HIV-associated gut microbial alterations are dependent on host and geographic context.

HIV-associated changes in intestinal microbiota are believed to be important drivers of disease progression. However, the majority of studies have focused on populations in high-income countries rather than in developing regions where HIV burden is greatest. To better understand the impact of HIV on fecal microbiota globally, we compare the fecal microbial community of individuals in the U.S., Uganda, and Botswana. We identify significant bacterial taxa alterations with both treated and untreated HIV infection with a high degree of uniqueness in each cohort. HIV-associated taxa alterations are also significantly different between populations that report men who have sex with men (MSM) behavior and non-MSM populations. Additionally, while we find that HIV infection is consistently associated with higher soluble markers of immune activation, most specific bacterial taxa associated with these markers in each region are not shared and none are shared across all three geographic locations in our study. Our findings demonstrate that HIV-associated changes in fecal microbiota are overall distinct among geographical locations and sexual behavior groups, although a small number of taxa shared between pairs of geographic locations warrant further investigation, highlighting the importance of considering host context to fully assess the impact of the gut microbiome on human health and disease.

HIV, Social Networks, and Loneliness among Older Adults in Uganda.

Loneliness among older adults has been identified as a major public health problem. Yet little is known about loneliness, or the potential role of social networks in explaining loneliness, among older people with HIV (PWH) in sub-Saharan Africa, where 70% of PWH reside. To explore this issue, we analyzed data from 599 participants enrolled in the Quality of Life and Ageing with HIV in Rural Uganda study, including older adults with HIV in ambulatory care and a comparator group of people without HIV of similar age and gender. The 3-item UCLA Loneliness Scale was used to measure loneliness, and HIV status was the primary explanatory variable. The study found no statistically significant correlation between loneliness and HIV status. However, individuals with HIV had smaller households, less physical and financial support, and were less socially integrated compared to those without HIV. In multivariable logistic regressions, loneliness was more likely among individuals who lived alone (aOR:3.38, 95% CI:1.47-7.76) and less likely among those who were married (aOR:0.34, 95% CI:0.22-0.53) and had a higher level of social integration (aOR:0.86, 95% CI: 0.79-0.92). Despite having smaller social networks and less support, older adults with HIV had similar levels of loneliness as those without HIV, which may be attributed to resiliency and access to HIV-related health services among individuals with HIV. Nonetheless, further research is necessary to better understand the mechanisms involved.

Patient-provider experiences with chronic non-communicable disease care during COVID-19 lockdowns in rural Uganda: A qualitative analysis.

Non-communicable diseases (NCDs) are a growing health burden in Sub-Saharan Africa and especially Uganda, where they account for over one third of all deaths. During the COVID-19 pandemic, public health control measures such as societal "lockdowns" had a significant impact on longitudinal NCD care though no studies have looked at the lived experience around NCD care during the pandemic. Our objective was to understand the experience of NCD care for both patients and providers in southwestern Uganda during the COVID-19 pandemic. We conducted in-depth, in-person qualitative interviews with 20 patients living with hypertension, diabetes, and/or cardiac disease purposefully selected from the outpatient clinics at Mbarara Regional Referral Hospital and 11 healthcare providers from public health facilities in Mbarara, southwestern Uganda. We analyzed transcripts according to conventional content analysis. We identified four major themes that emerged from the interviews; (1) difficulty accessing medication; (2) food insecurity; (3) barriers to the delivery of NCD clinical care and (4) alternative forms of care. Pre-existing challenges with NCD care were exacerbated during COVID-19 lockdown periods and care was severely disrupted, leading to worsened patient health and even death. The barriers to care were exacerbations of underlying systemic problems with NCD care delivery that require targeted interventions. Future work should leverage digital health interventions, de-centralizing NCD care, improving follow-up, providing social supports to NCD patients, and rectifying supply chain issues.

Correlates of physical activity among people living with and without HIV in rural Uganda.

