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1.
BMC Med Ethics ; 22(1): 35, 2021 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-33789618

RESUMO

BACKGROUND: Whereas many adolescents and young people with HIV require the transfer of care from paediatric/adolescent clinics to adult ART clinics, this transition is beset with a multitude of factors that have the potential to hinder or facilitate the process, thereby raising ethical challenges of the transition process. Decisions made regarding therapy, such as when and how to transition to adult HIV care, should consider ethical benefits and risks. Understanding and addressing ethical challenges in the healthcare transition could ensure a smooth and successful transition. The purpose of this study was to analyze the ethical challenges of transitioning HIV care for adolescents into adult HIV clinics. METHODS: Data presented were derived from 191 adolescents attending nine different health facilities in Uganda, who constituted 18 focus group discussions. In the discussions, facilitators and barriers regarding adolescents transitioning to adult HIV clinics were explored. Guided by the Silences Framework for data interpretation, thematic data analysis was used to analyze the data. The principles of bioethics and the four-boxes ethics framework for clinical care (patient autonomy, medical indications, the context of care, and quality of life) were used to analyze the ethical issues surrounding the transition from adolescent to adult HIV care. RESULTS: The key emerging ethical issues were: reduced patient autonomy; increased risk of harm from stigma and loss of privacy and confidentiality; unfriendly adult clinics induce disengagement and disruption of the care continuum; patient preference to transition as a cohort, and contextual factors are critical to a successful transition. CONCLUSION: The priority outcomes of the healthcare transition for adolescents should address ethical challenges of the healthcare transition such as loss of autonomy, stigma, loss of privacy, and discontinuity of care to ensure retention in HIV care, facilitate long-term self-care, offer ongoing all-inclusive healthcare, promote adolescent health and wellbeing and foster trust in the healthcare system. Identifying and addressing the ethical issues related to what hinders or facilitates successful transitions with targeted interventions for the transition process may ensure adolescents and young people with HIV infection remain healthy across the healthcare transition.

2.
BMC Med Ethics ; 22(1): 1, 2021 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-33388052

RESUMO

BACKGROUND: Factors that could potentially act as facilitators and barriers to successful recruitment strategies in perinatal clinical trials are not well documented. The objective was to assess lay persons' understanding of the informed consent for randomized clinical trial in emergency obstetric and newborn care. METHODS: This was a qualitative study conducted among survivors of severe obstetric complications who were attending the post-natal clinic of Kawempe National Referral Hospital, Uganda, 6-8 weeks after surviving severe obstetric complications during pregnancy or childbirth. The study that involved 18 in-depth interviews was conducted from June 1, 2019 to July 6, 2019. The issues explored included perceptions of the purpose and necessity to conduct such research how research-related information would be disclosed, and what could be the potential benefits and risks of participation. The data was analyzed by thematic analysis. RESULTS: Respondents felt that research was necessary to investigate the cause, prevention or complications of an illness, especially as much was known about some pregnancy and newborn complications. Most believed that the emergency contexts affects whether and what prospective participants may understand if information about research was disclosed. Whereas they did not see the value of procedures like randomization, they felt that if these and any other procedures necessary should be done transparently and fairly. The decisions to participate would significantly be influenced by possibility of risk to the unborn baby or the newborn. Solidarity was an important influence on decision-making. CONCLUSIONS: Respondents valued participation in RCTs in emergency obstetric and newborn care. However, they expressed concerns and valued openness, transparency and accountability with regard to how clinical trials information is disclosed and the decision-making process for clinical trial participation. While autonomy and solidarity are contradictory values, they complement each other during decision-making for informed consent.

