. Adult inclusion rate was 96.0%. Of the men, 58% reported to be fishermen. The HIV-prevalence among adults was 17.5% (95%CI: 15.8-19.4) and 6.1% (95%CI: 3.1-11.4) among HIV-exposed children. HIV prevalence was higher among women than among men (20.9% vs. 13.5%, p < 0.001). Among men, fishermen had a higher HIV prevalence (18.7%; 95%CI: 15.1-22.3) and a higher risk of being HIV-positive (aOR: 4.2; 95%CI: 2.0-9.1) than men of other occupations (p < 0.001). Progress towards the UNAIDS 90-90-90 targets was as follows: 86.5% (95%CI: 82.3-90.1%) of the HIV-positive participants were diagnosed, 98.7% (95%CI: 96.1-99.6%) of those aware were on antiretroviral therapy (ART), and 87.3% (95%CI: 82.3-91.0%) of those on ART were virally suppressed. Overall, 73% of all HIV-positive individuals were virally suppressed. Viral suppression was lower among individuals 15-24 years (45.5%) than among those 25-44 years (74.0%) and 45-69 years (85.0%), p < 0.001. Fishermen did not to have significant differences in the HIV cascade of care compared to men with other occupations. CONCLUSIONS: HIV prevalence was high in these fishing communities, particularly among women and fishermen. Important progress has been made along the HIV treatment cascade, and the UNAIDS goal for viral suppression in population was achieved. However, gaps remain and HIV care strategies focusing on young people are urgently needed. HIV preventive interventions should target particularly women, young people and fishermen though HIV preventive and care services should remain available to the whole fishing communities.

The cascade of HIV care among refugees and nationals in Nakivale Refugee Settlement in Uganda.

OBJECTIVES: Refugees living in Uganda come from HIV-endemic countries, and many remain in refugee settlements for over a decade. Our objective was to evaluate the HIV care cascade in Nakivale Refugee Settlement and to assess correlates of linkage to care. METHODS: We prospectively enrolled individuals accessing clinic-based HIV testing in Nakivale Refugee Settlement from March 2013 to July 2014. Newly HIV-diagnosed clients were followed for 3 months post-diagnosis. Clients underwent a baseline survey. The following outcomes were obtained from HIV clinic registers in Nakivale: clinic attendance ('linkage to HIV care'), CD4 testing, antiretroviral therapy (ART) eligibility, and ART initiation within 90 days of testing. Descriptive data were reported as frequency with 95% confidence interval (CI) or median with interquartile range (IQR). The impact of baseline variables on linkage to care was assessed with logistic regression models. RESULTS: Of 6850 adult clients tested for HIV, 276 (4%; CI: 3-5%) were diagnosed with HIV infection, 148 (54%; CI: 47-60%) of those were linked to HIV care, 54 (20%; CI: 15-25%) had a CD4 test, 22 (8%; CI: 5-12%) were eligible for ART, and 17 (6%; CI: 3-10%) initiated ART. The proportions of refugees and nationals at each step of the cascade were similar. We identified no significant predictors of linkage to care. CONCLUSIONS: Less than a quarter of newly HIV-diagnosed clients completed ART assessment, considerably lower than in other reports from sub-Saharan Africa. Understanding which factors hinder linkage to and engagement in care in the settlement will be important to inform interventions specific for this environment.

Cost effectiveness of facility and home based HIV voluntary counseling and testing strategies in rural Uganda.

BACKGROUND: In Uganda, the main stay for provision of human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) has been at health facilities. Home based VCT on the other hand, was initiated in the country to improve service coverage. OBJECTIVE: To evaluate the cost effectiveness of facility- and home-based HIV VCT strategies in rural southwestern Uganda. METHODS: Data on costs and effectiveness of facility- and home-based HIV VCT intervention strategies was collected in two sub-Counties in rural southwestern Uganda. Costing was performed using the ingredients approach. Effectiveness was measured as the number of HIV sero-positive clients identified. Incremental Cost-Effectiveness Ratios (ICERs) were calculated from the provider perspective. RESULTS: The cost per client tested were US$6.4 for facility based VCT and US$5.0 for home based VCT. The corresponding costs per positive case identified were US$86.5 and US$54.7 respectively. The incremental cost to providers per additional positive case identified by facility based VCT was US$3.5. CONCLUSION: Home based VCT was the least costly strategy per client tested and was also cost effective in identifying HIV sero-positive clients in rural areas. This strategy should therefore be promoted to improve service coverage and thereby facilitate early and extensive detection of clients eligible for treatment.

