Epidemiology of ebolavirus disease (EVD) and occupational EVD in health care workers in Sub-Saharan Africa: Need for strengthened public health preparedness.

Ebolavirus disease (EVD) is a severe contagious disease in humans, and health care workers (HCW) are at risk of infection when caring for EVD patients. This paper highlights the epidemiologic profile of EVD and its impact on the health care workforce in Africa. A documentary study was conducted which consisted of a review of available literature regarding the epidemiology of EVD, occupational EVD (OEVD), and work safety issues in Sub-Saharan Africa; the literature findings are enriched by field experiences from the authors. EVD outbreaks have already caused 30,500 cases in humans of whom 12,933 died (as of September 9, 2015), and the number of infected HCW has dramatically increased. All eight HCW infected during the 2014 outbreak in Democratic Republic of the Congo died, whereas during the recent West African EVD epidemic more than 890 HCW were infected, with a case fatality rate of 57%. Occupational exposure to blood and other body fluids due to inadequate use of personal protective equipment and needle stick or sharp injuries are among factors that contribute to the occurrence of OEVD. Prevention of OEVD should be one of the top priorities in EVD outbreak preparedness and management, and research should be conducted to elucidate occupational and other factors that expose HCW to EVD. In addition to regularly training HCW to be adequately prepared to care for patients with EVD, it is critical to strengthen the general health care system and improve occupational safety in medical settings of countries at risk.

Antiretroviral treatment for HIV in rural Uganda: two-year treatment outcomes of a prospective health centre/community-based and hospital-based cohort.

BACKGROUND: In sub-Saharan Africa, a shortage of trained health professionals and limited geographical access to health facilities present major barriers to the expansion of antiretroviral therapy (ART). We tested the utility of a health centre (HC)/community-based approach in the provision of ART to persons living with HIV in a rural area in western Uganda. METHODS: The HIV treatment outcomes of the HC/community-based ART program were evaluated and compared with those of an ART program at a best-practice regional hospital. The HC/community-based cohort comprised 185 treatment-naïve patients enrolled in 2006. The hospital cohort comprised of 200 patients enrolled in the same time period. The HC/community-based program involved weekly home visits to patients by community volunteers who were trained to deliver antiretroviral drugs to monitor and support adherence to treatment, and to identify and report adverse reactions and other clinical symptoms. Treatment supporters in the homes also had the responsibility to remind patients to take their drugs regularly. ART treatment outcomes were measured by HIV-1 RNA viral load (VL) after two years of treatment. Adherence was determined through weekly pill counts. RESULTS: Successful ART treatment outcomes in the HC/community-based cohort were equivalent to those in the hospital-based cohort after two years of treatment in on-treatment analysis (VL≤400 copies/mL, 93.0% vs. 87.3%, p = 0.12), and in intention-to-treat analysis (VL≤400 copies/mL, 64.9% and 62.0%, p = 0.560). In multivariate analysis patients in the HC/community-based cohort were more likely to have virologic suppression compared to hospital-based patients (adjusted OR = 2.47, 95% CI 1.01-6.04). CONCLUSION: Acceptable rates of virologic suppression were achieved using existing rural clinic and community resources in a HC/community-based ART program run by clinical officers and supported by lay volunteers and treatment supporters. The results were equivalent to those of a hospital-based ART program run primarily by doctors.

Comparing antiretroviral treatment outcomes between a prospective community-based and hospital-based cohort of HIV patients in rural Uganda.

