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1.
J Acquir Immune Defic Syndr ; 80(5): 494-502, 2019 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-30664614

RESUMO

BACKGROUND: The desire for more children and pregnancy rates are influenced by many relationship dynamics and HIV serostatus of couples. SETTING: Rakai Community Cohort Study in Uganda. METHODS: Couple data were retrospectively linked from survey rounds between 2007 and 2015 to assess drivers of fertility desire and pregnancy incidence by HIV status (M-F-; M+F+; M-F+; and M+F-). Multivariable modified Poisson regression was used to estimate prevalence ratios of fertility desire, whereas multivariable Poisson regression was used to estimate incidence rate ratios of pregnancy associated with couple characteristics. RESULTS: Six thousand six hundred forty-seven couples contributed to 7656 person-years. Approximately 40% of couples (where at least 1 HIV+) desired more children. Unmet need for family planning was evident; couples of medium or low Socioeconomic status and with coresident children had lower fertility desires but higher pregnancy rates. Older age, being in a polygamous union, and having a HIV+ spouse in care were associated with lower fertility desire while having an older male partner was associated with higher fertility desire. Pregnancy incidence was lower with older age, among women using hormonal contraception and condoms, HIV+ concordant couples and couples where the HIV+ spouse was in care while pregnancy incidence were higher among women who desired more children, and serodiscordant couples (M-F+). CONCLUSIONS: There are many drivers of fertility desires and pregnancy rates, and HIV does not diminish the desire for more children. Unmet need for family planning was evident and highlighted the need to understand and meet the contraceptive needs of couples.


Assuntos
Infecções por HIV/psicologia , Complicações Infecciosas na Gravidez/epidemiologia , Adolescente , Adulto , Fatores Etários , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Distribuição de Poisson , Gravidez , Complicações Infecciosas na Gravidez/psicologia , Fatores Sexuais , Inquéritos e Questionários , Uganda , Adulto Jovem
2.
BMC Public Health ; 18(1): 1278, 2018 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-30453966

RESUMO

BACKGROUND: Free VMMC services have been available in Uganda since 2010. However, uptake in Northern Uganda remains disproportionately low. We aimed to determine if this is due to men's insufficient knowledge on VMMC, and if women's knowledge on VMMC has any association with VMMC status of their male sexual partners. METHODS: In this cross sectional study, participants were asked their circumcision status (or that of their male sexual partner for female respondents) and presented with 14 questions on VMMC benefits, procedure, risk, and misconceptions. Chi square tests or fisher exact tests were used to compare circumcision prevalence among those who gave correct responses versus those who failed to and if p < 0.05, the comparison groups were balanced with propensity score weights in modified poisson models to estimate prevalence ratios, PR. RESULTS: A total of 396 men and 50 women were included in the analyses. Circumcision was 42% less prevalent among males who failed to reject the misconception that VMMC reduces sexual performance (PR = 0.58, 95% CI 0.38-0.89, p = 0.012), and less prevalent among male sexual partners of females who failed to reject the same misconception (PR = 0.22, 95% CI = 0.07-0.76, p = 0.016). Circumcision was also 35% less prevalent among male respondents who failed to reject the misconception that VMMC increases a man's desire for more sexual partners i.e. promiscuity (PR = 0.65, 95% CI = 0.46-0.92, p = 0.014). CONCLUSION: Misconceptions regarding change in sexual drive or performance were associated with circumcision status in this population, while knowledge of VMMC benefits, risks and procedure was not.


Assuntos
Circuncisão Masculina , Conhecimentos, Atitudes e Prática em Saúde , Programas Voluntários , Adolescente , Adulto , Circuncisão Masculina/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Uganda , Adulto Jovem
3.
J Res Pract ; 14(1)2018.
Artigo em Inglês | MEDLINE | ID: mdl-30057632

RESUMO

We report on the implementation experience of carrying out data collection and other activities for a public health evaluation study on whether U.S. President's Emergency Plan for AIDS Relief (PEPFAR) investment improved utilization of health services and health system strengthening in Uganda. The retrospective study period focused on the PEPFAR scale-up, from mid-2005 through mid-2011, a period of expansion of PEPFAR programing and health services. We visited 315 health care facilities in Uganda in 2011 and 2012 to collect routine health management information system data forms, as well as to conduct interviews with health system leaders. An earlier phase of this research project collected data from all 112 health district headquarters, reported elsewhere. This article describes the lessons learned from collecting data from health care facilities, project management, useful technologies, and mistakes. We used several new technologies to facilitate data collection, including portable document scanners, smartphones, and web-based data collection, along with older but reliable technologies such as car batteries for power, folding tables to create space, and letters of introduction from appropriate authorities to create entrée. Research in limited-resource settings requires an approach that values the skills and talents of local people, institutions and government agencies, and a tolerance for the unexpected. The development of personal relationships was key to the success of the project. We observed that capacity building activities were repaid many fold, especially in data management and technology.

