Case-control study of risk factors for incident HIV infection in rural Uganda

OBJECTIVE: To identify risk factors associated with HIV incidence in a rural Ugandan population. DESIGN: Case-control study. METHODS: Men and women who seroconverted between 1990 and 1997 (cases) and seronegative subjects (controls) were drawn from a general population cohort of approximately 5000 adults in rural, southwestern Uganda. Information on risk factors was ascertained through a detailed interview and physical examination by clinicians who were blind to the study subjects' HIV status. All patients were interviewed within 2 years of their estimated date of seroconversion. RESULTS: Data were available on 130 men (37 cases, 93 controls) and 133 women (46 cases, 87 controls). There was a significantly higher risk of infection in men (odds ratio [OR], 6.51; 95% confidence interval [CI], 1.06-39.84) and women (OR, 4.75; 95% CI, 1.26-17.9) who were unmarried and in a steady relationship, and in men who were divorced, separated, or widowed (OR, 4.33; 95% CI, 1.32-14.25) compared with those who were married. There was a significantly higher risk of HIV infection in men (OR, 3.78; 95% CI, 1.20-11.93) and women (OR, 20.78; 95% CI, 2.94-141.2) who reported > or =5 lifetime sexual partners compared with those who reported at most 1 partner. For men, there was an increased risk of infection associated with receiving increasing numbers of injections in the 6 months prior to interview (p < .001 for trend). Women reporting sex against their will in the year prior to interview were at higher risk of infection (OR, 7.84; 95% CI, 1.29-47.86; p = .020). CONCLUSIONS: The strongest risk factor for HIV incidence in this rural Ugandan population is lifetime sexual partners. The increased risks found for women reporting coercive sex and men reporting injections require further investigation.     

Factors impacting sustainability of community health worker programming in rural Uganda: a qualitative study

BackgroundDespite significant global progress towards decreased child mortality in past decades, maternal and child mortality continues to be high, especially in sub Saharan Africa. Most of these deaths are preventable with known interventions. Community health workers (CHWs) are well-positioned to promote these life-saving interventions; however, sustaining CHW programs remains a challenge.MethodsA sustainability-focused qualitative evaluation, was done between July and August 2018 in 2 rural districts in southwest Uganda. Using semi-structured interview tools, we conducted 6 Focus Group discussions (FGDs) with CHWs and 17 in-depth interviews (IDIs) with various district stakeholders to gain insights into factors affecting sustainability of a district-wide maternal, newborn and child health (MNCH)-oriented CHW intervention. Data was managed using NVivo software (version 12) with themes using thematic analysis.ResultsIdentified factors impacting CHW program sustainability included ‘health system effectiveness’ (availability of supplies, medicines and services and availability of facility health providers), CHW program-related factors'' (CHW selection and training, CHW recognition), ‘community attitudes and beliefs’ and ‘stakeholder engagement’.ConclusionTo sustain CHW programs in rural Uganda and globally, planners, policymakers and funders should maximize community engagement in establishing CHW networks and strengthen accountability, supply chains and linkages with communities and health facilities     

Re-focusing HIV prevention messages: a qualitative study in rural Uganda

Background

After 30 years, the human immunodeficiency virus (HIV) remains an epidemic of global concern. To support the increasing emphasis on biomedical interventions for prevention requires a renewed and reframed focus on HIV prevention messages to motivate engagement in risk-reduction activities. This paper examines youth and adult perceptions of HIV prevention messages and HIV risk assessment in a generalized HIV epidemic context in Uganda.

Methods

We conducted 24 focus group discussions and 24 in-depth interviews with 15–45 year olds (n = 218) from three communities in the Rakai district of Uganda in 2012.

Results

We found generational differences in the how people viewed HIV, skepticism around introduction of new interventions, continued misconceptions and fears about condoms, and gender differences in content and salience of HIV prevention messages.

Conclusions

Shifts in HIV education are needed to address gaps in HIV messaging to foster engagement in risk reduction strategies and adoption of newer biomedical approaches to HIV prevention.

     

Acute respiratory infection in children: a survey in the rural community

The prevalence of Acute Respiratory Infections was 7.6% in a total of 10,951 children below 5 yrs surveyed. The annual incidence was estimated to be 2.6 episodes per child. The prevalence was highest in the 6 months--2 yrs of age. Majority of the episodes were mild in nature (86.2%), while only 1.7% episodes were severe in nature. A substantial number of episodes (27.3%) did not receive any treatment. There was no association between the severity of ARI episodes and the treatment received. Registered medical practitioners were the main source of treatment. Far distance of the hospital was the reason for not receiving any treatment among untreated cases. The outcome was better in those episodes treated by a qualified MBBS doctor, as compared to other sources of treatment.     

