The clinical utility of cystatin C based eGFR in assessing renal function among HIV/AIDs patients on ART at Mildmay Uganda.

BACKGROUND: In clinical practice, Measurement of estimated glomerular filtration rates (eGFR) is the gold standard assessing renal function the glomerular filtration rate often estimated from plasma creatinine. Several studies have shown Cystatin C based eGFR (Cys C) to be a better parameter for the diagnosis of impaired renal function. Cystatin C based eGFR has been proposed as a potential renal function marker but its use in HIV&AIDS patients has not been well evaluated. METHODS: A cross sectional study was carried out on 914 HIV&AIDS patients on antiretroviral therapy (ART) attending Mildmay Uganda for care and treatment between January to March 2015. Serum Cystatin C based eGFR was measured using the particle enhanced immunoturbidimetric assay. Creatinine was analyzed using enzymatic Creatinine PAP method and creatinine clearance was calculated according to C&G. RESULTS: The sensitivity of Cystatin C based eGFR was 15.1% (95% CI = 8.4, 24) with specificity 99.3% (95% CI = 98- 99.7). The positive and negative predictive values were 70.0% (95% CI 45.7-88.1) and 91.2% (95% CI 98.11-92.94) respectively. The positive likelihood ratio was 18.81 and negative likelihood ratio was 0.85. Cystatin C based eGFR had diagnostic accuracy of 90.7 and area under curve was 0.768. CONCLUSION: Cystatin C based eGFR exhibited a high specificity and a high positive likelihood ratio in diagnosis of kidney disease among HIV&AIDS patients. Cystatin C based eGFR can be used as a confirmatory test.

Effectiveness of intensive adherence counselling in achieving an undetectable viral load among people on antiretroviral therapy with low-level viraemia in Uganda.

INTRODUCTION: Uganda was using a threshold of 1000 copies/mL to determine viral non-suppression for antiretroviral therapy monitoring among people living with HIV, prior to this study. It was not clear whether people living with HIV with low-level viraemia (LLV, ≥50 to <1000 copies/mL) would benefit from intensive adherence counselling (IAC). The purpose of this study was to determine the effectiveness of IAC among people living with HIV, receiving antiretroviral therapy, and with LLV in Uganda, to guide key policy decisions in HIV care, including the review of the viral load (VL) testing algorithm. METHODS: This cluster-randomized clinical trial comprised adults from eight HIV clinics who were living with HIV, receiving ART, and had recent VL results indicating LLV (tested from July 2022 to October 2022). Participants in the intervention arm clinics received three once-monthly sessions of IAC, and those in the comparison non-intervention arm clinics received the standard of care. At the end of the study, all participants were re-tested for VL to determine the proportions of those who then had an undetectable VL (<50 copies/mL). We assessed the statistical association between cross-tabulated variables using Fisher's exact test and then modified Poisson regression. RESULTS: A total of 136 participants were enrolled into the study at eight HIV clinics. All 68 participants in the intervention arm completed all IAC sessions. Only one participant in the non-intervention arm was lost to follow-up. The average follow-up time was 3.7 months (standard deviation [SD] 0.2) and 3.5 months (SD 0.1) in the intervention and non-intervention arms, respectively. In total, 59 (43.7%) of 135 people living with HIV achieved an undetectable VL during the study follow-up period. The effect of IAC on attaining an undetectable VL among people with LLV was nearly twice as high in the intervention arm (57.4%) than in the non-intervention arm (29.9%): adjusted risk ratio 1.9 (95% confidence interval 1.0-3.5), p = 0.037. CONCLUSION: IAC doubled the likelihood of an undetectable VL among people living with HIV with LLV. Therefore, IAC has been instituted as an intervention to manage people living with HIV with LLV in Uganda, and this should also be adopted in other Sub-Saharan African countries with similar settings. GOV IDENTIFIER: NCT05514418.

Increased Levels of Caspase-1 and IL-1ß Among Adults With Persistent Immune Activation After 12 Years of Suppressive Antiretroviral Therapy in the Infectious Diseases Institute HIV Treatment Cohort.