4.
Int J Health Policy Manag ; 6(2): 83-95, 2017 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-28812783

RESUMO

BACKGROUND: Vertically oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the President's Emergency Plan for AIDS Relief (PEPFAR), have successfully contributed to reducing HIV/AIDS related morbidity and mortality. However, there is still debate about whether these disease-specific programs have improved or harmed health systems overall, especially with respect to non-HIV health needs. METHODS: As part of a larger evaluation of PEPFAR's effects on the health system between 2005-2011, we collected qualitative and quantitative data through semi-structured interviews with District Health Officers (DHOs) from all 112 districts in Uganda. We asked DHOs to share their perceptions about the ways in which HIV programs (largely PEPFAR in the Ugandan context) had helped and harmed the health system. We then identified key themes among their responses using qualitative content analysis. RESULTS: Ugandan DHOs said PEPFAR had generally helped the health system by improving training, integrating HIV and non-HIV care, and directly providing resources. To a lesser extent, DHOs said PEPFAR caused the health system to focus too narrowly on HIV/AIDS, increased workload for already overburdened staff, and encouraged doctors to leave public sector jobs for higher-paid positions with HIV/AIDS programs. CONCLUSION: Health system leaders in Uganda at the district level were appreciative of resources aimed at HIV they could often apply for broader purposes. As HIV infection becomes a chronic disease requiring strong health systems to manage sustained patient care over time, Uganda's weak health systems will require broad infrastructure improvements inconsistent with narrow vertical health programming.


Assuntos
Síndrome de Imunodeficiência Adquirida/terapia , Controle de Doenças Transmissíveis/organização & administração , Surtos de Doenças/prevenção & controle , Implementação de Plano de Saúde/organização & administração , Síndrome de Imunodeficiência Adquirida/prevenção & controle , Feminino , Infecções por HIV/terapia , Acesso aos Serviços de Saúde , Humanos , Cooperação Internacional , Masculino , Parcerias Público-Privadas/organização & administração , Uganda
5.
BJU Int ; 119(1): 164-170, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27597563

RESUMO

OBJECTIVES: To assess the safety and acceptability of early infant circumcision (EIC) provided by trained clinical officers (COs) and registered nurse midwives (RNMWs) in rural Uganda. SUBJECTS AND METHODS: We conducted a randomised trial of EIC using the Mogen clamp provided by newly trained COs and RNMWs in four health centres in rural Rakai, Uganda. The trial was registered with clinicaltrials.gov # NCT02596282. In all, 501 healthy neonates aged 1-28 days with normal birth weight and gestational age were randomised to COs (n = 256) and RNMWs (n = 245) for EIC, and were followed-up at 1, 7 and 28 days. RESULTS: In all, 701 mothers were directly invited to participate in the trial, 525 consented to circumcision (74.9%) and 23 were found ineligible on screening (4.4%). The procedure took an average of 10.5 min. Adherence to follow-up was >90% at all scheduled visits. The rates of moderate/severe adverse events were 2.4% for COs and 1.6% for RNMWs (P = 0.9). All wounds were healed by 28 days after circumcision. Maternal satisfaction with the procedure was 99.6% for infants circumcised by COs and 100% among infants circumcised by RNMWs. CONCLUSIONS: EIC was acceptable in this rural Ugandan population and can be safely performed by RNMWs who have direct contact with the mothers during pregnancy and delivery. EIC services should be made available to parents who are interested in the service.


Assuntos
Circuncisão Masculina/instrumentação , Pessoal de Saúde , Humanos , Recém-Nascido , Masculino , Enfermeiras Obstétricas , Enfermeiras e Enfermeiros , Uganda
6.
BJU Int ; 119(4): 631-637, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27753243

RESUMO

OBJECTIVE: To assess acquisition of knowledge and competence in performing Early Infant Male Circumcision (EIMC) by non-physicians trained using a structured curriculum. SUBJECTS AND METHODS: Training in provision of EIMC using the Mogen clamp was conducted for 10 Clinical Officers (COs) and 10 Registered Nurse Midwives (RNMWs), in Rakai, Uganda. Healthy infants whose mothers consented to study participation were assigned to the trainees, each of whom performed at least 10 EIMCs. Ongoing assessment and feedback for competency were done, and safety assessed by adverse events. RESULTS: Despite similar baseline knowledge, COs acquired more didactic knowledge than RNMWs (P = 0.043). In all, 100 EIMCs were assessed for gain in competency. The greatest improvement in competency was between the first and third procedures, and all trainees achieved 80% competency and retention of skills by the seventh procedure. The median (interquartile range) time to complete a procedure was 14.5 (10-47) min for the COs, and 15 (10-50) min for the RNMWs (P = 0.180). The procedure times declined by 2.2 min for each subsequent EIMC (P = 0.005), and rates of improvement were similar for COs and RNMWs. Adverse events were comparable between providers (3.5%), of which 1% were of moderate severity. CONCLUSION: Competence-based training of non-physicians improved knowledge and competency in EIMC performed by COs and RNMWs in Uganda.


