The 2022 symposium on dementia and brain aging in low- and middle-income countries: Highlights on research, diagnosis, care, and impact.

Two of every three persons living with dementia reside in low- and middle-income countries (LMICs). The projected increase in global dementia rates is expected to affect LMICs disproportionately. However, the majority of global dementia care costs occur in high-income countries (HICs), with dementia research predominantly focusing on HICs. This imbalance necessitates LMIC-focused research to ensure that characterization of dementia accurately reflects the involvement and specificities of diverse populations. Development of effective preventive, diagnostic, and therapeutic approaches for dementia in LMICs requires targeted, personalized, and harmonized efforts. Our article represents timely discussions at the 2022 Symposium on Dementia and Brain Aging in LMICs that identified the foremost opportunities to advance dementia research, differential diagnosis, use of neuropsychometric tools, awareness, and treatment options. We highlight key topics discussed at the meeting and provide future recommendations to foster a more equitable landscape for dementia prevention, diagnosis, care, policy, and management in LMICs. HIGHLIGHTS: Two-thirds of persons with dementia live in LMICs, yet research and costs are skewed toward HICs. LMICs expect dementia prevalence to more than double, accompanied by socioeconomic disparities. The 2022 Symposium on Dementia in LMICs addressed advances in research, diagnosis, prevention, and policy. The Nairobi Declaration urges global action to enhance dementia outcomes in LMICs.

Improving alcohol and substance use screening in school-age children: translation, adaptation and psychometric evaluation of the CRAFFT tool for Lumasaaba, Uganda.

BACKGROUND: Children at risk of substance use disorders (SUD) should be detected using brief structured tools for early intervention. This study sought to translate and adapt the Car, Relax, Alone, Forget, Family/Friends, Trouble (CRAFFT) tool to determine its diagnostic accuracy, and the optimum cut-point to identify substance use disorders (SUD) risk in Ugandan children aged 6 to 13 years. METHODS: This was a sequential mixed-methods study conducted in two phases. In the first qualitative phase, in Kampala and Mbale, the clinician-administered CRAFFT tool version 2.1 was translated into the local Lumasaaba dialect and culturally adapted through focus group discussions (FGDs) and in-depth interviews, in collaboration with the tool's authors. Expert reviews and translations by bilingual experts provided insights on linguistic comprehensibility and cultural appropriateness, while pilot testing with the target population evaluated the tool's preliminary effectiveness. In the second phase, the CRAFFT tool, adapted to Lumasaaba, was quantitatively validated against the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) for diagnosing SUD in Mbale district, through a survey. Participants, chosen randomly from schools stratified according to ownership, location, and school size, were assessed for the tool's reliability and validity, including comparisons to the MINI KID as the Gold Standard for diagnosing SUD. Data were analyzed using STATA-15. Receiver-operating-characteristic analysis was performed to determine the sensitivity, specificity, and criterion validity of the CRAFFT with the MINI-KID. RESULTS: Of the 470 children enrolled, 2.1% (n = 10) had missing data on key variables, leaving 460 for analysis. The median age and interquartile range (IQR) was 11 (9-12) years and 56.6% were girls. A total of 116 (25.2%) children had consumed alcohol in the last twelve-month period and 7 (1.5%) had used other substances. The mean CRAFFT score for all the children (n = 460) was 0.32 (SD 0.95). The prevalence of any alcohol use disorder (2 or more positive answers on the MINI KID) in the last 12 months was 7.2% (n = 32). The Lumasaaba version of the CRAFFT tool demonstrated good internal consistency (Cronbach's α = 0.86) and inter-item correlation (Spearman correlation coefficient of 0.84 (p < 0.001). At a cut-off score of 1.00, the CRAFFT had optimal sensitivity (91%) and specificity (92%) (Area Under the Curve (AUC) 0.91; 95% CI 0.86-0.97) to screen for SUD. A total of 62 (13.5%) had CRAFFT scores of > 1. CONCLUSION: The Lumasaaba version of the CRAFFT tool has sufficient sensitivity and specificity to identify school-age children at risk of SUD.

Using Grounded Theory to Develop a Substantive Theory for Grandparent-Caregiving in Uganda: The GRACE Model.