BACKGROUND: Improved availability of antiretroviral therapy in sub-Saharan Africa is intended to benefit all eligible HIV-infected patients; however in reality antiretroviral services are mainly offered in urban hospitals. Poor rural patients have difficulty accessing the drugs, making the provision of antiretroviral therapy inequitable. Initial tests of community-based treatment programs in Uganda suggest that home-based treatment of HIV/AIDS may equal hospital-based treatment; however the literature reveals limited experiences with such programs. THE RESEARCH: This intervention study aimed to; 1) assess the effectiveness of a rural community-based ART program in a subcounty (Rwimi) of Uganda; and 2) compare treatment outcomes and mortality in a rural community-based antiretroviral therapy program with a well-established hospital-based program. Ethics approvals were obtained in Canada and Uganda. RESULTS AND OUTCOMES: Successful treatment outcomes after two years in both the community and hospital cohorts were high. All-cause mortality was similar in both cohorts. However, community-based patients were more likely to achieve viral suppression and had good adherence to treatment. The community-based program was slightly more cost-effective. Per capita costs in both settings were unsustainable, representing more than Uganda's Primary Health Care Services current expenditures per person per year for all health services. The unpaid community volunteers showed high participation and low attrition rates for the two years that this program was evaluated. CHALLENGES AND SUCCESSES: Key successes of this study include the demonstration that antiretroviral therapy can be provided in a rural setting, the creation of a research infrastructure and culture within Kabarole's health system, and the establishment of a research collaboration capable of enriching the global health graduate program at the University of Alberta. Challenging questions about the long-term feasibility and sustainability of a community-based ARV program in Uganda still remain. THE PARTNERSHIP: This project is a continuation of previous successful collaborations between the School of Public Health of Makerere University, the School of Public Health of University of Alberta, the Kabarole District Administration and the Kabarole Research and Resource Center.

Gender-related mortality for HIV-infected patients on highly active antiretroviral therapy (HAART) in rural Uganda.

The purpose of this study was to examine gender differences in mortality for human immunodeficiency virus (HIV) patients in rural Western Uganda after six months of highly active antiretroviral therapy (HAART). Three hundred eighty five patients were followed up for six months after initiating HAART. Statistical analysis included descriptive, univariate and multivariate methods, using Kaplan-Meier estimates of survival distribution and Cox proportional hazards regression. Mortality in female patients (9.0%) was lower than mortality in males (13.5%), with the difference being almost statistically significant (adjusted hazard ratio for females 0.55; 95% confidence interval [CI]: 0.28-1.07; P = 0.08). At baseline, female patients had a significantly higher CD4+ cell count than male patients (median 147 cells/µL vs 120 cells/µL; P < 0.01). A higher CD4+ cell count and primary level education were strongly associated with better survival. The higher CD4+ cell count in females may indicate that they accessed HAART services at an earlier stage of their disease progression than males. A borderline statistically significant lower mortality rate in females shows that females fare better on treatment in this context than males. The association between lower mortality and higher CD4+ levels suggest that males are not accessing treatment early enough and that more concerted efforts need to be made by HAART programs to reach male HIV patients.

Barriers to accessing highly active antiretroviral therapy by HIV-positive women attending an antenatal clinic in a regional hospital in western Uganda.

BACKGROUND: The aim of this study was to describe barriers to accessing and accepting highly active antiretroviral therapy (HAART) by HIV-positive mothers in the Ugandan Kabarole District's Programme for the Prevention of Mother to Child Transmission-Plus (PMTCT-Plus). METHODS: Our study was a qualitative descriptive exploratory study using thematic analysis. Individual in-depth interviews (n = 45) were conducted with randomly selected HIV-positive mothers who attended this programme, and who: (a) never enrolled in HAART (n = 17); (b) enrolled but did not come back to receive HAART (n = 2); (c) defaulted/interrupted HAART (n = 14); and (d) are currently adhering to HAART (n = 12). A focus group was also conducted to verify the results from the interviews. RESULTS: Results indicated that economic concerns, particularly transport costs from residences to the clinics, represented the greatest barrier to accessing treatment. In addition, HIV-related stigma and non-disclosure of HIV status to clients' sexual partners, long waiting times at the clinic and suboptimal provider-patient interactions at the hospital emerged as significant barriers. CONCLUSIONS: These barriers to antiretroviral treatment of pregnant and post-natal women need to be addressed in order to improve HAART uptake and adherence for this group of the population. This would improve their survival and, at the same time, drastically reduce HIV transmission from mother to child.

Gender differences in antiretroviral treatment outcomes of HIV patients in rural Uganda.