Background: Antiretroviral therapy (ART) has led to diminishing AIDS-related mortality but a concomitant increase in non-communicable diseases (NCDs) for people with HIV (PWH). Whereas physical activity (PA) has been shown to help prevent NCDs and NCD outcomes in other settings, there are few data on PA and its correlates among PWH in high-endemic settings. We aimed to compare PA by HIV serostatus in rural Uganda. Methods: We analysed data from the UGANDAC study, an observational cohort including PWH in ambulatory HIV care in Mbarara, Uganda, and age- and gender-matched people without HIV (PWOH). Our primary outcome of interest was PA, which we assessed using the International Physical Activity Questionnaire and considered as a continuous measure of metabolic equivalents in minutes/week (MET-min/week). Our primary exposure of interest was HIV serostatus. We fit univariable and multivariable linear regression models to estimate the relationship between HIV and PA levels, with and without addition of sociodemographic and clinical correlates of PA (MET-min/week). In secondary analyses, we explored relationships restricted to rural residents, and interactions between gender and serostatus. Results: We enrolled 309 participants, evenly divided by serostatus and gender. The mean age of PWH was 52 [standard deviation (SD) 7.2] and 52.6 (SD 7.3) for PWOH. In general, participants engaged in high levels of PA regardless of serostatus, with 81.2% (251/309) meeting criteria for high PA. However, PWOH reported higher mean levels of PA met-minutes/week than PWH (9,128 vs 7,152, p ≤ 0.001), and a greater proportion of PWOH (88.3%; 136/154) met the criteria for high PA compared to PWH (74.2%; 115/155). In adjusted models, lower levels of PA persisted among PWH (ß = -1,734, 95% CI: -2,645, -824, p ≤ 0.001). Results were similar in a sensitivity analysis limited to people living in rural areas. Conclusion: In a rural Ugandan cohort, PWOH had higher levels of PA than PWH. Interventions that encourage PA among PWH may have a role in improving NCD risk profiles among PWH in the region.

Associations of the COVID-19 pandemic with quality of life: A cross-sectional study of older-age people with and without HIV in rural Uganda.

Background: COVID-19-related lockdowns and other public health measures may have differentially affected the quality of life (QOL) of older people with and without human immunodeficiency virus (HIV) in rural Uganda. Methods: The Quality of Life and Aging with HIV in Rural Uganda study enrolled people with and without HIV aged over 49 from October 2020 to October 2021. We collected data on COVID-19-related stressors (behavior changes, concerns, interruptions in health care, income, and food) and the participants' QOL. We used linear regression to estimate the associations between COVID-19-related stressors and QOL, adjusting for demographic characteristics, mental and physical health, and time before vs after the lockdown during the second COVID-19 wave in Uganda. Interaction between HIV and COVID-19-related stressors evaluated effect modification. Results: We analyzed complete data from 562 participants. Mean age was 58 (standard deviation (SD) = 7); 265 (47%) participants were female, 386 (69%) were married, 279 (50%) had HIV, and 400 (71%) were farmers. Those making ≥5 COVID-19-related behavior changes compared to those making ≤2 had worse general QOL (estimated linear regression coefficient (b) = - 4.77; 95% confidence interval (CI) = -6.61, -2.94) and health-related QOL (b = -4.60; 95% CI = -8.69, -0.51). Having access to sufficient food after the start of the COVID-19 pandemic (b = 3.10, 95% CI = 1.54, 4.66) and being interviewed after the start of the second lockdown (b = 2.79, 95% CI = 1.30, 4.28) were associated with better general QOL. Having HIV was associated with better health-related QOL (b = 5.67, 95% CI = 2.91,8.42). HIV was not associated with, nor did it modify the association of COVID-19-related stressors with general QOL. Conclusions: In the context of the COVID-19 pandemic in an HIV-endemic, low-resource setting, there was reduced QOL among older Ugandans making multiple COVID-19 related behavioral changes. Nonetheless, good QOL during the second COVID-19 wave may suggest resilience among older Ugandans.

The benefits of care: treated HIV infection and health-related quality of life among older-aged people in Uganda.

OBJECTIVES: The objective of this study is to explore how HIV care affects health-related quality of life (HRQoL) among older people in Uganda. METHODS: We enrolled older-aged (≥49 years) people with HIV receiving HIV care and treatment, along with age- and sex-similar people without HIV. We measured health-related quality of life using the EQ-5D-3L scale. RESULTS: People with HIV (n = 298) and people without HIV (n = 302) were similar in median age (58.4 vs. 58.5 years), gender, and number of comorbidities. People with HIV had higher self-reported health status (b = 7.0; 95% confidence interval [CI], 4.2-9.7), higher EQ-5D utility index (b = 0.05; 95% CI, 0.02-0.07), and were more likely to report no problems with self-care (adjusted odds ratio [AOR], 2.0; 95% CI, 1.2-3.3) or pain/discomfort (AOR = 1.8, 95% CI, 1.3-2.8). Relationships between HIV serostatus and health-related quality of life differed by gender, but not age. CONCLUSIONS: Older people with HIV receiving care and treatment reported higher health-related quality of life than people without HIV in Uganda. Access to primary care through HIV programs and/or social network mobilization may explain this difference, but further research is needed to elucidate the mechanisms.