INTRODUCTION: Few studies have focused on developing theories to explain caregiving as performed by grandparents who provide care for their grandchildren in any setting. Theory development that is grounded in the experiences and cultural context of those being studied is needed to inform research, subsequent care, and overall well-being, especially of populations that are understudied. METHODS: This manuscript was informed by Constructivist Grounded Theory, semi-structured in-depth and individual interviews. Also, three methodological phases were followed: (a) concurrent data collection and analysis procedures, (b) developing categories and relationships among them, and (c) defining the core category and building the substantive theory. RESULTS: The methodological steps involved in generating a substantive theory, the GRAndparent-CarEgiving (GRACE) model, are reported. DISCUSSION: Research, and subsequently the well-being and health care of grandparent-caregivers, needs to be informed by culturally congruent theories that are founded in the experiences and cultural context of the individuals being investigated.

A 'hidden problem': Nature, prevalence and factors associated with sexual dysfunction in persons living with HIV/AIDS in Uganda.

BACKGROUND: We conducted a clinic-based cross-sectional survey among 710 people living with HIV/AIDS in stable 'sexual' relationships in central and southwestern Uganda. Although sexual function is rarely discussed due to the private nature of sexual life. Yet, sexual problems may predispose to negative health and social outcomes including marital conflict. Among individuals living with HIV/AIDS, sexual function and dysfunction have hardly been studied especially in sub-Saharan Africa. In this study, we aimed to determine the nature, prevalence and factors associated with sexual dysfunction (SD) among people living with HIV/AIDS (PLWHA) in Uganda. METHODS: We conducted a clinic based cross sectional survey among 710 PLWHA in stable 'sexual' relationships in central region and southwestern Uganda. We collected data on socio-demographic characteristics (age, highest educational attainment, religion, food security, employment, income level, marital status and socio-economic status); psychiatric problems (major depressive disorder, suicidality and HIV-related neurocognitive impairment); psychosocial factors (maladaptive coping styles, negative life events, social support, resilience, HIV stigma); and clinical factors (CD4 counts, body weight, height, HIV clinical stage, treatment adherence). RESULTS: Sexual dysfunction (SD) was more prevalent in women (38.7%) than men (17.6%) and majority (89.3% of men and 66.3% of women) did not seek help for the SD. Among men, being of a religion other than Christianity was significantly associated with SD (OR = 5.30, 95%CI 1.60-17.51, p = 0.006). Among women, older age (> 45 years) (OR = 2.96, 95%CI 1.82-4.79, p<0.01), being widowed (OR = 1.80, 95%CI 1.03-3.12, p = 0.051) or being separated from the spouse (OR = 1.69, 95% CI 1.09-2.59, p = 0.051) were significantly associated with SD. Depressive symptoms were significantly associated with SD in both men (OR = 0.27, 95%CI 0.74-0.99) and women (OR = 1.61, 95%CI 1.04-2.48, p = 0.032). In women, high CD4 count (OR = 1.42, 95% CI 1-2.01, p = 0.05) was associated with SD. CONCLUSION: Sexual dysfunction has considerable prevalence among PLWHA in Uganda. It is associated with socio-demographic, psychiatric and clinical illness factors. To further improve the quality of life of PLWHA, they should be screened for sexual dysfunction as part of routine assessment.

The impact of COVID-19 changes and disruptions on generalized anxiety disorder among young adults living with HIV (YLHIV) in Uganda.

In the context of the COVID-19 pandemic, we investigated associations between specific COVID-19-related changes and its impact on generalized anxiety disorder (GAD) levels among vulnerable young adults living with HIV (YALHIV) in a low-resource setting in Southern Uganda. This research utilized data from 500 YALHIV aged 19 to 25 from the Suubi+Adherence-R2 COVID-19 Supplement study. Disruptions were assessed using an 8-item modified Coronavirus Impact Scale, while anxiety was measured with the GAD-7 questionnaire. Hierarchical logistic regression analysis and multivariate linear regression were employed, guided by the Social Determinants of Health framework. Key findings highlighted changes in routines, family income, stress from the pandemic, changes in family stress and discord, and reduced access to mental health services heightened levels of probable GAD for YALHIV during the pandemic. Additionally, female young adults showed greater levels than males. These results underscore the urgency to develop tailored support mechanisms for YALHIV, especially during challenging and unprecedented times.