Gender differences in treatment outcomes of 305 persons living with HIV receiving antiretroviral treatment (ART) in Kabarole district, western Uganda, were evaluated. The primary treatment outcome was virological suppression defined as HIV-1 RNA viral load (VL) <400 copies/ml and the secondary outcome measure was the increase in the CD4 cell count after six months on ART. Statistical analysis included descriptive, univariate, and multivariate methods. Proportionally, more females chose to seek treatment compared to males. After six months of treatment, females were more likely to have viral suppression (VL > 400 copies/ml) as compared to males (odds ratio 2.14, 95% confidence interval 0.99-4.63, p=0.05). While females had a significantly higher baseline CD4 cell count at initiation of treatment compared to males, the increase in CD4 cell count after six months on ART was similar in males and females. The reasons for better ART outcomes for females should be further investigated. Ideally, ART programs should work toward equitable treatment outcomes for men and women, if the cause of the gender differential lies in patient behavior and the way ART services are delivered.

Quality of life of HIV patients in a rural area of western Uganda: impact of a community-based antiretroviral treatment program.

OBJECTIVE: Community-based antiretroviral treatment (CBART) programs should aim to achieve positive quality of life outcomes. The purpose of this study was to investigate changes in the health related quality of life (HRQOL) outcomes of patients in a CBART program supported by community volunteers in one sub-county in western Uganda located 50 km from the nearest urban centre. METHODS: We administered a translated version of the MOS-HIV survey and collected clinical data at baseline and after one year from 130 patients. Inclusion criteria included residency in the sub-county, eighteen years of age or, treatment-naïve, eligible for ART based on CD4 cell count <200 cells/mm3 or WHO clinical stage 3 or 4, and willing to accept daily treatment support by family/friends and to be visited by a community volunteer weekly. We assessed changes in physical health (PHS) and mental health (MHS) summary scores and examined associations between patient characteristics and changes in HRQOL. RESULTS: After one year, we observed significant increases in mean PHS (42.7 to 50.1; p<0.01) and MHS (43.5 to 49.5; p<0.01) scores. Lower age (p<0.01) and lower baseline PHS scores (p<0.01) were associated with increases in PHS scores and lower age (p=0.03) and lower baseline MHS scores (p<0.01) were associated with increases in MHS scores. Fifteen patients (12%) had reductions in their HRQOL after one year which were not associated with patient or clinical characteristics, including virological suppression. CONCLUSIONS: The observed improvements in HRQOL demonstrate that positive treatment outcomes can be achieved in CBART programs in rural Uganda. However, some patients appear to experience declines in their overall well-being, despite achieving virological suppression. HRQOL surveys can be useful in identifying these patients, who may require additional attention and support to achieve the full benefits of ART.

Results of a community-based antiretroviral treatment program for HIV-1 infection in Western Uganda.

OBJECTIVE: To compare the treatment outcomes and mortality in a rural community-based ART (CBART) program with a hospital-based ART program in the same district. METHODS: The study design was a non-randomized cohort study consisting of 185 persons living with HIV (PLWHIV) in the CBART cohort and 200 PLWHIV in the hospital cohort. Eligibility for both cohorts was: being HIV-infected and eligible for ART, being treatment naïve, age 18 years or older, and being a resident of Rwimi sub-county. The intervention consisted of a community-based program which included weekly home visits to patients by trained volunteers who delivered antiretroviral drugs (ARVs), monitored and supported adherence to treatment, and identified and reported adverse reactions and other clinical symptoms. Outcome variables were compared to patients in a hospital-based cohort who received the standard care delivered to all other HIV patients in the hospital. The main outcome measures were HIV-1 RNA viral load (VL), CD4 cell count and mortality after six months of treatment. RESULTS: Successful ART treatment outcome as measured by virological suppression (VL<400 copies/ml) in the CBART cohort were similar to those in the hospital-based cohort (90.1% vs 89.3%, p=0.47). The median CD4 cell count increased significantly in both cohorts (community-based cohort 159 cells/microl vs 145 cells/microl in the hospital-based cohort). Mortality was not significantly different in both cohorts (community-based cohort 11.9%, hospital-based cohort 9.0%). CONCLUSION: The findings show that outcomes of a CBART intervention in a rural area compare favorably to outcomes of hospital-based care. If the study results are sustainable over a longer time period, this model could be considered for ART roll-out to impoverished rural/remote populations in Uganda and elsewhere.