Background: We sought evidence of activated pyroptosis and the inflammasome pathways among human immunodeficiency virus (HIV)-infected adults after 12 years of suppressive antiretroviral therapy (ART) and persistent immune activation in the Infectious Diseases Institute HIV treatment cohort in Uganda. Methods: In a cross-sectional study, using peripheral blood mononuclear cells of HIV-infected individuals with high and low immune activation (CD4/CD8+CD38+HLA-DR+ cells) relative to HIV-negative reference group, caspase-1 expression was measured using flow cytometry and plasma interleukin 18 and interleukin 1ß (IL-1ß) levels using enzyme-linked immunosorbent assay. Results: There was higher expression of caspase-1 by CD4 T cells of ART-treated individuals with high immune activation relative to those with lower immune activation (P = .04). Similarly, plasma levels of IL-1ß were higher among ART-treated individuals with high immune activation levels relative to those with low immune activation levels (P = .009). We observed a low positive correlation between caspase-1 expression by CD4/CD8 T cells and immune activation levels (r= 0.497 and r= 0.329, respectively). Conclusions: Caspase-1 and IL-1ß were high among individuals with high immune activation despite 12 years of suppressive ART. There is a need to further understand the role of persistent abortive infection and the latent HIV reservoir characteristics as drivers of persistent activation and inflammation and to subsequently intervene to prevent the complications of chronic immune activation during long-term ART.

How to improve research capacity strengthening efforts: learning from the monitoring and evaluation of four research consortia in Africa.

Recent efforts to shift the control and leadership of health research on African issues to Africa have led to increased investments for scientific research capacity strengthening (RCS) on the continent and a greater demand for accountability, value for money and demonstration of return on investment. There is limited literature on monitoring and evaluation (M&E) of RCS systems and there is a clear need to further explore whether the M&E frameworks and approaches that are currently used are fit for purpose. The M&E approaches taken by four African RCS consortia funded under the Developing Excellence in Leadership, Training and Science in Africa (DELTAS) I initiative were assessed using several methods, including a framework comparison of the M&E approaches, semi-structured interviews and facilitated discussion sessions. The findings revealed a wide range in the number of indicators used in the M&E plans of individual consortium, which were uniformly quantitative and at the output and outcome levels. Consortia revealed that additional information could have been captured to better evaluate the success of activities and measure the ripple effects of their efforts. While it is beneficial for RCS consortia to develop and implement their own M&E plans, this could be strengthened by routine engagement with funders/programme managers to further align efforts. It is also important for M&E plans to consider qualitative data capture for assessment of RCS efforts. Efforts could be further enhanced by supporting platforms for cross-consortia sharing, particularly when trying to assess more complex effects. Consortia should make sure that processes for developmental evaluation, and capturing and using the associated learning, are in place. Sharing the learning associated with M&E of RCS efforts is vital to improve future efforts. Investing and improving this aspect of RCS will help ensure tracking of progress and impact of future efforts, and ensure accountability and the return on investment. The findings are also likely applicable well beyond health research.

Hopes, joys and fears: Meaning and perceptions of viral load testing and low-level viraemia among people on antiretroviral therapy in Uganda: A qualitative study.

Uganda applies the World Health Organization threshold of 1,000 copies/ml to determine HIV viral non-suppression. While there is an emerging concern of low-level viraemia (≥50 to <1,000 copies/ml), there is limited understanding of how people on antiretroviral therapy perceive viral load testing and low-level viremia in resource-limited settings. This qualitative study used the health belief model to explore the meaning that people living with HIV attach to viral load testing and low-level viraemia in Uganda. We used stratified purposive sampling to select people on antiretroviral therapy from eight high volume health facilities from the Central, Eastern, Northern and Western regions of Uganda. We used an interview guide, based on the health belief model, to conduct 32 in-depth interviews, which were audio-recorded and transcribed verbatim. Thematic analysis technique was used to analyze the data with the help of ATLAS.ti 6. The descriptions of viral load testing used by the participants nearly matched the medical meaning, and many people living with HIV understood what viral load testing was. Perceived benefits for viral load testing were the ability to show; the amount of HIV in the body, how the people living with HIV take their drugs, whether the drugs are working, and also guide the next treatments steps for the patients. Participants reported HIV stigma, lack of transport, lack of awareness for viral load testing, delayed and missing viral load results and few health workers as the main barriers to viral load testing. On the contrary, most participants did not know what low-level viraemia meant, while several perceived it as having a reduced viral load that is suppressed. Many people living with HIV are unaware about low-level viraemia, and hence do not understand its associated risks. Likewise, some people living with HIV are still not aware about viral load testing. Lack of transport, HIV stigma and delayed viral load results are major barriers to viral load testing. Hence, there is an imminent need to institute more strategies to create awareness about both low-level viraemia and viral load testing, manage HIV related stigma, and improve turnaround time for viral load results.