HIV Infection and 90-Day Stroke Outcomes in Uganda: A Prospective Observational Cohort Study.

Background and Objectives: Little is known about the impact of HIV infection on the clinical presentation and outcomes after stroke in the modern antiretroviral therapy (ART) era. We aimed to compare stroke characteristics and outcomes between persons with HIV (PWH) and without HIV (PWOH) presenting with stroke in Uganda. Methods: We conducted a matched cohort study at Mulago National Referral Hospital and Mbarara Regional Referral Hospital between January 2018 and November 2020. We enrolled consecutive PWH presenting with CT-confirmed acute or subacute stroke (symptom onset ≤14 days) and matched them by sex and stroke type to 2 consecutive available PWOH admitted to the same hospital. We obtained baseline clinical data and followed participants for 90 days from the day of clinical presentation. We compared stroke severity (defined by the NIH stroke scale [NIHSS]) and 90-day all-cause mortality and morbidity (using the modified Rankin Scale [mRS]) by HIV serostatus with and without adjustment for confounders. Results: We enrolled 105 PWH and 157 PWOH with stroke. PWH were younger (mean [SD] age 49 [14] vs 59 [16] years, p < 0.001), and nearly 80% (82/105) were on ART for a median of 5 years and a median CD4 count of 214 cells/uL (interquartile range 140, 337). Compared with PWOH, PWH presented with a 3-point lower median NIHSS (16 vs 19, p = 0.011), a 20% lower proportion of all-cause mortality at 90 days (p = 0.001), and had less disability at 90 days (median mRS 4 vs 5, p = 0.004). Age and NIHSS-adjusted odds ratio of 90-day all-cause mortality in PWH compared with PWOH was 0.45 (95% CI 0.22-0.96, p = 0.037). Discussion: In the modern ART era, PWH with acute stroke in Uganda present with modest stroke and are significantly less likely to die within 90 days than PWOH. This potentially reflects the protective effects of ART, enhanced health care access, and their younger age at stroke presentation.

Diagnostic performance of fecal Helicobacter pylori antigen test in Uganda.

We evaluated the diagnostic performance of a qualitative stool antigen test (SAT) in individuals with dyspepsia in rural Uganda using the polymerase chain reaction-based 16S ribosomal RNA assay (16S rRNA) for nucleotide sequences for two common H. pylori-associated genes as the reference standard. We enrolled 150 adults with dyspepsia with no self-reported use of antibiotic and/or antiacid medication medications within a fortnight. We performed blinded SAT on fecal specimens and 16S rRNA tests on gastric specimens. Using nonlinear mixed models, SAT had a sensitivity of 85⋅1% (95%CI 76⋅54%, 93⋅6%), and specificity of 97⋅6% (95%CI 94⋅3, 100). Twelve individuals with dyspepsia need to be tested to correctly diagnose 10 with H. pylori infection using SAT. The SAT is a robust diagnostic test to improve the diagnosis of H. pylori infection in people with dyspepsia in resource-limited settings.

Priorities for health and wellbeing for older people with and without HIV in Uganda: a qualitative methods study.