Assuntos
Circuncisão Masculina/educação , Circuncisão Masculina/métodos , Competência Clínica/normas , Instrumentos Cirúrgicos , Atitude do Pessoal de Saúde , Currículo , Humanos , Recém-Nascido , Masculino , Uganda
7.
Health Policy Plan ; 31(7): 897-909, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27017824

RESUMO

OBJECTIVES : PEPFAR's initial rapid scale-up approach was largely a vertical effort focused fairly exclusively on AIDS. The purpose of our research was to identify spill-over health system effects, if any, of investments intended to stem the HIV epidemic over a 6-year period with evidence from Uganda. The test of whether there were health system expansions (aside from direct HIV programming) was evidence of increases in utilization of non-HIV services-such as outpatient visits, in-facility births or immunizations-that could be associated with varying levels of PEPFAR investments at the district level. METHODS : Uganda's Health Management Information System article-based records were available from mid-2005 onwards. We visited all 112 District Health offices to collect routine monthly reports (which contain data aggregated from monthly facility reports) and annual reports (which contain data aggregated from annual facility reports). Counts of individuals on anti-retroviral therapy (ART) at year-end served as our primary predictor variable. We grouped district-months into tertiles of high, medium or low PEPFAR investment based on their total reported number of patients on ART at the end of the year. We generated incidence-rate ratios, interpreted as the relative rate of the outcome measure in relation to the lowest investment PEPFAR tertile, holding constant control variables in the model. RESULTS : We found PEPFAR investment overall was associated with small declines in service volumes in several key areas of non-HIV care (outpatient care for young children, TB tests and in-facility deliveries), after adjusting for sanitation, elementary education and HIV prevalence. For example, districts with medium and high ART investment had 11% fewer outpatient visits for children aged 4 and younger compared with low investment districts, incidence rate ratio (IRR) of 0.89 for high investment compared with low (95% CI, 0.85-0.94) and IRR of 0.93 for medium compared with low (0.90-0.96). Similarly, 22% fewer TB sputum tests were performed in high investment districts compared with low investment, [IRR 0.78 (0.72-0.85)] and 13% fewer in medium compared with low, [IRR 0.88 (0.83-0.94)]. Districts with medium and high ART investment had 5% fewer in-facility deliveries compared with low investment districts [IRR 0.95 for high compared with low, (91-1.00) and 0.96 for medium compared with low (0.93-0.99)]. Although not statistically significant, the rate of maternal deaths in high investment district-months was 13% lower than observed in low investment districts. CONCLUSIONS : This study sought to understand whether PEPFAR, as a vertical programme, may have had a spill-over effect on the health system generally, as measured by utilization. Our conclusion is that it did not, at least not in Uganda.


Assuntos
Assistência à Saúde/organização & administração , Apoio Financeiro , Serviços de Saúde/estatística & dados numéricos , Cooperação Internacional , Saúde Global , Infecções por HIV/tratamento farmacológico , Humanos , Estudos Retrospectivos , Uganda
8.
Int J Equity Health ; 14: 74, 2015 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-26337975

RESUMO

INTRODUCTION: Pneumonia and diarrhoea disproportionately affect children in resource-poor settings. Integrated community case management (iCCM) involves community health workers treating diarrhoea, pneumonia and malaria. Studies on impact of iCCM on appropriate treatment and its effects on equity in access to the same are limited. The objective of this study was to measure the impact of integrated community case management (iCCM) as the first point of care on uptake of appropriate treatment for children with a classification of pneumonia (cough and fast breathing) and/or diarrhoea and to measure the magnitude and distribution of socioeconomic status related inequality in use of iCCM. METHODS: Following introduction of iCCM, data from cross-sectional household surveys were examined for socioeconomic inequalities in uptake of treatment and use of iCCM among children with a classification of pneumonia or diarrhoea using the Erreygers' corrected concentration index (CCI). Propensity score matching methods were used to estimate the average treatment effects on the treated (ATT) for children treated under the iCCM programme with recommended antibiotics for pneumonia, and ORS plus or minus zinc for diarrhoea. FINDINGS: Overall, more children treated under iCCM received appropriate antibiotics for pneumonia (ATT = 34.7%, p < 0.001) and ORS for diarrhoea (ATT = 41.2%, p < 0.001) compared to children not attending iCCM. No such increase was observed for children receiving ORS-zinc combination (ATT = -0.145, p < 0.05). There were no obvious inequalities in the uptake of appropriate treatment for pneumonia among the poorest and least poor (CCI = -0.070; SE = 0.083). Receiving ORS for diarrhoea was more prevalent among the least poor groups (CCI = 0.199; SE = 0.118). The use of iCCM for pneumonia was more prevalent among the poorest groups (CCI = -0.099; SE = 0.073). The use of iCCM for diarrhoea was not significantly different among the poorest and least poor (CCI = -0.073; SE = 0.085). CONCLUSION: iCCM is a potentially equitable strategy that significantly increased the uptake of appropriate antibiotic treatment for pneumonia and ORS for diarrhoea, but not the uptake of zinc for diarrhoea. For maximum impact, interventions increasing zinc uptake should be considered when scaling up iCCM programmes.