Building clinical pharmacology laboratory capacity in low- and middle-income countries: Experience from Uganda.

Background: Research and clinical use of clinical pharmacology laboratories are limited in low- and middle-income countries. We describe our experience in building and sustaining laboratory capacity for clinical pharmacology at the Infectious Diseases Institute, Kampala, Uganda. Intervention: Existing laboratory infrastructure was repurposed, and new equipment was acquired. Laboratory personnel were hired and trained to optimise, validate, and develop in-house methods for testing antiretroviral, anti-tuberculosis and other drugs, including 10 high-performance liquid chromatography methods and four mass spectrometry methods. We reviewed all research collaborations and projects for which samples were assayed in the laboratory from January 2006 to November 2020. We assessed laboratory staff mentorship from collaborative relationships and the contribution of research projects towards human resource development, assay development, and equipment and maintenance costs. We further assessed the quality of testing and use of the laboratory for research and clinical care. Lessons learnt: Fourteen years post inception, the clinical pharmacology laboratory had contributed significantly to the overall research output at the institute by supporting 26 pharmacokinetic studies. The laboratory has actively participated in an international external quality assurance programme for the last four years. For clinical care, a therapeutic drug monitoring service is accessible to patients living with HIV at the Adult Infectious Diseases clinic in Kampala, Uganda. Recommendations: Driven primarily by research projects, clinical pharmacology laboratory capacity was successfully established in Uganda, resulting in sustained research output and clinical support. Strategies implemented in building capacity for this laboratory may guide similar processes in other low- and middle-income countries.

Factors Associated with Retention in HIV Care Among HIV-Positive Adolescents in Public Antiretroviral Therapy Clinics in Ibanda District, Rural South Western Uganda.

Background: Retention in antiretroviral therapy (ART) care is a key indicator of Human Immunodeficiency Virus (HIV) treatment success as it improves adherence, critical for better treatment outcomes and prevention of drug resistance. HIV treatment among adolescents living with HIV (ALHIV) is characterized by loss to follow-up, poor ART adherence, and eventual death. This study assessed retention in ART care and the associated factors among ALHIV in Ibanda district, rural South Western Uganda. Methods: This was a retrospective cohort study using clinical data from ALHIV enrolled from 2019 to 2020 in eight health facilities in Ibanda district. Data from the Electronic Medical Record (EMR) system was extracted to assess the associated factors and participants' status two years after enrollment. Data were analyzed using EPIdata version 3.1 in which Univariate and multivariate cox proportional hazard regression analyses were determined. A hazard ratio (HR) at a 95% confidence interval was obtained, and a P-value <0.05 was considered statistically significant. Results: Eighty-four ALHIV comprising 86.9% (N = 73) females were enrolled. The majority 63.1% (N = 53) resided in semi/peri-urban, and 44.0% (N = 37) stayed less than 5 km from the facility. Only 35.7% (N = 30) were active on ART, while 17 (20.2%) and 36 (42.9%) were lost to follow-up and transfer-outs, respectively. Factors associated with low retention were: ALHIV that moved 5-10Km (HR = 5.371; 95% CI: 1.227-23.5050, p = 0.026), used differential service delivery model was Facility-Based Group (FBG) (HR = 12.419; 95% CI: 4.034-38.236, p < 0.001) and those enrolled on the Young Adolescent Program Support (YAPs) (HR = 4.868; 95CI:1.851-12.803; p = 0.001). Retention reduced with increasing ART duration, ALHIV on (TDF/3TC/EFV) (p < 0.001), lived more than 10Km (p = 0.043) and did not benefit from any intervention (p < 0.001). Conclusion: Results showed low retention in care and the urgent need to strengthen individual case management strategies for ALHIV, thus interventions focusing on peer support are desired.