Psychological Distress among family caregivers of persons with Alzheimer's Disease and Related Dementias in Uganda.

Background: Alzheimer's disease and related dementia (ADRD) present growing global health challenges, especially in aging populations such as Uganda. In Uganda, familial caregiving, predominantly undertaken by female relatives, is the primary form of support for patients with ADRD. Cultural stigma around dementia and limited access to support services amplify caregivers' challenges. This study examined psychological distress, depression, and quality of life (QoL) among family caregivers of patients with ADRD in Wakiso District, Uganda. Methods: This cross-sectional study involved 90 caregivers from three sub-counties in Wakiso selected through purposive sampling to capture diverse experiences. Data were collected using the Kessler Psychological Distress Scale, Caregiver Dementia Quality of Life Measurement Scale, and Center for Epidemiologic Studies Depression Scale, with an 80% response rate achieved through local collaboration. Statistical analyses focused on psychological distress, QoL, and depression. Results: The study included 82.2% females and 17.8% males, with a median age of 52 years for females and 35 years, respectively. Females were more likely to be single or widowed, whereas males were more likely to be married. The study revealed a high prevalence of psychological distress and depression among caregivers (64.4%) regardless of sex. The analysis indicated that having children was a significant predictor of better QoL (OR 3.04, 95% CI 1.79-5.66, p=0.034) and lower risk of depression (OR 0.10, 95% CI 0.01-0.86, p=0.036). No other sociodemographic factor was significantly associated with health outcomes across the models. Conclusion: Our findings revealed a heavy burden of psychological distress and depression among Ugandan caregivers of patients with ADRD, highlighting the need for structured support systems, including mental health services and gender-responsive interventions, in low-resource settings.

Prevalence and Factors Associated with Anxiety Disorders Among Pregnant Women at Mulago National Referral Hospital, Uganda.

Background: Anxiety disorders in pregnancy are common and represent a global concern. However, data regarding the magnitude of anxiety among pregnant women in Uganda are limited, and yet, these data could pave way for implementing effective mitigation measures. We determined the prevalence of anxiety disorders and associated factors among pregnant women at Mulago Hospital Uganda. Methods: A cross-sectional study was conducted among pregnant women attending antenatal care clinic at Mulago Hospital between September and November 2015. Systematic sampling was used to enroll eligible women. An interviewer-administered demographic questionnaire and the Hamilton Anxiety Rating Scale for Antenatal Anxiety (HAMA-A) scale were used to assess demographic features and anxiety, respectively. Women with HAMA-A score ≥17 were considered to have anxiety disorder. Factors associated with anxiety disorders were determined using multivariate logistic regression. Results: A total of 501 pregnant women were enrolled into the study; the prevalence of anxiety disorders was 13% (n=65; 95% CI: 9.8-15.7%). Factors that were significantly associated with anxiety disorders were low income of the participants (adjusted odds ratio [AOR]=2.65, 95% CI: 1.16-6.06), bad relationship with spouse (AOR = 2.50, 95% CI: 1.01-5.82) and history of hypertension in previous pregnancy (AOR = 4.17, 95% CI: 1.68-10.37). Conclusion: Approximately one in ten women surveyed exhibited anxiety disorders. Anxiety disorders were associated with low-income levels, bad spousal relationships, and a history of hypertension during previous pregnancies. Multidisciplinary approaches that integrate mental health support, social services, and partner involvement may help address anxiety disorders in pregnancy and contribute to improved maternal and child outcomes.

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.

The Relationship between Age at Initiation of Regular Drinking of Alcohol and Viral Suppression Status, and Depression Symptoms Among People Living with HIV in South-Western Uganda.