Assuntos
Administração de Caso/organização & administração , Agentes Comunitários de Saúde , Diarreia/tratamento farmacológico , Pneumonia/tratamento farmacológico , Classe Social , Estudos Transversais , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Humanos , Pontuação de Propensão , Uganda
9.
J Acquir Immune Defic Syndr ; 69(3): 377-84, 2015 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-25835605

RESUMO

OBJECTIVE: To assess fertility desires by availability and use of antiretroviral therapy and prevention of mother-to-child transmission (ART/PMTCT) services in Rakai, Uganda. DESIGN: Retrospective analyses of longitudinal data from the Rakai Community Cohort Study. METHODS: Study participants were retrospectively identified and categorized by HIV status. Availability of ART/PMTCT services in Rakai was defined in three periods: (1) pre-ART/PMTCT (<2005), (2) ART/PMTCT rollout (2005-2006), and (3) universal ART/PMTCT (>2006); and use of ART/PMTCT was coded as yes if the woman received services. Trends in fertility desires were assessed by χ. "Modified" Poisson regression was performed using generalized linear models with a log link and Poisson family to estimate prevalence rate ratios (PRRs) and 95% confidence intervals (CIs) of desire for another child among previously and currently pregnant women; PRRs were adjusted for demographic and behavioral factors. RESULTS: A total of 4227 sexually active women in Rakai, including 436 HIV+ women, contributed 13,970 observations over 5 survey rounds. Fertility desires increased in the population in the ART/PMTCT rollout [adjusted (adj.) PRR: 1.08, 95% CI: 1.04 to 1.13] and the universal availability periods (adj. PRR: 1.11, 95% CI: 1.08 to 1.14) compared with pre-ART/PMTCT period. A total of 862 woman observations used ART/PMTCT services. Fertility desires were similar among ART/PMTCT service users and nonusers in cross-sectional analysis (adj. PRR: 0.84, 95% CI: 0.62 to 1.14) and 1 year after ART/PMTCT use (adj. PRR: 1.27, 95% CI: 0.83 to 1.94). CONCLUSIONS: Availability of ART/PMTCT may increase fertility desires of previously pregnant women in Rakai, Uganda. Use of ART/PMTCT services was not correlated with fertility desires of previously or current pregnant women.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Adolescente , Adulto , Atitude Frente a Saúde , Estudos de Coortes , Feminino , Fertilidade , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/transmissão , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/prevenção & controle , Estudos Retrospectivos , Uganda/epidemiologia , Adulto Jovem
10.
J Sex Transm Dis ; 2014: 916597, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-26316977

RESUMO

Background. Data on the incidence of Trichomonas vaginalis and use of hormonal contraception (HC) are limited. Methods. 2,374 sexually active women aged 15-49 years from cohort surveys in Rakai, Uganda, were included. Incidence of T. vaginalis was estimated per 100 person years (py) and association between HC (DMPA, Norplant, and oral contraceptives) and T. vaginalis infection was assessed by incidence rate ratios (IRR), using Poisson regression models. Results. At baseline, 34.9% had used HC in the last 12 months, 12.8% HIV+, 39.7% with high BV-scores (7-10), and 3.1% syphilis positive. The 12-month incidence of T. vaginalis was 2.4/100 py; CI (1.90, 3.25). When stratified by type of HC used, compared to women who did not use HC or condoms, incidence of T. vaginalis was significantly higher among users of Norplant (adj.IRR = 3.01, CI: 1.07-8.49) and significantly lower among DMPA users (adj.IRR = 0.55, CI: 0.30, 0.98) and women who discontinued HC use at follow-up (adj.IRR = 0.30, CI: 0.09, 0.99). HIV infection was associated with an increase in incidence of T. vaginalis (adj.IRR = 2.34, CI: 1.44, 3.78). Conclusions. Use of Norplant and being HIV+ significantly increased the risk of T. vaginalis, while use of DMPA and discontinuation of overall HC use were associated with a decreased incidence of T. vaginalis.