An evaluation of a peer supervision pilot project among community health workers in rural Uganda

BackgroundLiving Goods operates a Community Health Worker (CHW) program in 19 districts of Uganda, where CHWs are supervised by full time Community Health Supervisors. This model is effective, but expensive. Evidence indicates that peer supervision can be a substitute and cheaper model for CHW supervision. We describe our experience and outcomes while implementing peer supervision among CHWs in Mayuge districtObjectives1. To compare health services delivery outcomes between the two supervision models. 2. To compare costs of the two supervision models..MethodsInternal organizational records from January to December 2019 were reviewed. Focus group discussions and in-depth interviews with participating CHWs were also conducted. Qualitative analysis was performed using thematic content analysis. Quantitative data was summarized to generate averages, percentages and graphs.FindingsCHWs under the peer supervision performed better than those under standard supervision against all key performance indicators. The total cost to maintain the peer supervision model for 1 year was USD $176 per CHW versus USD $273 among CHWs under the standard supervision model. Peer supervision thus resulted in overall cost savings of 36%. There was lower attrition among CHWs under peer supervision compared to standard supervision (10% versus 17%).ConclusionsPeer supervision is a feasible and more affordable model of supervising CHWs.     

Ethical issues in early detection of HIV infection to reduce vertical transmission

Proposals to make prenatal HIV testing routine and universal dramatize ethical issues regarding early detection of HIV. These proposals would abolish pretest counseling and written informed consent for prenatal HIV testing. Ethical concerns include whether pregnant women are adequately informed that they may refuse such testing and whether patients have an opportunity to obtain more detailed information about the benefits and risks of HIV testing in this context. Several pertinent research questions need to be studied, including whether pregnant women find routine universal HIV testing acceptable and whether safeguards adequately protect women who receive testing. If analogous policies to enhance early detection of HIV are considered in other clinical contexts, the important clinical and ethical differences between vertical transmission and other situations of HIV transmission must be kept clearly in mind.     

First documented transmission of HIV infection in a health care worker in West Bengal

This is a case report of HIV infection in a nursing staff in Kolkata. She got the infection through needle stick injury while transferring blood from a syringe to specimen collection tube without taking any precaution and no post-exposure prophylaxis (PEP) was advised. This is the first documentation of transmission of HIV infection in a worker engaged in health care delivery system in Bengal.     

Mycobacterium tuberculosis transmission in a country with low tuberculosis incidence: role of immigration and HIV infection

Immigrants from high-burden countries and HIV-coinfected individuals are risk groups for tuberculosis (TB) in countries with low TB incidence. Therefore, we studied their role in transmission of Mycobacterium tuberculosis in Switzerland. We included all TB patients from the Swiss HIV Cohort and a sample of patients from the national TB registry. We identified molecular clusters by spoligotyping and mycobacterial interspersed repetitive-unit-variable-number tandem-repeat (MIRU-VNTR) analysis and used weighted logistic regression adjusted for age and sex to identify risk factors for clustering, taking sampling proportions into account. In total, we analyzed 520 TB cases diagnosed between 2000 and 2008; 401 were foreign born, and 113 were HIV coinfected. The Euro-American M. tuberculosis lineage dominated throughout the study period (378 strains; 72.7%), with no evidence for another lineage, such as the Beijing genotype, emerging. We identified 35 molecular clusters with 90 patients, indicating recent transmission; 31 clusters involved foreign-born patients, and 15 involved HIV-infected patients. Birth origin was not associated with clustering (adjusted odds ratio [aOR], 1.58; 95% confidence interval [CI], 0.73 to 3.43; P = 0.25, comparing Swiss-born with foreign-born patients), but clustering was reduced in HIV-infected patients (aOR, 0.49; 95% CI, 0.26 to 0.93; P = 0.030). Cavitary disease, male sex, and younger age were all associated with molecular clustering. In conclusion, most TB patients in Switzerland were foreign born, but transmission of M. tuberculosis was not more common among immigrants and was reduced in HIV-infected patients followed up in the national HIV cohort study. Continued access to health services and clinical follow-up will be essential to control TB in this population.     

The price of development: HIV infection in a semiurban community of Ghana

OBJECTIVE: To describe the epidemiology of HIV infection in the Manya Krobo District, Ghana, and its potential link to the building of the Akosombo dam. METHODS: A questionnaire and a blood sample were collected among 1228 consecutive pregnant women seen at the prenatal clinics of the two major hospitals of the district. RESULTS: Overall, prevalence of HIV and of serologically confirmed syphilis were 14.9% and 0.7%, respectively. HIV infection was more prevalent among the Krobo ethnic group (137 of 742 [18.5%]) than among other ethnic groups (46 of 486 [9.5%]; p <.001). Two distinct patterns of HIV distribution were identified. Among the Krobos, HIV was common among all age groups, reached a plateau (21.9%) in the 30- to 34-year-old group and was associated strongly with having lived in C?te d'Ivoire and with having received only primary school education. Among the other ethnic groups, prevalence decreased with age, from 17.2% in the 13- to 19-year-old age group to 1.4% among women aged 35 years or older, and HIV infection was associated with having had first sexual intercourse before the age of 17 years. In logistic regression analysis, the independent risk factors for HIV infection were age, schooling, age at first sexual intercourse; having lived in C?te d'Ivoire; age and schooling showed significant interactions with ethnic group. CONCLUSIONS: The high HIV prevalence documented in this part of Ghana seems to be, to some extent, a consequence of construction of the Akosombo dam in the 1960s. The flooding of the land, the failures of the resettlement program and the ensuing poverty prompted economically driven migration, specially to C?te d'Ivoire, where many migrants became infected with HIV. Local transmission followed. This illustrates that HIV can disseminate widely in a society where most men are circumcised and where genital ulcerative diseases are uncommon and should be an indication for less complacency about HIV control in West Africa.     