Alcohol use is an important factor in achieving and maintaining viral suppression and optimal mental health among persons with HIV (PWH), however, the effect of age at first regular drinking on viral suppression and depression remains poorly understood. Here, using secondary data from the Alcohol Drinkers' Exposure to Preventive Therapy for Tuberculosis (ADEPT-T) study, we used logistic regression analyses to explore whether there is an association between age at first regular drinking and viral suppression (< 40 copies/ml), or presence of depressive symptoms (Center for Epidemiologic Studies Depression, CES-D ≥ 16) among 262 PWH. The median age at first regular drinking was 20.5 years (IQR: 10), with high proportions starting under age 12 (12.2%) and as teens (13.4%). The majority had an undetectable viral load (91.7%) and 11% had symptoms of probable depression. We found no significant association between age at first regular drinking and viral suppression (i.e., child (aOR = 0.76 95%CI: 0.18, 3.26), adolescent (aOR = 0.74 95%CI: 0.18, 2.97) and young adult (aOR = 1.27 95%CI: 0.40, 3.97)) nor with depressive symptoms (i.e., child (aOR = 0.72 95%CI: 0.19, 2.83), adolescent (aOR = 0.59 95%CI: 0.14, 2.50) and young adult (aOR = 0.57 95%CI: 0.22, 1.53)). Age at first regular drinking among PWH did not appear to be associated with either viral suppression or the presence of depressive symptoms, suggesting interventions may best be focused on the harmful effects of current alcohol use.

Grandmothers as Primary Caregivers for Their Grandchildren in Uganda: Challenges Faced and Potential for a Sustainable Livelihood Intervention.

Global drivers of health, such as poverty, climate change, and public health crises, pose significant impact on many vulnerable groups, such as grandmother-caregivers (GMCs). Engaging community partners in this problem could help in understanding salient issues and devising solutions to alleviate the challenges faced by GMCs. The purpose of the current study was to engage community members in rural Uganda in identifying challenges experienced by GMCs and explore the potential for a sustainable livelihood for this population. We used a community-engaged ethnographic methodology for our qualitative study, which was informed by the Sustainable Livelihood Framework. Themes emerged in two domains: GMC Challenges and Potential for Sustainable Livelihoods and Intervention Recommendations. The challenges experienced by GMCs are multifaceted as are the potential solutions. Our findings have the potential to inform community development interventions that support the livelihoods and well-being of GMCs in Uganda and similar settings. [Research in Gerontological Nursing, 17(1), 43-52.].

Equipping undergraduate medical and nursing students with elderly health care assessment skills at Makerere University, College of Health Sciences, Uganda.

BACKGROUND: Elderly health care training and aging science remain the least prioritized discipline of medical education in many African countries. With scant scientific evidence on elderly health care in low-income countries, coupled with limited exposure to elderly health care training, this project aimed to equip undergraduate health professional students with elderly health care assessment skills and research through an online course and a clinical placement. METHODS: Students (3rd year) underwent online elderly health care training through the Alison courses published by the Advanced Learning Academy in Ireland. The students were then subjected to an online exam with a pass mark of 80%. Students were also trained on standard elderly health care assessment tools through a one-day session. For practical skills on data collection, each student assessed 15 elderly patients at the Mulago National Referral Hospital Assessment Centre. All tools once filled in were assessed for completion. A one-day reflection session was held with students, faculty and the project leads to share findings from the various tools used to assess elderly individuals. The students shared their experiences and provided feedback on the online training as well as the hardships they may have experienced while administering the tools. A certificate of participation was provided to the students at the end of the project. RESULTS: All the students (10) gained knowledge on elderly assessment skills, the impact of aging on various body systems, and how to manage common occurrences among elderly individuals. The average score in the post-exam was 82% (standard deviation ± 2.01). All students (10) reported having had this as their first training on the assessment of functionality among elderly individuals. CONCLUSIONS: The students gained knowledge of elderly health assessments as well as the impact of aging on various body systems. They also gained insight into how to care for the elderly holistically with an added understanding of how to manage spinal and traumatic brain injuries.

Feasibility and outcomes of using DIALOG+ in primary care to improve quality of life and mental distress of patients with long-term physical conditions: an exploratory non-controlled study in Bosnia and Herzegovina, Colombia and Uganda.