Community purchases of antimicrobials during the COVID-19 pandemic in Uganda: An increased risk for antimicrobial resistance.

Self-Medication (SM) involves the utilization of medicines to treat self-recognized symptoms or diseases without consultation and the irrational use of over-the-counter drugs. During the COVID-19 pandemic, the lack of definitive treatment led to increased SM. We aimed to estimate the extent of SM for drugs used to treat COVID-19 symptoms by collecting data from pharmacy sale records. The study was conducted in Kampala, Uganda, where we extracted data from community pharmacies with functional Electronic Health Records between January 2018 and October 2021 to enable a comparison of pre-and post-COVID-19. The data included the number of clients purchasing the following drugs used to treat COVID-19 and its symptoms: Antibiotics included Azithromycin, Erythromycin, and Ciprofloxacin; Supplements included Zinc and vitamin C, while Corticosteroids included dexamethasone. A negative binomial model was used to estimate the incident rate ratios for each drug to compare the effect of COVID-19 on SM. In the pre- COVID-19 period (1st January 2018 to 11th March 2020), 19,285 customers purchased antibiotics which included; Azithromycin (n = 6077), Ciprofloxacin (n = 6066) and Erythromycin (n = 997); health supplements including Vitamin C (430) and Zinc (n = 138); and Corticosteroid including Dexamethasone (n = 5577). During the COVID-19 pandemic (from 15th March 2020 to the data extraction date in October 2021), we observed a 99% increase in clients purchasing the same drugs. The number of clients purchasing Azithromycin increased by 19.7% to 279, Ciprofloxacin reduced by 58.8% to 96 clients, and those buying Erythromycin similarly reduced by 35.8% to 492 clients. In comparison, there were increases of 170%, 181%, and 377% for Vitamin C, Zinc, and Dexamethasone, respectively. The COVID-19 pandemic underscored the extent of SM in Uganda. We recommend future studies with a representation of data from pharmacies located in rural and urban areas to further study pandemics' effect on antimicrobials prescriptions, including obtaining pharmacists' perspectives using mixed methods approaches.

The association between low-level viraemia and subsequent viral non-suppression among people living with HIV/AIDS on antiretroviral therapy in Uganda.

BACKGROUND: Uganda's efforts to end the HIV epidemic by 2030 are threatened by the increasing number of PLHIV with low-level viraemia (LLV). We conducted a study to determine the prevalence of LLV and the association between LLV and subsequent viral non-suppression from 2016 to 2020 among PLHIV on ART in Uganda. METHOD: This was a retrospective cohort study, using the national viral load (VL) program data from 2016 to 2020. LLV was defined as a VL result of at least 50 copies/ml, but less than 1,000 copies/ml. Multivariable logistic regression was used to determine the factors associated with LLV, and cox proportional hazards regression model was used to determine the association between LLV and viral non-suppression. RESULTS: A cohort of 17,783 PLHIV, of which 1,466 PLHIV (8.2%) had LLV and 16,317 (91.8%) had a non-detectable VL was retrospectively followed from 2016 to 2020. There were increasing numbers of PLHIV with LLV from 2.0% in 2016 to 8.6% in 2020; and LLV was associated with male sex, second line ART regimen and being of lower age. 32.5% of the PLHIV with LLV (476 out of 1,466 PLHIV) became non-suppressed, as compared to 7.7% of the PLHIV (1,254 out of 16,317 PLHIV) with a non-detectable viral load who became non-suppressed during the follow-up period. PLHIV with LLV had 4.1 times the hazard rate of developing viral non-suppression, as compared to PLHIV with a non-detectable VL (adjusted hazard ratio was 4.1, 95% CI: 3.7 to 4.7, p < 0.001). CONCLUSION: Our study indicated that PLHIV with LLV increased from 2.0% in 2016 to 8.6% in 2020, and PLHIV with LLV had 4.1 times the hazard rate of developing viral non-suppression, as compared to PLHIV with a non-detectable VL. Hence the need to review the VL testing algorithm and also manage LLV in Uganda.