11.
BJU Int ; 113(1): 127-32, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24053645

RESUMO

OBJECTIVE: To assess completed wound healing after medical male circumcision (MMC) among human immunodeficiency virus (HIV)-negative and HIV-positive men with cluster of differentiation 4 (CD4) counts of <350 and ≥350 cells/mm(3) , as minimal data are available on the safety of MMC among HIV-positive men with low CD4 counts. PATIENTS AND METHODS: In all, 262 HIV-negative and 177 HIV-positive consenting males aged ≥12 years accepted MMC using the dorsal slit procedure and were enrolled in the study. Socio-demographic and behavioural data and blood for HIV testing and CD4 counts were collected at baseline. Participants were followed weekly to collect information on resumption of sex, condom use and both self-reported and clinically assessed wound healing. The proportions healed among HIV-positive men were compared with HIV-negative men. Time to complete wound healing was assessed by Kaplan-Meier survival analysis. RESULTS: There were no statistically significant differences in the proportion of men healed by HIV status. At 4 weeks, the proportions healed were 85.9% in HIV-negative men, 77.4% in HIV-positive men with a CD4 count of ≥350 cells/mm(3) and 87.1% in HIV-positive men with a CD4 count of <350 cells/mm(3) . The median time to healing was 4 weeks and did not vary by HIV or CD4 status. All men had certified complete wound healing at 6 weeks after MMC. In all, 1.4% of HIV-positive men with a CD4 count of <350 cells/mm(3) resumed sex before healing, compared with 8.5% among HIV-positive men with a CD4 count of ≥350 cells/mm(3) (P = 0.052) and 7.8% (P = 0.081) among HIV-negative men. CONCLUSION: Inclusion of HIV-positive men with low CD4 counts in MMC services is not deleterious to postoperative wound healing.


Assuntos
Circuncisão Masculina , Preservativos/estatística & dados numéricos , Soronegatividade para HIV/imunologia , Soropositividade para HIV/imunologia , Comportamento Sexual/estatística & dados numéricos , Cicatrização/imunologia , Adolescente , Adulto , Contagem de Linfócito CD4 , Coito , Seguimentos , Soropositividade para HIV/patologia , Acesso aos Serviços de Saúde , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Resultado do Tratamento , Uganda/epidemiologia
12.
J Acquir Immune Defic Syndr ; 63(5): 617-21, 2013 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-23614991

RESUMO

OBJECTIVES: Medical male circumcision (MMC) is recommended for HIV prevention in men. We assessed the acceptability and safety of the Shang Ring device compared with those of the dorsal slit method. METHODS: HIV-negative, uncircumcised men aged 18 years or older who requested free MMC services in rural Rakai, Uganda, were informed about the Shang Ring and dorsal slit procedures and offered a free choice of procedure. Men were followed at 7 days postoperatively to assess adverse events related to surgery and to remove the Shang Ring. Wound healing was assessed at 4 weeks postoperatively. RESULTS: Six hundred twenty-one men were enrolled, of whom 508 (81.8%) chose the Shang Ring and 113 the dorsal slit. The Shang Ring was provided to 504 men, among whom there were 4 failures of Ring placement (0.8%) that required surgical hemostasis and wound closure. Five hundred men received the Shang Ring and postoperative surgery-related moderate adverse events were 1.0%, compared with 0.8% among dorsal slit recipients. Complete wound healing at 4 weeks was 84% with the Ring and 100% with the dorsal slit (P < 0001). Resumption of intercourse before 4 weeks was 7.0% with the Ring and 15.0% with the dorsal slit (P = 0.01.) The mean time for surgery was 6.1 minutes with the Ring and 17.7 minutes with the dorsal slit. The mean time for Ring removal was 2.2 minutes. CONCLUSIONS: The Shang Ring is highly acceptable and safe in this setting, and could improve the efficiency of MMC services. However, back-up surgical services are needed in cases of Ring placement failures.


Assuntos
Circuncisão Masculina/efeitos adversos , Circuncisão Masculina/métodos , Aceitação pelo Paciente de Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Uganda , Cicatrização , Adulto Jovem
13.
Am J Trop Med Hyg ; 87(5 Suppl): 97-104, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23136284

RESUMO

Integrated community case management (iCCM) is a recommended strategy to curb child mortality. Drawing on diffusion of innovations (DOIs), the acceptability and adoption of iCCM were qualitatively explored. Data from focus group discussions and interviews with community members, community health workers (CHWs), and supervisors conducted in seven communities were analyzed using content analysis. Perceived relative advantage and compatibility of the program with sociocultural beliefs and healthcare expectations of the communities positively affected acceptability and adoption of iCCM. The degree of stringency, quality, and cost of access to healthcare were crucial to adoption. Failure of the health system to secure regular drug supplies, monetary support, and safe referrals globally hindered adoption. Individual CHW characteristics like undesired behavior, demotivation, and lack of reciprocated trust deterred adoption in some areas. Optimal functioning of iCCM programs will require community sensitization and targeted health systems strengthening to enhance observable program benefits like reduced child mortality.