INTRODUCTION: With improved HIV treatment availability in sub-Saharan Africa, the population of older people with HIV (PWH) is growing. In this qualitative study, we intended to understand (1) the lived experiences of ageing people in rural Uganda, with and without HIV, (2) their fears and health priorities as they grow older. METHODS: We conducted 36 semi-structured interviews with individuals with and without HIV in Mbarara, Uganda from October 2019 to February 2020. Interview guide topics included priorities in older age, physical functioning in daily activities, social functioning, HIV-related stigma and the impact of multimorbidity on health and independence. Interviews were conducted in Runyankole, transcribed, translated and inductively coded thematically by two researchers with tests for inter-coder reliability. RESULTS: The respondents were purposively sampled to be evenly divided by sex and HIV serostatus. The median age of respondents was 57 (49-73). Two-thirds were married or cohabitating, 94% had biological children and 75% cited farming as their primary livelihood. Overall, PWH considered themselves as healthy or healthier than people without HIV (PWOH). PWH rarely considered their HIV status a barrier to a healthy life, but some reported a constant sense of anxiety as it relates to their long-term health. Irrespective of HIV status, nearly all respondents noted concerns about memory loss, physical pain, reductions in energy and the effect of these changes on their ability to complete physical tasks like small-scale farming, and activities of daily living important to the quality of life, such as participating in community groups. Increasing reliance on others for social, physical and financial support was also a common theme. The most prevalent health concern among participants involved the threat of non-communicable diseases and perceptions that physical functioning may diminish. CONCLUSIONS: In rural Uganda, we found that PWH consider themselves to be healthy and do not anticipate a different ageing experience from PWOH. Common priorities shared by both groups included the desire for physical and financial independence, health maintenance and social support for daily functioning and social needs. Entities supporting geriatric care in Uganda would benefit from attention to concerns about functional limitations and reported needs as people age with and without HIV.

Association of body mass index with left ventricular diastolic dysfunction among ambulatory individuals with diabetes mellitus in rural Uganda: a cross-sectional study.

BACKGROUND: Left ventricular diastolic dysfunction (LVDD) is a recognized complication of diabetes mellitus that precedes and is a risk factor for heart failure. We aimed to determine the prevalence of LVDD and its association with body mass index in ambulatory adults with diabetes mellitus in rural Uganda. METHODS: We conducted a cross-sectional study, over 5 months, to enroll 195 ambulatory Ugandan adults living with diabetes mellitus for at least five years at Mbarara Regional Referral Hospital. We collected demographic, and clinical data and measured body mass index (BMI). Echocardiography was performed to determine LVDD by assessing the mitral inflow ventricular filling velocities (E/A and E/è ratios), tricuspid regurgitant jet peak velocity, and left atrium maximum volume index. We used logistic regression to estimate the odds ratio for the association of LVDD with BMI and evaluated the variation of associations by age and hypertension status. RESULTS: Of the 195 participants, 141 (72.31%) were female, the mean age was 62 [standard deviation, 11.50] years, and the median duration of diabetes diagnosis was 10 [interquartile range, 7, 15] years. Eighty-six percent (n = 168) had LVDD with the majority (n = 127, 65.1%) of participants in the grade 1 category of LVDD. In the adjusted model, the odds of LVDD for each 1 kg/m2 increase in BMI was 1.11 [95% confidence interval 1.00, 1.25, p = 0.04]. The adjusted odds of LVDD among individuals aged ≥ 50 years with BMI ≥ 25 kg/m2 was 13.82 times the odds of LVDD in individuals aged < 50 years with BMI < 25 kg/m2. CONCLUSION: LVDD is prevalent and positively associated with BMI among ambulatory Ugandan adults living with diabetes mellitus for at least five years. The association was higher for older overweight/obese than younger individuals with normal weight. Future studies should focus on the effect of weight loss on LVDD as a possible target for the prevention of heart failure.

Association between HIV and Prevalent Hypertension and Diabetes Mellitus in South Africa: Analysis of a Nationally Representative Cross-Sectional Survey.

OBJECTIVES: Cardiovascular disease (CVD) burden is increasing among persons living with HIV (PLWH) in sub-Saharan Africa. It is unclear whether this reflects absolute increase in HIV-related CVD risk or unmasking by improved survival. Therefore, we examined whether HIV is associated with adverse cardiometabolic profiles among South African adults. METHODS: We analyzed a nationally representative dataset (n=6420), estimating the weighted prevalence of hypertension, diabetes, and 10-year predicted risk of incident fatal/nonfatal CVD (if aged ≥40 years). Associations between HIV and cardiometabolic indices were assessed using log-binomial regression models adjusted for sociodemographic factors. RESULTS: HIV population prevalence was 18.9%, with a median age of 36 years. Hypertension (44.2% vs 45.4%), diabetes (18.6% vs 20.4%), and overweight/obesity (body mass index ≥25 kg/m2: 54.9% vs 52.0%) prevalence did not substantially differ by HIV status, although PLWH had a lower 10-year predicted CVD risk (median: 5.1% vs 13.5%). In adjusted models, females who are HIV-negative had a 5 mm Hg higher median systolic blood pressure (128 vs 123 mmHg) than female PLWH. CONCLUSIONS: PLWH in South Africa have better cardiometabolic disease profiles than the general population, and social determinants, rather than HIV, may have a greater influence on cardiometabolic risk. Designating PLWH a CVD high-risk group in South Africa is likely unwarranted.