3.
BMC Pregnancy Childbirth ; 20(1): 650, 2020 Oct 27.
Artigo em Inglês | MEDLINE | ID: mdl-33109097

RESUMO

BACKGROUND: Rwanda has a high unmet need for family planning which could be reduced by improving access to postpartum intrauterine contraceptives device (PPIUCD) insertion. The objective of the study was to assess the prevalence and factors associated with the uptake of PPIUCD among postpartum women in Muhima Hospital. METHODS: A concurrent mixed-method study was used. Three hundred eight three (383) immediate postpartum mothers, and 10 health services providers were interviewed using a structured questionnaire and in-depth interviews respectively. Logistics regression was done to assess for factors associated with PPIUCD uptake and thematic analysis was used for qualitative data. RESULTS: The prevalence for PPIUCD use was 28.1%, women who had spontaneous vaginal delivery were more likely to take up PPIUCD (Adjusted Odds Ratio (AOR) 2.623, 95% CI = 2.017-6.507 compared to those who had cesarean section; women who received PPIUCD counselling during the antenatal period were more likely to use PPIUCD ((AOR 2.072, 95% CI = 1.018-4.218) as compared to those who didn't receive any form of counselling; mothers who received spouse approval were more likely to use PPIUCD (AOR 2.591,95% CI = 1.485-4.492); as compared to those who didn't receive any spousal approval; women who had more than one child were more likely to use PPIUCD (AOR =2.265, 95% CI = 1.472-3.163) as compared to prime gravida; Mothers with birth to pregnancy interval less than two years were more likely to use PPIUCD (AOR =2.123, CI =1.477-2.706) as compared to those who had birth to pregnancy interval more than 2 years. From the qualitative findings, health education of mothers and partners on PPIUCD, training of health care providers, and availability of supplies to provide PPIUCD influenced the use of PPIUCD. CONCLUSION: The acceptability to use for PPIUCD was high in this population. PPIUCD uptake was associated with normal birth, PPIUCD counselling, spousal approval, parity, birth interval, level of education. Health education of mothers and partners on PPIUCD, training of health providers, and availability of supplies to provide PPIUCD influenced uptake of PPIUCD.

4.
BMC Health Serv Res ; 20(1): 835, 2020 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-32891150

RESUMO

BACKGROUND: There is a growing number of adolescents and young adults living with HIV (YPLHIV) who require the transfer of care from pediatric/ adolescent clinics to adult Antiretroviral therapy (ART) clinics. A successful transition is critical for optimum health outcomes, yet facilities may lack infrastructure, human resources (with appropriate knowledge and skills), and a supportive environment, as only 3% of clinics in Uganda caring for YPLHIV have a process for supporting this critical transition from pediatric to adult care, and, facilitators and barriers of a successful transition are not well documented. The purpose of this study was to explore the facilitators and barriers of transitioning among adolescents from adolescent clinics to adult ART clinics. METHOD: Eighteen focus group discussions were held in nine health facilities with 174 adolescents and YPLHIV to assess barriers and facilitators regarding transitioning to adult clinics. The focus group discussions were audio-recorded and transcribed. The Silences Framework using a thematic approach guided the analysis. RESULTS: The key emerging issues were: Unfriendly adults in adult clinics, Care provided in the adolescent clinics, fear of stigma from health care providers, Congestion and long waiting time, fear to lose friends were barriers to transitioning. Transitioning preparation is key to a successful transition, moving as a cohort facilitates transition, and care in adult clinics offers new opportunities, could facilitate readiness and transition. CONCLUSION: YPLHIV expressed fear to transition to adult clinics mainly because of the perceived better care provided in the adolescent clinic, thus constituting a barrier to smooth transition A range of individual, social and health system and services-related factors hindered transitioning. The expectation of transitioning as a group, assurance of similar care as in the adolescent clinic, and guarantees of confidentiality, privacy, and autonomy in decision-making for care was perceived as facilitators. Understanding barriers and facilitators can enable the Ministry of Health to improve the quality of life of YPLHIV through linkage to care, adherence, retention, and viral suppression. There is a need to better planning and preparation for clinical providers and YPLHIV with a focus on age-appropriate and individualized case management transition as well as focus on improving both clinical and psychosocial support throughout the process.