Assuntos
Administração de Caso/organização & administração , Serviços de Saúde Comunitária/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Instalações de Saúde , Acesso aos Serviços de Saúde , Adolescente , Adulto , Agentes Comunitários de Saúde , Cultura , Estudos de Avaliação como Assunto , Feminino , Grupos Focais , Humanos , Malária/terapia , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , Uganda , Adulto Jovem
14.
PLoS One ; 7(4): e35432, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22539972

RESUMO

BACKGROUND: Child survival is dependent on several factors including high vaccination coverage. Timely receipt of vaccines ensures optimal immune response to the vaccines. Yet timeliness is not usually emphasized in estimating population immunity. In addition to examining timeliness of the recommended Expanded Programme for Immunisation (EPI) vaccines, this paper identifies predictors of untimely vaccination among children aged 10 to 23 months in Kampala. METHODS: In addition to the household survey interview questions, additional data sources for variables included data collection of child's weight and length. Vaccination dates were obtained from child health cards. Timeliness of vaccinations were assessed with Kaplan-Meier time-to-event analysis for each vaccine based on the following time ranges (lowest-highest target age): BCG (birth-8 weeks), polio 0 (birth-4 weeks), three polio and three pentavalent vaccines (4 weeks-2 months; 8 weeks-4 months; 12 weeks-6 months) and measles vaccine (38 weeks-12 months). Cox regression analysis was used to identify factors associated with vaccination timeliness. RESULTS: About half of 821 children received all vaccines within the recommended time ranges (45.6%; 95% CI 39.8-51.2). Timely receipt of vaccinations was lowest for measles (67.5%; 95% CI 60.5-73.8) and highest for BCG vaccine (92.7%: 95% CI 88.1-95.6). For measles, 10.7% (95% CI 6.8-16.4) of the vaccinations were administered earlier than the recommended time. Vaccinations that were not received within the recommended age ranges were associated with increasing number of children per woman (adjusted hazard ratio (AHR); 1.84, 95% CI 1.29-2.64), non-delivery at health facilities (AHR 1.58, 95% CI 1.02-2.46), being unmarried (AHR 1.49, 95% CI 1.15-1.94) or being in the lowest wealth quintile (AHR 1.38, 95% CI 1.11-1.72). CONCLUSIONS: Strategies to improve vaccination practices among the poorest, single, multiparous women and among mothers who do not deliver at health facilities are necessary to improve timeliness of vaccinations.


Assuntos
Vacinação/estatística & dados numéricos , Vacina BCG/imunologia , Estudos Transversais , Feminino , Humanos , Esquemas de Imunização , Lactente , Entrevistas como Assunto , Vacina contra Sarampo/imunologia , Mães/psicologia , Fatores de Tempo , Uganda
15.
AIDS ; 26(5): 609-15, 2012 Mar 13.
Artigo em Inglês | MEDLINE | ID: mdl-22210632

RESUMO

BACKGROUND: The efficacy of male circumcision for HIV prevention over 2 years has been demonstrated in three randomized trials, but the longer-term effectiveness of male circumcision is unknown. METHODS: We conducted a randomized trial of male circumcision in 4996 HIV-negative men aged 15-49 in Rakai, Uganda. Following trial closure, we offered male circumcision to control participants and have maintained surveillance for up to 4.79 years. HIV incidence per 100 person-years was assessed in an as-treated analysis, and the effectiveness of male circumcision was estimated using Cox regression models, adjusted for sociodemographic and time-dependent sexual behaviors. For men uncircumcised at trial closure, sexual risk behaviors at the last trial and first posttrial visits were assessed by subsequent circumcision acceptance to detect behavioral risk compensation. RESULTS: By 15 December 2010, 78.4% of uncircumcised trial participants accepted male circumcision following trial closure. During posttrial surveillance, overall HIV incidence was 0.50/100 person-years in circumcised men and 1.93/100 person-years in uncircumcised men {adjusted effectiveness 73% [95% confidence interval (CI) 55-84%]}. In control arm participants, posttrial HIV incidence was 0.54/100 person-years in circumcised and 1.71/100 person-years in uncircumcised men [adjusted effectiveness 67% (95% CI 38-83%)]. There were no significant differences in sociodemographic characteristics and sexual behaviors between controls accepting male circumcision and those remaining uncircumcised. CONCLUSION: High effectiveness of male circumcision for HIV prevention was maintained for almost 5 years following trial closure. There was no self-selection or evidence of behavioral risk compensation associated with posttrial male circumcision acceptance.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/epidemiologia , Assunção de Riscos , Comportamento Sexual/estatística & dados numéricos , Adolescente , Adulto , Seguimentos , Infecções por HIV/prevenção & controle , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Uganda/epidemiologia , Adulto Jovem
16.
BJU Int ; 109(7): 1068-71, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21883854