An Analysis of Stroke Risk Factors by HIV Serostatus in Uganda: Implications for Stroke Prevention in Sub-Saharan Africa.

OBJECTIVE: HIV infection is an important stroke risk factor in sub-Saharan Africa.  However, data on stroke risk factors in the era of antiretroviral therapy (ART) are sparse. We aimed to determine if stroke risk factors differed by HIV serostatus in Uganda. METHODS: We conducted a matched cohort study, enrolling persons living with HIV (PWH) with acute stroke, matched by sex and stroke type to HIV uninfected (HIV-) individuals. We collected data on stroke risk factors and fitted logistic regression models for analysis. RESULTS: We enrolled 262 participants:105 PWH and 157 HIV-. The median ART duration was 5 years, and the median CD4 cell count was 214 cells/uL. PWH with ischemic stroke had higher odds of hypertriglyceridemia (AOR 1.63; 95% CI 1.04, 2.55, p=0.03), alcohol consumption (AOR 2.84; 95% CI 1.32, 6.14, p=0.008), and depression (AOR 5.64; 95%CI 1.32, 24.02, p=0.02) while HIV- persons with ischemic stroke were more likely to be > 55 years of age (AOR 0.43; 95%CI 0.20-0.95, p=0.037), have an irregular heart rhythm (AOR 0.31; 95%CI 0.10-0.98, p=0.047) and report low fruit consumption (AOR 0.39; 95%CI 0.18-0.83, p=0.014).  Among all participants with hemorrhagic stroke (n=78) we found no differences in the prevalence of risk factors between PWH and HIV-. CONCLUSIONS: PWH with ischemic stroke in Uganda present at a younger age, and with a combination of traditional and psychosocial risk factors. By contrast, HIV- persons more commonly present with arrhythmia. A differential approach to stroke prevention might be needed in these populations.

Lung function and atherosclerosis: a cross-sectional study of multimorbidity in rural Uganda.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of global mortality. In high-income settings, the presence of cardiovascular disease among people with COPD increases mortality and complicates longitudinal disease management. An estimated 26 million people are living with COPD in sub-Saharan Africa, where risk factors for co-occurring pulmonary and cardiovascular disease may differ from high-income settings but remain uncharacterized. As non-communicable diseases have become the leading cause of death in sub-Saharan Africa, defining multimorbidity in this setting is critical to inform the required scale-up of existing healthcare infrastructure. METHODS: We measured lung function and carotid intima media thickness (cIMT) among participants in the UGANDAC Study. Study participants were over 40 years old and equally divided into people living with HIV (PLWH) and an age- and sex-similar, HIV-uninfected control population. We fit multivariable linear regression models to characterize the relationship between lung function (forced expiratory volume in one second, FEV1) and pre-clinical atherosclerosis (cIMT), and evaluated for effect modification by age, sex, smoking history, HIV, and socioeconomic status. RESULTS: Of 265 participants, median age was 52 years, 125 (47%) were women, and 140 (53%) were PLWH. Most participants who met criteria for COPD were PLWH (13/17, 76%). Median cIMT was 0.67 mm (IQR: 0.60 to 0.74), which did not differ by HIV serostatus. In models adjusted for age, sex, socioeconomic status, smoking, and HIV, lower FEV1 was associated with increased cIMT (ß = 0.006 per 200 mL FEV1 decrease; 95% CI 0.002 to 0.011, p = 0.01). There was no evidence that age, sex, HIV serostatus, smoking, or socioeconomic status modified the relationship between FEV1 and cIMT. CONCLUSIONS: Impaired lung function was associated with increased cIMT, a measure of pre-clinical atherosclerosis, among adults with and without HIV in rural Uganda. Future work should explore how co-occurring lung and cardiovascular disease might share risk factors and contribute to health outcomes in sub-Saharan Africa.

Prevalence and correlates of carotid plaque in a mixed HIV-serostatus cohort in Uganda.