INTRODUCTION: The management of long-term physical conditions is a challenge worldwide, absorbing a majority resources despite the importance of acute care. The management of these conditions is done largely in primary care and so interventions to improve primary care could have an enormous impact. However, very little data exist on how to do this. Mental distress is frequently comorbid with long term physical conditions, and can impact on health behaviour and adherence, leading to poorer outcomes. DIALOG+ is a low-cost, patient-centred and solution-focused intervention, which is used in routine patient-clinician meetings and has been shown to improve outcomes in mental health care. The question arises as to whether it could also be used in primary care to improve the quality of life and mental health of patients with long-term physical conditions. This is particularly important for low- and middle-income countries with limited health care resources. METHODS: An exploratory non-controlled multi-site trial was conducted in Bosnia and Herzegovina, Colombia, and Uganda. Feasibility was determined by recruitment, retention, and session completion. Patient outcomes (quality of life, anxiety and depression symptoms, objective social situation) were assessed at baseline and after three approximately monthly DIALOG+ sessions. RESULTS: A total of 117 patients were enrolled in the study, 25 in Bosnia and Herzegovina, 32 in Colombia, and 60 in Uganda. In each country, more than 75% of anticipated participants were recruited, with retention rates over 90% and completion of the intervention exceeding 92%. Patients had significantly higher quality of life and fewer anxiety and depression symptoms at post-intervention follow-up, with moderate to large effect sizes. There were no significant improvements in objective social situation. CONCLUSION: The findings from this exploratory trial suggest that DIALOG+ is feasible in primary care settings for patients with long-term physical conditions and may substantially improve patient outcomes. Future research may test implementation and effectiveness of DIALOG+ in randomized controlled trials in wider primary care settings in low- and middle-income countries. TRIAL REGISTRATION: All studies were registered prospectively within the ISRCTN Registry. ISRCTN17003451, 02/12/2020 (Bosnia and Herzegovina), ISRCTN14018729, 01/12/2020 (Colombia) and ISRCTN50335796, 02/12/2020 (Uganda).

"She gives it to her child who doesn't even talk": a qualitative exploration of alcohol and drug use among primary school-age children in Uganda.

BACKGROUND: There is little research on alcohol and other drugs (AOD) use by school-age children in low-resource settings like Uganda. Including the voices of children in research can inform prevention and early intervention efforts for those at risk of AOD use. The aim of this study was to understand the perspectives of children aged 6 to 13 years regarding AOD in Uganda. METHODS: This qualitative study was conducted in Mbale district, Uganda from February to March 2020. Eight focus group discussions (FGDs) were conducted with 56 primary school-age children, stratified by age (6-9 and 10-13 years), sex (male and female), and school status (in school and out of school). All FGDs were conducted in either Lumasaaba or Luganda. The FGDs were audio-recorded, transcribed verbatim, and translated into English. Data were coded, and overarching themes were identified using thematic framework analysis. RESULTS: Two themes identified were (1) Children's perceptions and experiences with AODs. The participants understood alcohol by its consistency, colour, odour, and by brand/logo. They described the types and quantities of AOD consumed by school-age children, brewing processes for homemade alcoholic drinks, and short and long-term consequences of the use of alcohol. (2) Contributing factors to childhood drinking included: Stress relief for children who experienced multiple adversities (orphaned, poverty-stricken, and hailing from broken homes), fitting in with friends, influence from families, and media exposure that made alcohol look cool. Children would start drinking at an early age) or were given alcohol by their parents, sometimes before they could start talking. In the community, alcohol and other drugs were cheap and available and children could drink from anywhere, including in the classroom. CONCLUSIONS: Children eligible for primary education in Uganda can easily access and use AOD. Several factors were identified as contributing to alcohol and other drug use among children, including availability and accessibility, advertising, lack of parental awareness and supervision, peer influence, adverse childhood experiences, socioeconomic factors, and cultural norms. There is a need for multi-sectoral action for awareness of childhood AOD use and deliberate consideration of children in the planning, design, and implementation of research, policies, and programs for prevention and early intervention.

Cognitive performance in depression in low- and middle-income countries: A systematic review with meta-analytic components.