Effectiveness of active case-finding strategies in tuberculosis control in Kampala, Uganda.

BACKGROUND: Passive case finding (PCF) is the strategy implemented by most developing countries to detect new cases of tuberculosis (TB), but detection rates remain low. Active case finding (ACF) is an alternative strategy, although cost is a barrier to implementation. We estimated the cost-effectiveness of a city-wide ACF programme in Kampala, Uganda, compared to the PCF strategy. METHODS: We developed a decision tree and Markov model to compare ACF vs. PCF across several outcome measures. Parameter estimates for costs, probabilities and utility scores were obtained from published reports and peer-reviewed journal articles. The main outcome measures were TB cases detected, deaths averted, life years saved (LYS) and quality-adjusted life years (QALYs). RESULTS: Our model found that ACF implemented city-wide would result in an additional 1594 TB cases detected in 1 year, 675 deaths averted over a 5-year period, 21,928 LYS, and would cost an additional US$109 per additional QALY. The 25-34 year age group received most health benefits (556 cases detected, 229 deaths averted, 8058 LYS), and the programme was most cost-effective in the 45-54 year age group (US$51/QALY). CONCLUSIONS: ACF is an effective strategy for TB control and improving quality of life and is also cost-effective.

Aflatoxin levels in common foods of South Western Uganda: a risk factor to hepatocellular carcinoma.

Prolonged exposure to aflatoxins by humans and animals leads to adverse effects to the various body systems of affected individuals including death. Studies have linked aflatoxins to hepatocellular carcinoma (HCC). In Uganda, HCC is observed to be on increase in communities of South-Western Uganda. A cross-sectional study was therefore conducted in five districts of the region and 90 various food samples were collected for total aflatoxin determination. They included ground nuts, cassava, millet, sorghum flour and eshabwe sauce. The aflatoxin levels were determined using Vicam aflatest method. The results were compared with acceptable European Union aflatoxin levels. Aflatoxin levels in the food samples ranged from 0 to 55 ppb with a mean total aflatoxin level of 15.7 +/- 4.9 ppb. Eshabwe sauce had the highest mean total aflatoxin levels (18.6 +/- 2.4 ppb). Traditional methods of food processing in this study were found to be contributing risk factor of food contamination and hence the observed increased HCC cases and mortalities in the region.

Widow inheritance and HIV/AIDS in rural Uganda.

Despite current efforts to combat HIV/AIDS through behavioural change, ingrained socio-cultural practices such as widow inheritance in south-western Uganda has not changed. Low education, unemployment, dowry, widows' socioeconomic demands and the inheritor's greed for the deceased's wealth, influence widow inheritance. Voluntary counselling and testing is needed for the widows and their inheritors; formal dowry should be removed from marriage and widow inheritance stripped of its sexual component.

Oral health status of school children in Mbarara, Uganda.