5.
Philos Ethics Humanit Med ; 15(1): 6, 2020 08 26.
Artigo em Inglês | MEDLINE | ID: mdl-32843035

RESUMO

BACKGROUND: Randomized controlled trials (RCTs) are central to generating knowledge about effectiveness of interventions as well as risk, protective and prognostic factors related to diseases in emergency newborn care. Whether prospective participants understand the purpose of research, and what they perceive as the influence of the context on their understanding of the informed consent process for RCTs in emergency obstetric and newborn care are not well documented. METHODS: Conceptual review. DISCUSSION: Research is necessary to identify how the illnesses may be prevented, to explore the causes, and to investigate what medications could be used to manage such illness. Voluntary informed consent requires that prospective participants understand the disclose information about the research, and use this to make autonomous informed decision about participation, in line with their preferences and values. Yet the emergency context affects how information may be disclosed to prospective research participants, how much participants may comprehend, and how participants may express their voluntary decision to participate, all of which pose a threat to the validity of the informed consent. I challenge the claim that the 'understanding' of research is always necessary for ethical informed consent for research during emergency care. I argue for reconceptualization of the value of understanding, through recognition of other values that may be equally important. I then present a reflective perspective that frames moral reflection about autonomy, beneficence and justice in research in emergency research. CONCLUSION: While participant 'understanding' of research is important, it is neither necessary nor sufficient for a valid informed consent, and may compete with other values with which it needs to be considered.

6.
Philos Ethics Humanit Med ; 14(1): 11, 2019 09 06.
Artigo em Inglês | MEDLINE | ID: mdl-31492178

RESUMO

BACKGROUND: There is longstanding consensus on the need to include pregnant women in research. The goal of clinical research is to find highly regulated, carefully controlled, morally responsible ways to generate evidence about how to effectively and safely prevent illness or treat sick people. This manuscripts present a conceptual analysis of the ethicality of clinical trials in 3 scenarios: where the pregnant is involved in clinical trials as a participant during pregnancy for data that addresses pregnancy complications, where the pregnant woman consents to clinical trial participation for an unborn baby that has complications, to generate data on complications at this stage of life, and where the mother may consent for participation of their newborn child in clinical trials. METHODS: Conceptual analysis. FINDINGS: Investigators often choose to exclude pregnant women and newborns from research, even where there is possibility for them to benefit from the study intervention. Objections include vulnerability of pregnant women, altered pharmacokinetics and risk of adverse effects, with a need to balance potential maternal and fetal risks and benefits of research participation. While the objections may be valid, not performing research magnifies what should be a carefully controlled risk during research, pushing this risk into the clinical setting, and subsequently posing a challenge to clinicians who are faced with making treatment decisions for pregnant patients with limited evidence of efficacy and safety. The potential benefits of fair inclusion in clinical trials outweigh the potential risks. CONCLUSION: Research involving pregnant women is necessary to provide women with effective treatment during pregnancy, to promote fetal safety (such as by avoiding the clinical use of drugs that may be harmful to the developing fetus), and to reduce avoidable harm from suboptimal care (such as from underdosing) and to provide pregnant women, their fetuses and newborns (with access to potential benefits of research participation).


Assuntos
Princípios Morais , Seleção de Pacientes/ética , Complicações na Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Feminino , Humanos , Gravidez
7.
BMC Pediatr ; 19(1): 218, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-31266486

RESUMO

BACKGROUND: Research guidelines generally recognize vulnerable populations to include neonates with the aim of enhancing protections from harm. In practice, such guidance results in limiting participation in randomized clinical trials (RCTs). Yet while medical care of neonates should be based on best research evidence to ensure that safe, efficacious treatment or procedures are used, this seldom happens in contemporary practice. DISCUSSION: The compelling need to generate information on effectiveness and safety of procedures and medications that are already in use during neonatal care has led to increase in calls for pragmatic randomized clinical trials (PCTs). This raises ethical concerns as to whether exclusion of the vulnerable populations from research participations constitutes harm. First, neonates are denied access to both potentially beneficial research outputs and an opportunity to generate data on how interventions or medications perform in diverse clinical settings and inform clinical decision-making. Secondly, risks and harms in PCTs may differ from traditional RCTs, and can be reduced by modifications in study designs. The latter may involve assessment of effectiveness of comparable medication, devices or practices (whose safety data is available), randomization at the group level rather than at the individual level, avoidance of invasive and innovative study procedures, reliance on locally available data on relevant patient outcomes, and employment of procedures that tend to meet the criteria of minimal risk for human subject research. Thirdly, informed consent procedures should be modified from those of traditional RCTs, as neonates in traditional RCTs may be vulnerable to different extents in PCTs. Lastly, regulatory and oversight procedures designed for traditional RCT settings need modification, as they may not be translatable, feasible, appropriate or even ethical to apply in PCTs. CONCLUSION: The principle of justice, commonly interpreted as preventing an inequitable burden of research, should also allow fair access to potential benefits from PCTs for neonates and other vulnerable populations. Under certain conditions, prospective randomized trials involving neonates should be ethically permissible to allow inclusion of neonates in research. This may require modification of the research design, consent procedures or regulations for research oversight.