BACKGROUND: Depression is highly prevalent in low- and middle- income countries (LMIC) and associated with significant cognitive dysfunction across multiple domains. However, little is known about neurocognitive tests used in people with depression in LMIC. We aimed to investigate cognitive performance and cognitive tests in depression research in LMIC. METHODS: APA PsycInfo, Embase, Ovid MEDLINE, and Global Health were systematically searched for studies that implemented a cognitive performance test in a depressed, LMIC population. Tool quality was assessed using an adapted scale for quality of measures in cross-cultural settings. Data extracted included demographics, depression and cognitive performance measures, and cognitive performance comparisons between depression and control groups. RESULTS: 29 studies met eligibility criteria, involving a total of 19,100 participants from 11 LMIC. 93.1 % of studies were conducted in upper middle-income countries. 67 cognitive performance tools were implemented. Reliability was reported for 5.6 % of cognitive performance tests and validity was reported for 8.3 %. 36.1 % of tests used were culturally adapted. 75.9 % of included studies implemented at least one memory test. Cognitive deficits were observed in all depressed groups, especially in memory (Cohen's d = -1.60, 95 % CI -2.02 to -1.18). LIMITATIONS: Heterogeneity between studies; averaged results across memory subtypes; no assessment of depression severity and cognitive deficits associations; restrictive search terms. CONCLUSIONS: Cognitive impairments in depression, especially in memory, are prevalent in LMIC. This research has drawn attention to the burden of cognitive dysfunction in depression in LMIC, and to the disparate research gap in LMIC. PROSPERO registration CRD42022315397.

Association of severe malaria with cognitive and behavioural outcomes in low- and middle-income countries: a meta-analysis and systematic review.

BACKGROUND: Malaria affects 24 million children globally, resulting in nearly 500,000 child deaths annually in low- and middle-income countries (LMICs). Recent studies have provided evidence that severe malaria infection results in sustained impairment in cognition and behaviour among young children; however, a formal meta-analysis has not been published. The objective was to assess the association between severe malaria infection with cognitive and behavioural outcomes among children living in LMICs. METHODS: Six online bibliographic databases were searched and reviewed in November 2022. Studies included involved children < 18 years of age living in LMICs with active or past severe malaria infection and measured cognitive and/or behaviour outcomes. The quality of studies was assessed. Definitions of severe malaria included cerebral malaria, severe malarial anaemia, and author-defined severe malaria. Results from all studies were qualitatively summarized. For studies with relevant data on attention, learning, memory, language, internalizing behaviour and externalizing behaviour, results were pooled and a meta-analysis was performed. A random-effects model was used across included cohorts, yielding a standardized mean difference between the severe malaria group and control group. RESULTS: Out of 3,803 initial records meeting the search criteria, 24 studies were included in the review, with data from 14 studies eligible for meta-analysis inclusion. Studies across sub-Saharan Africa assessed 11 cohorts of children from pre-school to school age. Of all the studies, composite measures of cognition were the most affected areas of development. Overall, attention, memory, and behavioural problems were domains most commonly found to have lower scores in children with severe malaria. Meta-analysis revealed that children with severe malaria had worse scores compared to children without malaria in attention (standardized mean difference (SMD) -0.68, 95% CI -1.26 to -0.10), memory (SMD -0.52, 95% CI -0.99 to -0.06), and externalizing behavioural problems (SMD 0.45, 95% CI 0.13-0.78). CONCLUSION: Severe malaria is associated with worse neuropsychological outcomes for children living in LMICs, specifically in attention, memory, and externalizing behaviours. More research is needed to identify the long-term implications of these findings. Further interventions are needed to prevent cognitive and behavioural problems after severe malaria infection. TRIAL REGISTRATION: This systematic review was registered under PROSPERO: CRD42020154777.

Feasibility of screening for cognitive impairment among older persons and referral by community health workers in Wakiso district, Uganda.