Assessment of cardiovascular risk factors in people with HIV infection treated with ART in rural South Africa: a cross sectional study

Background

The risk of cardiovascular diseases (CVD) in human immunodeficiency virus (HIV) infected people on antiretroviral therapy (ART) from some rural parts of Africa is not well known. We assessed CVD risk factors, the estimated 5-year Data collection on adverse effects of anti-HIV drugs (DA.) risk score and the 10-year Framingham risk score in persons with HIV infection on ART in a rural area in South Africa.

Methods

A cross-sectional study in which the data on demographic, lifestyle, and chronic disease were collected using the World Health Organization Stepwise approach to surveillance questionnaire. Biochemical parameters were tested using standard biochemical methods. CD4 counts were performed using PIMA analyser and viral load was tested using the branched deoxyribonucleic acid technique. Student t test and Chi square test were used on continuous and categorical variables respectively. Bivariate and multivariate logistic regression were used to analyze predictors of CVD risk factors. Estimates of 5 and 10-year CVD risk were calculated using online tools. The Cohen’s kappa coefficient was used to assess the agreement between CVD risk equations.

Results

The mean age of participants was 44.8 ± 11.8 years; 79.9 % were females. Most of the participants (85 %) had an undetectable viral load and a mean CD4 count of 462 ± 235 cell/mm³. The most common CVD risk factors were low high density lipoprotein cholesterol (HDL-C) (43.8 %), hypercholesterolaemia (33.2 %) and a high Apolipoprotein (Apo) B/ApoA ratio (45.4 %).Using the Framingham equation, 6.7 % of participants had a moderate to high 10-year CVD risk while the DAD risk equation showed that 31.1 % of participants had a moderate to high 5-year CVD risk. Most participants had a low CVD risk by both risk equations. The level of agreement between the two risk equations was 73.8 % (k = 0.23; 95 % CI 0.10–0.35; p value 0.001).

Conclusion

CVD risk factors were common among this rural population on ART. The high proportion of participants with a moderate to high CVD risk, observed with the DAD risk equation, clearly represents a considerable health burden that can possibly be reduced by increasing educational programs on CVD prevention for people on ART. There is however a need to develop and evaluate a race/ethnicity-specific CVD risk estimation tool for HIV infected Africans.

     

Population-based HIV testing and counseling in rural Uganda: participation and risk characteristics.

OBJECTIVES: To assess self-selection in a population-based voluntary HIV testing and counseling (VTC) program by comparing the HIV risk characteristics of users and nonusers of VTC in rural Uganda. DESIGN: A 1994 to 1995 community-randomized trial in the Rakai District of Uganda enrolled adults aged 15 to 59 years and ascertained their HIV status, sociodemographic characteristics, risk behaviors, and AIDS-associated symptoms. All subjects were offered confidential individual VTC at no cost. METHODS: We compared users and nonusers of VTC among 10,950 participants (4764 male and 6186 female) enrolled at baseline using multivariate logistic regression. RESULTS: Women were significantly less likely to receive VTC than men (31.5% vs. 34.8%, p <.001). In multivariate analysis, younger age, HIV-positive status, and having no sexual partners in the past 5 years (and, significant for women only, having 2 or more sexual partners) were associated with lower VTC participation for both men and women. Among women, higher VTC participation was associated with symptoms suggestive of AIDS and other illnesses and shopkeeper occupations. CONCLUSIONS: During the initial phase of a population-based free VTC program in rural Uganda, certain high-risk groups were underrepresented among VTC recipients. There is a need to target VTC to ensure participation by high-risk individuals most in need of services.     

Barriers to the implementation of programs for the prevention of mother-to-child transmission of HIV: A cross-sectional survey in rural and urban Uganda

Background  

Implementation of programs for the prevention of mother-to-child transmission (PMTCT) of HIV faces a variety of barriers and challenges. The assessment of these challenges has generally been conducted in large urban health facilities. As programs expand into rural areas, the potential barriers that may be encountered there also need to be assessed. This study examines potential barriers that might affect the acceptability of interventions for PMTCT in rural and urban settings.