RESUMO

OBJECTIVE: To assess self-reported pain control during and after surgery with a mixture of lignocaine and bupivacaine compared with lignocaine alone among male circumcision (MC) service recipients in Rakai, Uganda. PATIENTS AND METHODS: The two formulations of local anaesthesia for MC were used alternatively at weekly intervals in 360 patients; 179 received lignocaine alone and 181 received the lignocaine and bupivacaine mixture (LBmix). The proportions of men reporting pain during or after surgery, and the need for additional anaesthesia during surgery were determined for the LBmix vs lignocaine using Poisson adjusted rate ratios (RRs). Characteristics including age, weight, surgeon (medical officer vs clinical officer), surgical method and duration of surgery were compared between the arms using two-sample t-tests and chi-square tests. RESULTS: Patient and provider characteristics were comparable between the two anaesthetic groups. A higher proportion of patients reported pain during surgery in the lignocaine group (adjusted RR 11.6, 95% confidence interval [CI] 3.5-37.9, P < 0.001), required additional anaesthesia (adjusted RR 4.8, 95% CI 1.4-17.1, P = 0.015), and were more likely to report pain during the immediate postoperative period (adjusted RR 3.4, 95% CI 2.3-5.0, P < 0.001). These differences were particularly marked among patients with MC times longer than the median (adjusted RR 13.4, 95% CI 3.1-57.0, P < 0.001). CONCLUSION: The LBmix significantly reduced pain associated with MC and the need for additional anaesthesia during MC.


Assuntos
Anestésicos Combinados/administração & dosagem , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Circuncisão Masculina , Lidocaína/administração & dosagem , Adolescente , Adulto , Criança , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Uganda , Adulto Jovem
17.
Int J Cancer ; 129(12): 2970-5, 2011 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-21462185

RESUMO

Male circumcision (MC) reduces penile high-risk human papillomavirus (HR-HPV) on the coronal sulcus and urethra. HR-HPV varies by anatomic site, and it is unknown whether MC decreases HR-HPV on the penile shaft. We assessed the efficacy of MC to reduce HR-HPV on the penile shaft and compared it to known efficacy of MC to reduce HR-HPV on the coronal sulcus. HIV-negative men randomized to receive immediate circumcision (intervention) or circumcision delayed for 24 months (control) were evaluated for HR-HPV at 12 months postenrollment using the Roche HPV Linear Array assay. Among swabs with detectable ß-globin or HPV, year 1 HR-HPV prevalence on the coronal sulcus was 21.5% in the intervention arm and 36.3% in the control arm men [adjusted prevalence risk ratios (PRRs) = 0.57, 95% CI 0.39-0.84, p = 0.005]. On the shaft, year 1 HR-HPV prevalence was 15.5% in the intervention and 23.8% in the control arm (adjusted PRR = 0.66, 95% CI 0.39-1.12, p = 0.12). Efficacy of MC to reduce HR-HPV on the shaft was similar to efficacy on the coronal sulcus (p = 0.52). In a sensitivity analysis in which swabs without detectable ß-globin or HPV were included as HPV negative, prevalence of HR-HPV on the shaft was lower in the intervention arm (7.8%) than control arm (13.6%; PRR 0.57, 95% CI 0.33-0.99, p < 0.05). HR-HPV was more frequently detected on the coronal sulcus than penile shaft among uncircumcised men (36.3% vs. 23.8%, respectively, p = 0.02) and circumcised men (21.5% vs. 15.5%, respectively, p = 0.24). MC reduced HR-HPV prevalence on both the coronal sulcus and shaft.


Assuntos
Circuncisão Masculina , Infecções por Papillomavirus/epidemiologia , Pênis/anatomia & histologia , Pênis/virologia , Adolescente , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Papillomaviridae/isolamento & purificação , Prevalência , Uganda
18.
Lancet ; 377(9761): 209-18, 2011 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-21216000

RESUMO

BACKGROUND: Randomised trials show that male circumcision reduces the prevalence and incidence of high-risk human papillomavirus (HPV) infection in men. We assessed the efficacy of male circumcision to reduce prevalence and incidence of high-risk HPV in female partners of circumcised men. METHODS: In two parallel but independent randomised controlled trials of male circumcision, we enrolled HIV-negative men and their female partners between 2003 and 2006, in Rakai, Uganda. With a computer-generated random number sequence in blocks of 20, men were assigned to undergo circumcision immediately (intervention) or after 24 months (control). HIV-uninfected female partners (648 of men from the intervention group, and 597 of men in the control group) were simultaneously enrolled and provided interview information and self-collected vaginal swabs at baseline, 12 months, and 24 months. Vaginal swabs were tested for high-risk HPV by Roche HPV Linear Array. Female HPV infection was a secondary endpoint of the trials, assessed as the prevalence of high-risk HPV infection 24 months after intervention and the incidence of new infections during the trial. Analysis was by intention-to-treat. An as-treated analysis was also done to account for study-group crossovers. The trials were registered, numbers NCT00425984 and NCT00124878. FINDINGS: During the trial, 18 men in the control group underwent circumcision elsewhere, and 31 in the intervention group did not undergo circumcision. At 24-month follow-up, data were available for 544 women in the intervention group and 488 in the control group; 151 (27·8%) women in the intervention group and 189 (38·7%) in the control group had high-risk HPV infection (prevalence risk ratio=0·72, 95% CI 0·60-0·85, p=0·001). During the trial, incidence of high-risk HPV infection in women was lower in the intervention group than in the control group (20·7 infections vs 26·9 infections per 100 person-years; incidence rate ratio=0·77, 0·63-0·93, p=0·008). INTERPRETATION: Our findings indicate that male circumcision should now be accepted as an efficacious intervention for reducing the prevalence and incidence of HPV infections in female partners. However, protection is only partial; the promotion of safe sex practices is also important. FUNDING: The Bill & Melinda Gates Foundation, National Institutes of Health, and Fogarty International Center.