Assuntos
Serviços Médicos de Emergência/ética , Cuidado do Lactente/ética , Seleção de Pacientes/ética , Ensaios Clínicos Pragmáticos como Assunto/ética , Controle de Acesso/ética , Humanos , Cuidado do Lactente/métodos , Recém-Nascido , Segurança do Paciente , Justiça Social/ética , Populações Vulneráveis
8.
BMC Pregnancy Childbirth ; 16: 205, 2016 08 04.
Artigo em Inglês | MEDLINE | ID: mdl-27492552

RESUMO

BACKGROUND: Hypertensive disorders of pregnancy are a major cause of morbidity and mortality. The objective was to estimate the disease burden attributable to hypertensive disorders of pregnancy in two referral hospitals in Uganda. METHODS: Through a prospective cohort study conducted in Jinja and Mulago hospitals in Uganda from March 1, 2013 and February 28, 2014, hypertension-related cases were analyzed. Maternal near miss cases were defined according to the WHO criteria. Maternal deaths were also analyzed. The maternal near miss incidence ratio, the case-specific severe maternal outcome ratio, the case-specific maternal mortality ratio and the case-fatality ratio were computed. RESULTS: Of 403 women with hypertensive disorders of pregnancy, 218 (54.1 %) had severe preeclampsia, 172 (42.7 %) had eclampsia, and 13 had chronic hypertension or Hemolysis, elevated liver enzymes or low platelets (HELLP) syndrome. The case-specific maternal near miss incidence ratios was 8.60 per 1,000 live births for all hypertensive disorders, 3.06 per 1,000 live births for severe preeclampsia and 5.11 per 1,000 live births for eclampsia. The case-specific severe maternal outcome ratio was 9.37 per 1,000 live births for all hypertensive disorders, and was 3.25 per 1,000 live births for severe preeclampsia and 5.61 per 1,000 live births for eclampsia. The case-specific maternal mortality ratio was 780 per 100,000 live births for all hypertensive disorders, and was 1940 per 100,000 live births for severe preeclampsia and 501 per 100,000 live births for eclampsia. The case-fatality ratio was 5.1 % overall (for all hypertensive disorders), but was 8 times higher for eclampsia compared to severe preeclampsia. Cyanosis, abnormal respiration, oliguria, circulatory collapse, coagulopathy, thrombocytopenia, and elevated serum lactate were significantly associated with severe maternal outcomes. CONCLUSION: There is high morbidity attributable to hypertensive disorders in pregnancy. Since some of the complications associated with morbidity can be recognized early, it is possible to prevent severe morbidity through early intervention with delivery, antihypertensive therapy and prophylactic magnesium sulphate treatment. The findings highlight the feasibility of implementing a facility-based surveillance system for severe maternal morbidity due to hypertensive disorders.