Factors associated with ocular injuries among adult road traffic accident patients presenting at Mulago National Referral Hospital, Uganda.

Background: Ocular trauma is the leading cause of unilateral blindness globally. Road traffic accidents are among the top risk factors for ocular trauma. Objectives: This study aimed to evaluate factors associated with ocular injuries among adult road traffic accident patients at Mulago Hospital, Uganda. Methods: A cross-sectional study was conducted among adult road traffic accident patients. History taking and ophthalmological examination were performed on consenting participants. Data was analysed using STATA version 14.0. Results: Overall, 428 road traffic accident cases were enrolled, of which majority (84.3%) were male. Age 30-39years (aOR = 0.58, 0.36 - 0.94, p = 0.027), being male (aOR = 2.64, 1.21 - 5.13, p = 0.004) and being a passenger of motor vehicle/cycle (aOR = 3.85, 1.49 - 9.93, p = 0.005) were the factors associated with ocular injuries among the participants. Conclusions: Age 30-39 years, male gender and being a passenger of motor vehicle/cycle were the factors associated with ocular injuries among the adult road traffic accident patients. Ocular injuries were more common among the road users who did not use safety measures. Use of safety measure by passengers of motor vehicles and cycles is recommended.

A Quasi-experimental Study Evaluating the Effectiveness of Cryotherapy on Chemotherapy-induced Oral Mucositis Prevention at the Uganda Cancer Institute.

INTRODUCTION: Low-cost interventions such as cryotherapy are not routinely practiced in sub-Saharan Africa to prevent chemotherapeutic-induced oral mucositis. We investigated the feasibility and effect of cryotherapy on oral mucositis at the Uganda Cancer Institute. METHODS: This was a quasi-experimental nonequivalent research study design. We had two groups with each group meant to have 100 participants. We analyzed based on participants who underwent the protocol procedures. RESULTS: Only cancer types were significantly different between the control and intervention groups (χ2=31.09, df =18, p=.030). Twenty percent (n=19) out of the 95, while 8.2% (n=7) out of the 85 in the control and intervention groups respectively developed moderate to severe mucositis (Mantel-Cox and Generalized Wilcoxon p= .026 and p=.031, respectively). CONCLUSION: The use of cryotherapy in our local setting and many sub-Saharan African countries is feasible and affordable to prevent and control chemotherapy-induced oral mucositis.

Association of HIV, cardiovascular risk factors, and carotid intimal media thickness: A cross-sectional study in Western Kenya.

The carotid intimal media thickness (CIMT) is a validated measure of subclinical atherosclerosis. Human immunodeficiency virus (HIV) is a risk factor for cardiovascular disease (CVD) and has been associated with CIMT in North America and Europe; however, there are limited data from Sub-Saharan Africa (SSA). In this cross-sectional study, we measured CIMT in a cohort of 262 people living with HIV (PLHIV) on antiretroviral therapy (ART) for ≥6 months and HIV-negative adults in western Kenya. Using linear regression, we examined the associations between CVD risk factors and CIMT, both overall and stratified according to the HIV status. Among the PLHIV, we examined the association between CIMT and HIV-related factors. Of 262 participants, approximately half were women. The HIV-negative group had a higher prevalence of age ≥55 years (P = .002), previously diagnosed hypertension (P = .02), treatment for hypertension (P = .03), and elevated blood pressure (BP) (P = .01). Overall prevalence of carotid plaques was low (15/262 [6.0%]). HIV-positive status was not significantly associated with a greater mean CIMT (P = .19). In multivariable regression models, PLHIV with elevated blood pressure or treatment for hypertension had a greater mean CIMT (P = .002). However, the CD4 count, viral load, and ART regimen were not associated with differences in CIMT. In the HIV-negative group, older age (P = .006), high total cholesterol levels (P = .01), and diabetes (P = .02) were associated with a greater mean CIMT. In this cross-sectional study of Kenyan adults, traditional CVD risk factors were found to be more prevalent among HIV-negative participants. After multivariable regression analysis, we found no association between HIV status and CIMT, and PLHIV had fewer CVD risk factors associated with CIMT than HIV-negative participants did. HIV-specific factors were not associated with the CIMT.