BACKGROUND: The extent to which the risk of atherosclerotic cardiovascular disease (ACVD) is increased among people living with HIV (PLWH) in sub-Saharan Africa remains unknown. SETTING: Cross-sectional analysis nested within the Ugandan Noncommunicable Diseases and Aging Cohort, including PLWH in rural Uganda > 40 years taking antiretroviral therapy (ART) for at least 3 years, and a population-based control group of HIV-uninfected age- and sex-matched persons. METHODS: We conducted carotid ultrasonography and collected ACVD risk factor data. Our outcome of interest was carotid plaque, defined as > 1.5 mm thickness from the intima-lumen interface to the media-adventitia interface. We fit multivariable logistic regression models to estimate correlates of carotid plaque including HIV-specific and traditional cardiovascular risk factors. RESULTS: We enrolled 155 (50.2%) PLWH and 154 (49.8%) HIV-uninfected comparators, with a mean age of  51.4 years. Among PLWH, the median CD4 count was 433 cells/mm3 and 97.4% were virologically suppressed. Carotid plaque prevalence was higher among PLWH (8.4% vs 3.3%). HIV infection (aOR 3.90; 95% CI 1.12-13.60) and current smokers (aOR 6.60; 95% CI 1.22-35.80) had higher odds of carotid plaque, whereas moderate (aOR 0.13, 95% CI 0.01-1.55) and vigorous intensity of physical activity (aOR 0.34, 95% CI 0.07-1.52) were associated with decreased odds of carotid plaque. CONCLUSION: In rural Uganda, PLWH have higher prevalence of carotid plaque compared to age- and sex-matched HIV-uninfected comparators. Future work should explore how biomedical and lifestyle modifications might reduce atherosclerotic burden among PLWH in the region.

Acceptability and feasibility of a mobile health application for blood pressure monitoring in rural Uganda.

BACKGROUND: Mobile technologies to improve blood pressure control in resource-limited settings are needed. We adapted and evaluated the acceptability and feasibility of PositiveLinks, a mobile phone application for self-monitoring, social support, and engagement in care for people living with HIV, among patients with hypertension in rural Uganda. METHODS: We enrolled adults on treatment for hypertension at Mbarara Regional Referral Hospital and Mbarara Municipal health center IV, southwestern Uganda. We provided and educated all participants on the use of PositiveLinks application and automated blood pressure monitors. We administered a baseline questionnaire and performed in-depth interviews 30 days later to explore acceptability, feasibility, medication adherence, social support, and blood pressure control. RESULTS: A total of 37 participants completed the interviews, mean age of 58 years (SD 10.8) and 28 (75.7%) were female. All participants embraced the PositiveLinks mobile app and were enthusiastic about self-monitoring of blood pressure, 35 (94.6%) experienced peer to peer support. Among the 35 participants non-adherent to medications at baseline, 31 had improved medication adherence. All except 1 of the 31(83.8%) who had uncontrolled blood pressure at baseline, had self-reported controlled blood pressure after 30 days of use of PositiveLinks. CONCLUSION: Patients with hypertension in rural Uganda embraced the PositiveLinks mobile application and had improved medication adherence, social support, and blood pressure control. Further assessment of cost-effectiveness of the application in blood pressure control in resource-limited settings will be pursued in future studies.

Treated HIV Infection and Progression of Carotid Atherosclerosis in Rural Uganda: A Prospective Observational Cohort Study.

Background Although ≈70% of the world's population of people living with HIV reside in sub-Saharan Africa, there are minimal prospective data on the contributions of HIV infection to atherosclerosis in the region. Methods and Results We conducted a prospective observational cohort study of people living with HIV on antiretroviral therapy >40 years of age in rural Uganda, along with population-based comparators not infected with HIV. We collected data on cardiovascular disease risk factors and carotid ultrasound measurements annually. We fitted linear mixed effects models, adjusted for cardiovascular disease risk factors, to estimate the association between HIV serostatus and progression of carotid intima media thickness (cIMT). We enrolled 155 people living with HIV and 154 individuals not infected with HIV and collected cIMT images at 1045 visits during a median of 4 annual visits per participant (interquartile range 3-4, range 1-5). Age (median 50.9 years) and sex (49% female) were similar by HIV serostatus. At enrollment, there was no difference in mean cIMT by HIV serostatus (0.665 versus 0.680 mm, P=0.15). In multivariable models, increasing age, blood pressure, and non-high-density lipoprotein cholesterol were associated with greater cIMT (P<0.05), however change in cIMT per year was also no different by HIV serostatus (0.004 mm/year for HIV negative [95% CI, 0.001-0.007 mm], 0.006 mm/year for people living with HIV [95% CI, 0.003-0.008 mm], HIV×time interaction P=0.25). Conclusions In rural Uganda, treated HIV infection was not associated with faster cIMT progression. These results do not support classification of treated HIV infection as a risk factor for subclinical atherosclerosis progression in rural sub-Saharan Africa. Registration URL: https://www.ClinicalTrials.gov; Unique identifier: NCT02445079.