BACKGROUND: Despite the need for oral health morbidity surveys to aid in reviewing of the oral health services, dental data of Ugandan children is scanty. OBJECTIVES: To describe the magnitude and distribution of selected oral health conditions among primary school children in Mbarara, Uganda. METHODS: A stratified two-stage cluster sample of 437 children aged 5-6, 8-9 and 11-12 was enrolled. The selected conditions included: dental caries, plaque, calculus, gingivitis, fluorosis and malocclusion (maxillary overjet). These conditions were diagnosed and scored in accordance with World Health Organisation (WHO) criteria. RESULTS: The mean decayed, missing, filled permanent teeth (DMFT) was 1.5(±0.8 SD). Females had higher DMFT (1.6±0.8SD) than males (1.3±0.8SD). Decayed, filled milk teeth (dt) was 2.7(±1.8SD) but more in males 3.1(±2.1SD) than in females 2.4(±1.6SD). Children in private schools were likely to have more caries in both permanent teeth (DMFT: 1.6±0.9SD) and milk teeth (dt: 3.0±1.9SD). Day-scholars were likely to have more caries in permanent teeth (DFMT: 1.50.8SD). Those in boarding were likely to have more caries in milk teeth (dt: 3±2.2SD). Milk teeth caries decreased with age (p<0.0001). Eight (1.8%) had very mild to moderate fluorosis. Nine (2%) lost permanent canines due to practice of "nylon teeth mutilation." Majority 325(75%) had dental plaque, which increased with age (p<0.0001). Males significantly had plaque. Children in private schools were associated with less plaque (OR: 0.6, 95%CI: 0.4-0.9), as were those in boarding schools. Some 113(25.9%) had calculus that increased with age (p<0.0001). Calculus was more prevalent in males, government schools, and among day-scholars. Females were less likely to have maxillary overjet (OR: 0.5, 95% CI: 0.3-0.8). Day-scholars were 2 times more likely to have maxillary overjet (OR: 1.9, 95%CI: 1.1-3.5). None had severe gingivitis. CONCLUSION: The oral hygiene of school children was poor with high plaque prevalence demonstrating a lack of established oral hygiene practices. A comprehensive community-focused oral health care intervention that includes oral health education in homes and the strengthening of school health programme is needed to improve the oral health status of children in Mbarara.

Birth plans and health facility based delivery in rural Uganda.

OBJECTIVES: To evaluate whether the completion of birth plans is associated with delivery in a health facility and the perceptual causes of birth plan completion and health facility based delivery were explored according to a well-tested health behaviour theory. DESIGN: A community survey. SETTING: Rakai and Luwero districts. SUBJECTS: A total of 415 (202 in Rakai and 213 in Luwero district) respondents were randomly selected and interviewed using a mixed survey questionnaire composed of open and close-ended questions. MAIN OUTCOME MEASURES: Health facility based delivery. RESULTS: The results demonstrate a statistically significant relationship between the completion of birth plans and delivery in a health facility (OR = 1.86, 95% CI =1.1, 3.1). The fear of consequences of delivering at home was found to be an important driving force in promoting the completion of birth plans, thereby indirectly influencing the likelihood of delivery in a health facility. CONCLUSION: Given the empirical evidence presented here, this study suggests that birth plans are an important tool in improving the rate of health facility based deliveries and thus essential in the fight against maternal mortality in Uganda. It is further recommended that campaigns market the use of birth plans as a way to reduce uncertainty and manage fear and the unknown about pregnancy.

Contraceptive use among in and out-of school adolescents in rural southwest Uganda.

OBJECTIVE: To compare the level of contraceptive use among in and out-of school rural Ugandan adolescents. DESIGN: Cross sectional survey. SETTING: Mbarara district. SUBJECTS: Five hundred in-school and 220 out-of school adolescents aged 15-19 years. MAIN OUTCOME MEASURE: Contraceptive use. RESULTS: Contraceptive prevalence was 171 (23.8%), with 99 (19.8%) among in-school and 72 (32.7%) in out-of school (OR=0.8, 95% CI=0.5-1.3). Of the 286 who had had sexual intercourse, 171 (59.8%) were current users with 99 (57.9%) in-school and 72 (42.1%) out-of school. The predominant method was the male condom with 80 (56.7%) in-school and 61 (43.3%) out-of-school (p=0.3). Sixty five (67%) of in-school aged 18-19 used contraceptives compared to those less than 18 years (OR=0.4, 95% CI=0.2-0.8). The out-of school who were urban residents 51(75%) were more likely to use contraceptives (OR=0.3, 95% CI=0.1-0.6). Out-of school with secondary education 37(84.1%) were more likely to use contraceptives (OR=0.2, 95% CI=0.1-0.5). Cost was a barrier for contraceptive use among in-school users 37(77.1%) (OR=2.6, 95% CI=1.7-5.4). Stigma surrounding their sexual activity was a barrier to out-of school 25 (58.1%) (OR=0.4, 95% CI=0.2-0.8). CONCLUSION: Contraceptive use among rural sexually active adolescents is low although the prevalence is higher in out-of school. Reorientation of contraceptive services to make them more accessible through strengthening of school health programme and establishment of out-of school adolescent health programme are urgently needed.