Longitudinal patients' cohorts for impactful research and HIV care at the Infectious Diseases Institute.

Introduction: Observational studies provide important evidence supporting the feasibility and effectiveness of health interventions. The 20-year-old Infectious Diseases Institute (IDI) established to respond to infectious diseases, specifically HIV/AIDS, invested in the set-up of longitudinal cohorts. In this paper we discuss the results of these cohorts and their impact on the response to the HIV pandemic in Uganda. Methods: IDI invested in experienced system developers, clinic and laboratory capacity to create the infrastructure to host longitudinal cohorts. Several cohorts were created, including patients initiated and followed up on ART, specialized cohorts (e.g. TB co-infection) and long-term cohorts with patients on ART for over 10 years and aged 60 and above. These cohorts function as platforms for sub-studies, attracting collaborators and students. Results: Data from the IDI cohorts contributed evidence to ART programs on when to start, which drugs to use, how to best monitor and which models of care to implement. Sub-studies contributed to management of opportunistic infections, understanding immunological response and the emerging complications of non-communicable diseases. Conclusion: Cohorts provide a platform for clinical care, training, and research to inform strategic responses and put Makerere University at the center of the response to the HIV pandemic in the region.

Use of individual development plans: experiences from junior faculty in the "NURTURE" mentored research program at Makerere University College of Health Sciences.

Introduction: Individual Development Plan (IDP) is a multi-component career planning worksheet that guides trainees through an iterative self-assessment. This paper provides the first investigation of IDP use and experiences among junior faculty at academic institutions in low- and middle-income countries (LMICs) where IDP is seldomly used by trainees. Methods: An online survey determined the utilization and impact of IDP among junior faculty trainees enrolled on "NURTURE" mentored research program to support career development for faculty at Makerere University College of Health Sciences (MakCHS) between 2016-2020. Responses were received between March and June 2021, a period of intense COVID-19 pandemic in the country. Results: Of 64 trainees 64(39%) were female and 60/64(98%) developed an IDP during the fellowship period; of whom 45/60(75%) had never been exposed to IDP. Trainees' benefits included intentional thinking about own career goals and support to execute the goals as well as self-management skills of time management and communication, among others. Conclusion: IDP was well-received by junior faculty trainees, with several self-management and motivation benefits to the scholars. We recommend that academic programs and faculty at academic institutions in LMIC should consider taking on the IDP approach to promote focused career development for all trainees including junior faculty.

Mobile Phone-based Intervention to promote un-interrupted HIV treatment during the COVID-19 pandemic.

Introduction: Keeping HIV-infected adults away from the health care system during the COVID-19 travel restrictions, presents a challenge to HIV treatment adherence. Methods: This study focused on the initial two phases where Phase 1 designed a Makerere College of Health Sciences (MakCHS) Unstructured Supplementary Service Data (USSD)-based application; and Phase 2 piloted patient enrolment onto the application and determined the feasibility of remote follow-up of patients receiving long-term antiretroviral therapy (ART). Results: A off/online user application, MakCHS Health app, was developed. Overall, 112 patients [(66(59%) female] receiving ART at Mulago ISS clinic, Kampala, were enrolled onto the MakCHS Health app. Up to 89 (80%) utilized the app to access medical help. Patients' medical queries included needs for drug refills, missed taking HIV medication, medical illnesses, access to COVID-19 vaccination and other personal needs that required clinicians' attention. Conclusion: Piloting a MakCHS Health application for patient follow-up was feasible and well-received by HIV treatment providers and patients receiving ART. We recommend scale up of the application to enroll all patients receiving long-term treatment for HIV/AIDS, and subsequently expand to. other HIV treatment programs in similar settings.

Makerere University-Uganda Heart Institute collaborative cardiovascular disease training and research since 1988.