A qualitative inquiry of access to and quality of primary healthcare in seven communities in East and West Africa (SevenCEWA): perspectives of stakeholders, healthcare providers and users.

BACKGROUND: Universal health coverage is one of the Sustainable Development Goal targets known to improve population health and reduce financial burden. There is little qualitative data on access to and quality of primary healthcare in East and West Africa. The aim of this study was to describe the viewpoints of healthcare users, healthcare providers and other stakeholders on health-seeking behaviour, access to and quality of healthcare in seven communities in East and West Africa. METHODS: A qualitative study was conducted in four communities in Nigeria and one community each in Kenya, Uganda and Tanzania in 2018. Purposive sampling was used to recruit: 155 respondents (mostly healthcare users) for 24 focus group discussions, 25 healthcare users, healthcare providers and stakeholders for in-depth interviews and 11 healthcare providers and stakeholders for key informant interviews. The conceptual framework in this study combined elements of the Health Belief Model, Health Care Utilisation Model, four 'As' of access to care, and pathway model to better understand the a priori themes on access to and quality of primary healthcare as well as health-seeking behaviours of the study respondents. A content analysis of the data was done using MAXQDA 2018 qualitative software to identify these a priori themes and emerging themes. RESULTS: Access to primary healthcare in the seven communities was limited, especially use of health insurance. Quality of care was perceived to be unacceptable in public facilities whereas cost of care was unaffordable in private facilities. Health providers and users as well as stakeholders highlighted shortage of equipment, frequent drug stock-outs and long waiting times as major issues, but had varying opinions on satisfaction with care. Use of herbal medicines and other traditional treatments delayed or deterred seeking modern healthcare in the Nigerian sites. CONCLUSIONS: There was a substantial gap in primary healthcare coverage and quality in the selected communities in rural and urban East and West Africa. Alternative models of healthcare delivery that address social and health inequities, through affordable health insurance, can be used to fill this gap and facilitate achieving universal health coverage.

Patient experiences and perspectives on hypertension at a major referral hospital in rural southwestern Uganda: a qualitative analysis.

OBJECTIVES: Novel care models are needed to address the large burden of hypertension globally. We aimed to explore how patients in rural Uganda experience and perceive hypertension in order to understand factors that may inform development of a patient-centred care model for hypertension management in this setting. DESIGN: We conducted one-time, in-depth qualitative interviews focusing on participants' experiences and perceptions of the meaning and management of hypertension. SETTING: Outpatient clinic at Mbarara Regional Referral Hospital in Uganda. PARTICIPANTS: We enrolled patients who had hypertension and had used antihypertensive medication for at least 1 month. We used purposive sampling to recruit 30 participants with similar representation by gender and by absence or presence of comorbid conditions. RESULTS: Participants had been diagnosed and initiated care at various clinical stages of hypertension, which impacted their understanding of hypertension. Several participants saw hypertension as a chronic disease that can lead to complications if not controlled, while others attributed symptoms typically associated with other diseases to hypertension. Participants described inconsistent access to antihypertensive medications and difficulty with transport to the clinic (time needed and expense) as the major barriers to access to care. Initiation and maintenance of care were facilitated by family support and ready access to health facilities. Many participants identified an understanding of the important lifestyle and dietary changes required to control hypertension. CONCLUSIONS: Patients with hypertension in rural Uganda demonstrated a varied understanding and experience with hypertension. Interventions leveraging family support may help with patient education and clinical management. Integration of patient perspectives into the care model, patient-centred care, may serve as a successful model for hypertension and potentially delivery of care for other non-communicable diseases in Uganda and other similar resource-limited settings.