Assuntos
Hipertensão Induzida pela Gravidez/mortalidade , Mortalidade Materna , Adulto , Feminino , Humanos , Nascimento Vivo , Morbidade , Near Miss/estatística & dados numéricos , Gravidez , Estudos Prospectivos , Uganda/epidemiologia , Adulto Jovem
9.
Reprod Health ; 12: 96, 2015 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-26475268

RESUMO

BACKGROUND: The objective of this study was to explore the correlates of ever had sex among perinatally HIV-infected (PHIV) adolescents. METHODS: A cross-sectional survey of sexual behaviour was conducted with 624 PHIV adolescents living three regions (12 districts) of Uganda. Data was collected on socio demographic characteristics (age, sex, occupation, religion and education status), sexual practices and behaviours (Intimate relationships, sexual intercourse, age of sexual debut, condom use, multiple and concurrent sexual partners), consequences of sexual behaviours (pregnancy and STI's) and life style factors (use of alcohol, psychoactive substances and peer influence). Multivariable logistic-regression was used to ascertain the determinants of sexual activity. RESULTS: The majority of PHIV were female (59.3 %) and the mean age of the sample was 16.2 (±2.1) years. The mean age of sexual debut was 15.8 years; 16.2 % (101/624) reported symptoms for sexually transmitted infections (STI) and more than a third (213/624) reported ever had sex.Of these 76.5 % (165/213) used condoms inconsistently; and 49.3 % (105/213) had been pregnant or made someone pregnant. Of those in relationships, 56.3 % (223/396) did not disclose and were not aware of their partners' HIV status. Adolescents aged 15-19 years were more likely to have ever been sexually active (Adjusted odds ratio (AOR) 6.28, 95 % Confidence interval (CI): 2.63-14.99) compared to those aged 10-14 years. Adolescents who were living alone were more likely to have ever been sexually active compared to those living with one or both parents (AOR 4.33, 95 % CI: 1.13-16.62). The odds of being sexually active were lower among adolescents in school compared to those out of school (AOR 0.2, 95 % CI: 0.13-0.30), who had never been treated for STI (compared to those who had never been treated for STI) (AOR 0.19, 95 % 0.11-0.32) and adolescents who never drank alcohol (AOR 0.49, 95 % CI 0.28-0.87). CONCLUSION: PHIV adolescents have risky sexual behaviours characterized by being sexually active, inconsistent condom use, and having partners of unknown status. Risk reduction interventions are required to minimize unplanned pregnancies, STI, and HIV transmission by PHIV adolescents.


Assuntos
Infecções por HIV/epidemiologia , Comportamento Sexual/estatística & dados numéricos , Adolescente , Adulto , Estudos Transversais , Feminino , Infecções por HIV/transmissão , Humanos , Transmissão Vertical de Doença Infecciosa , Masculino , Razão de Chances , Uganda
10.
J Infect Dev Ctries ; 7(6): 436-47, 2013 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-23771287

RESUMO

INTRODUCTION: High-risk sexual behaviors such as multiple sexual partners, inconsistent condom use, acquisition of sexually transmitted infection (STIs), and non-use of contraceptives persist in HIV patients undergoing care. We conducted a systematic review of studies conducted in the era of increased access to HAART (2000-2010) to assess whether wide-scale use of HAART was associated with high-risk behavior among HAART-using patients. METHODOLOGY: We conducted a comprehensive search of databases (AIDSLINE, National Library of Medicine, MEDLINE, PubMed, CINHAL and EMBASE) from January 2002 to January 2010, reviewed conference proceedings and journals, and contacted the researchers involved. We analyzed the association of high-risk behaviors (non-disclosure of sero-status to sexual partners, inconsistent condom use, unprotected sexual intercourse, multiple sexual partners, non-use of contraceptives and acquisition of STIs) with using HAART. Information from eligible studies was abstracted using a standardized checklist. Fourteen English-language studies met the selection criteria of having high-risk behavior as an outcome in patients using HAART in sub-Saharan Africa. RESULTS: Of the 92 eligible articles screened, 14 met the criteria for inclusion as primary articles, 10 showed that HAART is not associated with increased high-risk behavior, two showed increase in acquisition of STIs among HAART-using patients, (which was inconsistent with other measures of high-risk behavior), and two studies showed short-term increase in high-risk behavior. CONCLUSIONS: Persistence of high-risk behavior in HAART-using patients suggests that more effort needs to be incorporated in HIV care to reduce such behavior to reduce HIV transmission to uninfected populations.