Assuntos
Circuncisão Masculina , Infecções por Papillomavirus/transmissão , Adolescente , Adulto , Feminino , Infecções por HIV/complicações , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/epidemiologia , Prevalência , Adulto Jovem
19.
AIDS ; 25(4): 473-7, 2011 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-21160416

RESUMO

OBJECTIVE: To evaluate the impact of antiretroviral therapy (ART) on HIV-1 transmission rates among HIV-1 discordant couples in Rakai, Uganda. DESIGN: Observational cohort study. METHODS: HIV-1 discordant couples were retrospectively identified between 2004 and 2009. Study participants underwent annual screening for HIV-1 and were interviewed to evaluate risk behaviors. Participants were offered voluntary counseling and testing and provided with risk reduction counseling. Free ART was offered to participants with a CD4 cell count of 250 cells/µl or less or WHO stage IV disease. HIV-1 incidence and sexual risk behaviors were compared before and after the HIV-1-positive index partners started ART. RESULTS: Two hundred and fifty HIV-1 discordant couples were followed between 2004 and 2009 and 32 HIV-1-positive partners initiated ART. Forty-two HIV-1 transmissions occurred over 459.4 person-years prior to ART initiation, incidence 9.2/100 person-years [95% confidence interval (CI) 6.59-12.36]. In 32 couples in which the HIV-1 index partners started ART, no HIV-1 transmissions occurred during 53.6 person-years. The 95% CI for the incidence rate difference was -11.91 to -6.38 (P = 0.0097). Couples reported more consistent condom use during ART use, but there was no significant difference in the number of sexual partners or other risk behaviors. Viral load was markedly reduced in persons on ART. CONCLUSION: HIV-1 transmission may be reduced among HIV-1 discordant couples after initiation of ART due to reductions in HIV-1 viral load and increased consistent condom use.


Assuntos
Antirretrovirais/uso terapêutico , Infecções por HIV/transmissão , HIV-1 , Adolescente , Adulto , Transmissão de Doença Infecciosa , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Humanos , Masculino , Assunção de Riscos , Parceiros Sexuais/psicologia , Uganda/epidemiologia , Carga Viral , Adulto Jovem
20.
J Infect Dis ; 201(10): 1463-9, 2010 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-20370481

RESUMO

UNLABELLED: In Rakai, Uganda, human immunodeficiency virus (HIV)-positive men were randomized to undergo either immediate circumcision (intervention arm) or delayed circumcision (control arm). Penile swab samples were assayed for high-risk human papillomavirus (HR-HPV) by Roche HPV Linear Array at enrollment and at 24 months (intervention arm, 103 subjects; control arm, 107 subjects). Rate ratios (RRs) of HR-HPV were estimated by Poisson regression. At 24 months, HR-HPV prevalence was found in 57 (55.3%) of 103 subjects in the intervention arm and in 77 (71.7%) of 107 subjects in the control arm (RR, 0.77; 95% confidence interval [CI], 0.62-0.97). Multiple HR-HPV infections were found in 19 (22.4%) of 85 subjects in the intervention arm and in 45 (42.5%) of 106 subjects in the control arm (RR, 0.53; 95% CI, 0.33-0.83). New HR-HPV genotypes were acquired by 34 (42.0%) of 81 subjects in the intervention arm and by 53 (57.0%) 85 subjects in the control arm (RR, 0.74; 95% CI, 0.54-1.01; P = .06). Multiple new HR-HPV genotypes were acquired by 8 (9.9%) of 81 subjects in the intervention arm and by 23 (24.7%) of 93 subjects in the control arm (RR, 0.40; 95% CI, 0.19-0.84; P = .01). Circumcision did not affect the acquisition of single HR-HPV infections (RR, 1.00; 95% CI 0.65-1.53) or clearance of HR-HPV infections (RR, 1.09; 95% CI 0.94-1.27). Circumcision of HIV-positive men reduced the prevalence and incidence of multiple HR-HPV infections. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00124878 .


Assuntos
Circuncisão Masculina , Infecções por HIV/complicações , Infecções por Papillomavirus/transmissão , Infecções por Papillomavirus/virologia , Adolescente , Adulto , Distribuição por Idade , Genótipo , Humanos , Incidência , Masculino , Papillomaviridae/classificação , Papillomaviridae/genética , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/epidemiologia , Comportamento Sexual , Fatores de Tempo , Uganda/epidemiologia , Adulto Jovem
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