Background: Makerere University College of Health Sciences has been collaborating with the Uganda Heart Institute to build capacity for research, training and clinical care in cardiovascular medicine for the last 34 years to appropriately respond to rising societal needs for advanced cardiovascular care which was lacking before this period. Aim: To describe the major milestones in the MakCHS-UHI cardiovascular training collaboration and chart way for future collaborations. Method: This short communication highlights some of the salient features and important milestones in the collaboration journey of the two institutions. Conclusion: Clinical centres of excellence in specialised fields of health care, such as the Uganda Heart Institute for Cardiology, provide a conducive academic environment for MakCHS clinical scientists to provide high quality evidence-based care to meet societal needs.

Health Service delivery and training at Makerere University College of Health Sciences: The role of the academic health centers' network.

Academic Health Centers provide a network of clinical training facilities for high quality service delivery, within clinical training and research settings. At an academic health/medical center, education, research, and clinical care are combined to provide the best possible clinical care, which uses cutting-edge technologies, resources and therapies other community hospitals may not have available. This paper summarizes the network of teaching hospitals for health care training in the last century of Makerere University College of Health Sciences, its local and regional impact, lessons learned and future of actively engaging the network of academic health centers to expand clinical training and research opportunities to meet the needs of the 21st Century populations. Medical schools and training hospitals need to integrate of their roles in research, education, and patient care to provide evidence-based interventions and innovations to both treat illness and improve health.

Infectious Diseases Institute at Makerere University College of Health Sciences: a case study of a sustainable capacity building model for health care, research and training.

The Infectious Diseases Institute (IDI), established in 2001, was the first autonomous institution of Makerere University set up as an example of what self-governing institutes can do in transforming the academic environment to become a rapidly progressive University addressing the needs of society This paper describes the success factors and lessons learned in development of sustainable centers of excellence to prepare academic institutions to respond appropriately to current and future challenges to global health. Key success factors included a) strong collaboration by local and international experts to combat the HIV pandemic, along with b) seed funding from Pfizer Inc., c) longstanding collaboration with Accordia Global Health Foundation to create and sustain institutional strengthening programs, d) development of a critical mass of multi-disciplinary research leaders and managers of the center, and e) a series of strong directors who built strong governance structures to execute the vision of the institute, with subsequent transition to local leadership. Conclusion: Twenty years of sustained investment in infrastructure, human capital, leadership, and collaborations present Makerere University and the sub-Saharan Africa region with an agile center of excellence with preparedness to meet the current and future challenges to global health.

Prevalence and risk factors for visual impairment among elderly patients attending the eye clinic at Mulago National Referral Hospital, Uganda: a cross-sectional study.

Background: The elderly have an increased risk of developing visual impairment (VI). Due to the increase in life expectancy of individuals in Sub-Saharan Africa, the population of the elderly is projected to increase. It is thus postulated that the prevalence of VI will increase which is currently unknown in Uganda. Objective: To determine the prevalence and risk factors for VI among the elderly at Mulago National Referral Hospital eye clinic in Uganda. Methods: This was a cross-sectional study carried out in 2020 with consecutive enrolment of patients aged 60 years and above. Obtaining history was followed by systemic and ocular examination. Statistical analysis was performed to determine the prevalence and factors associated with VI. Results: Of 346 elderly participants examined, 174 (50.3%) were males and median age was 67 (IQR 63-74). Prevalence of VI was 32.1%. Cataract was the leading cause of blindness 54.1%, followed by refractive error (21.6%), glaucoma (11.7%), and corneal opacities (5.4%). Age (adjusted Prevalence Ratio (aPR): 1.05, 95% CI (1.02, 1.06)), history of diabetes mellitus (aPR 1.46, 95%CI (1.04, 2.05)), history of hypertension (aPR 1.46, 95%CI (1.10, 1.93)), having completed primary level of education (aPR 0.74, 95%CI (0.55, 0.98)) and secondary level of education (aPR 0.47, 95%CI (0.30,0.73)), presence of a cataract at examination (aPR: 2.28, 95%CI (1.66, 3.13)) were statistically significantly associated with VI. Conclusion: In Mulago hospital, the prevalence of VI among the elderly is high with majority of the causes being correctable. We recommend that efforts towards early case identification of causes of VI among the elderly should be a priority.