BACKGROUND: In Uganda, cognitive impairment in older persons aged ≥ 60 years is often undiagnosed due to inadequate appreciation of the condition compounded with limitations of trained human resource able to conduct appropriate cognitive evaluations. Use of Community Health Workers (CHWs) especially in hard-to-reach communities can be an important link for older persons to the health facilities where they can receive adequate evaluations and interventions for cognitive challenges. The aim of the study was to assess the feasibility of screening for cognitive impairment among older persons and referral by CHWs in Wakiso district, Uganda. METHODS: This was a sequential explanatory mixed methods study. The CHWs received a one-day training on causes, signs and symptoms, and management of cognitive impairment and screened older persons ≥ 60 years for cognitive impairment using the Alzheimer's Disease scale 8 (AD8). Psychiatric clinical officers (PCOs) administered the AD8 and the Mini Mental State Examination to the older persons after assessment by the CHWs who then referred them for appropriate clinical care. We conducted Kappa statistic for agreement between the CHWs and PCOs and compared raw scores of the CHWs to Experts scores using Bland Altman and pair plots and corresponding analyses. We also conducted focus group discussions for the older persons, caregivers and CHWs. RESULTS: We collected data from 385 older persons. We involved 12 CHWs and 75% were females, majority were married (58.3%) with at least a secondary education (66.7%). There was 96.4% (CI 94.5-98.2%) agreement between PCOs and CHWs in identifying cognitive impairment with the PCOs identifying 54/385 (14.0: 95%CI 10.7-17.9%) older persons compared to 58/385 (15.1: 95%CI 11.6-19.0%) identified by CHWs. Of the 58 identified to have cognitive impairment by the CHWs, 93.1% were referred for care. The average difference between the score of the expert and that of the CHW was - 0.042 with a 95% CI of -1.335 to 1.252. Corresponding Bland Altman and pair plots showed high agreement between the measurements although CHWs scored higher values with increasing scores. CONCLUSION: CHWs can be trained to identify and refer older persons with cognitive impairment in the communities.

Cognitive impairment in people living with HIV: consensus recommendations for a new approach.

Current approaches to classifying cognitive impairment in people living with HIV can overestimate disease burden and lead to ambiguity around disease mechanisms. The 2007 criteria for HIV-associated neurocognitive disorders (HAND), sometimes called the Frascati criteria, can falsely classify over 20% of cognitively healthy individuals as having cognitive impairment. Minimum criteria for HAND are met on the basis of performance on cognitive tests alone, which might not be appropriate for populations with diverse educational and socioeconomic backgrounds. Imprecise phenotyping of cognitive impairment can limit mechanistic research, biomarker discovery and treatment trials. Importantly, overestimation of cognitive impairment carries the risk of creating fear among people living with HIV and worsening stigma and discrimination towards these individuals. To address this issue, we established the International HIV-Cognition Working Group, which is globally representative and involves the community of people living with HIV. We reached consensus on six recommendations towards a new approach for diagnosis and classification of cognitive impairment in people living with HIV, intended to focus discussion and debate going forward. We propose the conceptual separation of HIV-associated brain injury - including active or pretreatment legacy damage - from other causes of brain injury occurring in people living with HIV. We suggest moving away from a quantitative neuropsychological approach towards an emphasis on clinical context. Our recommendations are intended to better represent the changing profile of cognitive impairment in people living with HIV in diverse global settings and to provide a clearer framework of classification for clinical management and research studies.

Bridges-Round 2: A study protocol to examine the longitudinal HIV risk prevention and care continuum outcomes among orphaned youth transitioning to young adulthood.

BACKGROUND: Youth orphaned by HIV in sub-Saharan Africa experience immense hardships including social disadvantage, adverse childhood events and limited economic prospects. These adversities disrupt the normative developmental milestones and can gravely compromise their health and emotional wellbeing. The Bridges to the Future study (2012-2018) prospectively followed 1,383 adolescents, between 10-16 years, to evaluate the efficacy and cost-effectiveness of a family-based economic empowerment intervention comprising of child development accounts, financial literacy training, family income generating activities and peer mentorship. Study findings show efficacy of this contextually-driven intervention significantly improving mental health, school retention and performance and sexual health. However, critical questions, such as those related to the longitudinal impact of economic empowerment on HIV prevention and engagement in care remain. This paper presents a protocol for the follow-up phase titled, Bridges Round 2. METHODS: The Original Bridges study participants will be tracked for an additional four years (2022-2026) to examine the longitudinal developmental and behavioral health outcomes and potential mechanisms of the effect of protective health behaviors of the Bridges cohort. The study will include a new qualitative component to examine participants' experiences with the intervention, the use of biomedical data to provide the most precise results of the highly relevant, but currently unknown sexual health outcomes among study participants, as well as a cost-benefit analysis to inform policy and scale-up. DISCUSSION: Study findings may contribute to the scientific knowledge for low-resource communities on the potential value of providing modest economic resources to vulnerable boys and girls during childhood and early adolescence and how these resources may offer long-term protection against known HIV risks, poor mental health functioning and improve treatment among the HIV treatment care continuum.