Assuntos
Antirretrovirais/uso terapêutico , Terapia Antirretroviral de Alta Atividade , Infecções por HIV/tratamento farmacológico , Assunção de Riscos , Comportamento Sexual/estatística & dados numéricos , África ao Sul do Saara , Controle de Doenças Transmissíveis/métodos , Humanos
11.
J Infect Dev Ctries ; 6(3): 276-82, 2012 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-22421610

RESUMO

INTRODUCTION: Acquisition of sexually transmitted infections (STIs) is an epidemiological marker of high-risk sexual behavior in HIV-infected patients. We assessed the prevalence of STIs among patients attending an HIV care and support centre. METHODOLOGY: From January to August 2009, we assessed socio-demographic variables, sexuality, disclosure of sero-status and STI treatment for 400 patients attending the HIV care and support centre. Characteristics of those who had been treated and those who had never been treated for STIs were compared to identify factors independently associated with STIs. RESULTS: Of the 400 respondents, 25.3% were male, 47.3% were aged 25-34 years, over 85% were currently married or had ever been married, and 62% had primary level of education or less. Though 82.5% were on antiretroviral drugs, only 53.1% disclosed their sero-status to their regular partners and only 41.9% knew the sero-status of their regular partners. Furthermore, 151 (37.7%) had been treated for STIs. The STIs were gonorrhoea (15; 9.7%), chlamydia (11; 7.1%), Trichomonas vaginalis (5; 3.3%), syphilis (99; 64.3%), and mixed infections (21; 13.6%). Factors associated with STI treatment on univariable analysis were age at sexual debut, whether the respondent had had sex in the previous six months, frequency of sexual intercourse, having changed sexual partners, number of sexual partners, and age when the respondent had a first child. CONCLUSION: Unprotected sexual intercourse and STIs are common among patients seeking HIV care in Uganda. Only the age of sexual debut (odds ratio 0.82, confidence limits 0.71, 0.94) was independently (though inversely) associated with STIs.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Doenças Sexualmente Transmissíveis/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/etiologia , Adulto , Fatores Etários , Fármacos Anti-HIV/uso terapêutico , Feminino , Infecções por HIV/tratamento farmacológico , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Doenças Sexualmente Transmissíveis/complicações , Uganda/epidemiologia , Sexo sem Proteção , Adulto Jovem
12.
Cult Health Sex ; 12(4): 445-54, 2010 May.
Artigo em Inglês | MEDLINE | ID: mdl-20234957

RESUMO

Pregnancy decisions in women infected by HIV pose important public health and social problems, as they increase risk of both heterosexual and vertical HIV transmission. We sought to explore and gain deeper understanding of reasons why women conceive when they are HIV-positive. Through 22 in-depth interviews and 6 focus-group discussions, motivations for conception among HIV-positive women who came for delivery in Mulago Hospital, Uganda were explored. Participants were selected by maximum variation sampling; and personal, biological, situational and environmental factors were explored. Data was analysed by content analysis. Awareness and belief in vertical transmission risk reduction strategies; disclosure of HIV status; awareness of spouse's HIV sero-status; availability of antiretroviral therapy; gender issues with desire for parenthood; stigma of HIV and childlessness; influence of partners and family members; and the impact of the health of self and family members were factors that motivate HIV-positive women to conceive or influence pregnancy decisions in spite of their sero-status.


Assuntos
Comportamento Contraceptivo , Tomada de Decisões , Fertilização , Infecções por HIV/transmissão , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Complicações Infecciosas na Gravidez , Adolescente , Adulto , Fármacos Anti-HIV/uso terapêutico , Conscientização , Estudos Transversais , Feminino , Grupos Focais , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/psicologia , Soropositividade para HIV , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Serviços de Saúde Materna , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/prevenção & controle , Complicações Infecciosas na Gravidez/psicologia , Pesquisa Qualitativa , Comportamento de Redução do Risco , Uganda/epidemiologia , Adulto Jovem
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