Preventing HIV Infection in Pregnant Women in Western Uganda Through a Comprehensive Antenatal Care-Based Intervention: An Implementation Study.

We implemented and assessed a comprehensive, antenatal care (ANC)-embedded strategy to prevent HIV seroconversions during pregnancy in Uganda. HIV-negative first-time ANC clients were administered an HIV risk assessment tool and received individual risk counseling. Those attending ANC without partners obtained formal partner invitation letters. After three months, repeat HIV testing was carried out; non-attending women were reminded via phone. We analyzed uptake and acceptance, HIV incidence rate, and risk behavior engagement. Among 1081 participants, 116 (10.7%) reported risk behavior engagement at first visit; 148 (13.7%) were accompanied by partners. At the repeat visit (n = 848), 42 (5%, p < 0.001) reported risk behavior engagement; 248 (29.4%, p < 0.001) women came with partners. Seroconversion occurred in two women. Increased odds for risk behavior engagement were found in rural clients (aOR 3.96; 95% CI 1.53-10.26), women with positive or unknown partner HIV-status (2.86; 1.18-6.91), and women whose partners abused alcohol (2.68; 1.15-6.26). Overall, the assessed HIV prevention strategy for pregnant women seemed highly feasible and effective. Risk behavior during pregnancy was reduced by half and partner participation rates in ANC doubled. The observed HIV incidence rate was almost four times lower compared to a pre-intervention cohort in the same study setting.

A protein restricted diet induces a stable increased fat storage phenotype in flies.

Background: Scientific evidence has revealed possible confounders in diet induced obesity models of Drosophila melanogaster. High Sugar Diet (HSD) induction of obesity in flies has been associated with fly hyperosmolarity and glucotoxicity, while High Fat Diet (HFD) induction has been associated with lipotoxicity. The objective of this study was to assess for a healthy obesity phenotype by comparison of fly survival, physio-chemical and biochemical changes associated with HSD, HFD and Protein Restricted Diet (PRD) obesity induction models of male Drosophila melanogaster. Here, we provide information on a PRD as the plausible option in obesity research not involving cancer, diabetes, glucotoxicity and lipotoxicity studies. Methods: Obesity was induced by exposing Drosophila melanogaster white mutant w1118 to four experimental diets for four weeks. Group 1 was fed regular food (control), group 2 was fed a 0.5% less yeast than in regular feed (PRD), group 3 was fed a 30% w/v sucrose to regular cornmeal food (HSD) and group 4 was fed a 10% w/v food-grade coconut oil to regular cornmeal food (HFD). Peristaltic waves were measured on 3rd instar larvae of all experimental groups. Negative geotaxis, fly survival, body mass, catalase activity, triglycerides (TG/TP), sterol, and total protein were measured in adult Drosophila melanogaster after four weeks. Results: Triglycerides (TG/TP) and total protein levels were significantly higher in HSD phenotype. Sterols were higher in HFD phenotype. Though catalase enzyme activity was highest in PRD phenotype, this activity was not statistically significant when compared to that of HSD and HFD phenotypes. However, PRD phenotype had the lowest mass, highest survival rate and the highest negative geotaxis, thus demonstrating a balanced, stable and more viable metabolic status in the experimental model. Conclusion: A protein restricted diet induces a stable increased fat storage phenotype in Drosophila melanogaster.

Anti-obesity effects of Erythrina abyssinica stem bark extract in flies exposed to a high fat diet.

Background: An in vitro assay on Sigmoidin A from Erythrina abyssinica stem bark revealed its potency to inhibit pancreatic lipase. However, studies indicate activity of extract bioactive compounds in combination far exceed the favorable effects of each individual compound due to synergy and additive effects. In this study, we provide information on the effect of E. abyssinica stem bark extract in Drosophila melanogaster. The objective of the study was to determine the safety and effects of E. abyssinica stem bark extract on fly survival, body weight, triglycerides, sterol, total protein, and catalase activity of obese male D. melanogaster. Methods: Obesity was induced by exposing D. melanogaster white mutant w 1118 to coconut food for two weeks. Groups 1-3 were fed on coconut food + fenofibrate at 25 mM, 50 mM, and 75 mM. Groups 4-6 were fed on coconut food + E. abyssinica stem bark extract at concentrations of 2.5 g/ml, 5.0 g/ml, and 7.5 g/ml. The positive control was exposed to only coconut food while the negative control was on regular food. Fly survival observations were done for 15 days, while acute and chronic effects were done at 30 min and after 48 h respectively following treatment. Body mass, negative geotaxis, reducing power of the extract, triglycerides (TG/TP), sterol, total protein levels, and catalase activity were measured after 10 days of exposure to the experimental diets. Results: Fly survival changes were observed after 10 days and E. abyssinica stem bark extract had the strongest reducing power at 7.5 g/ml extract concentration. E. abyssinica stem bark extract reduced body mass, triglyceride levels (TG/TP), sterol levels, and modulated catalase activity at 7.5 g/ml extract concentration. Though the standard drug fenofibrate had the highest fat accumulation reduction potential, the extract at 7.5 g/ml was much safer in reducing fat accumulation in obese male D. melanogaster than other concentration used. Conclusion: Antioxidants in E. abyssinica stem bark extract are responsible for the observed anti-obesity activity.

Sexual Risk Behavior in HIV-Uninfected Pregnant Women in Western Uganda.

Our aim was to identify sexual risk behavior among HIV-negative pregnant women in Kabarole District, Uganda, by conducting a cross-sectional study among 1610 women within three healthcare settings. One in six women engaged in HIV-specific risk behaviors including multiple sexual partners or alcohol abuse; 80% of the pregnant women reported to generally abstain from using condoms. In multivariate analysis, predictors of sexual risk behavior included being a client of the public health facilities as compared to the private facility (AOR 3.6 and 4.8, p < 0.001), being single, widowed or divorced or not cohabiting with the partner (AOR 4.7 and 2.3, p < 0.001), as well as higher household wealth (AOR 1.8, p < 0.001) and lack of partner status knowledge (AOR 1.6, p = 0.008). Self-estimated risk perception was linked with engagement in HIV-related risk behaviors except for alcohol abuse. Our findings indicate that reducing risky behaviors in pregnancy in order to prevent HIV should be a high-priority public health concern.

Repercussions of the COVID-19 Response in Pregnant Women in Western Uganda: Knowledge, Behavior, and Emotional State after the First Lockdown in 2020.

Limited research exists on pregnant women's knowledge, attitudes, and behavior concerning COVID-19 in sub-Saharan Africa. We performed a cross-sectional study among 648 pregnant women in Fort Portal, Uganda, after the first lockdown starting in June 2020. Structured interviews were conducted at three different facilities during routine antenatal care, assessing sociodemographic background, knowledge of COVID-19, prevention behavior adherence, and psycho-emotional stress levels. We performed descriptive analyses and examined associated factors using multivariable logistic regression. In Fort Portal Region, 32.8% of pregnant women had a higher knowledge regarding the COVID-19 pandemic, while all women at least heard of COVID-19. 88.6% of the women showed low self-reported prevention behavior adherence. More than one third of the pregnant women experienced high psycho-emotional stress related to the pandemic (39.8%). The odds for psycho-emotional stress were increased among the age group 21-30 years (AOR 1.97; 95% CI 1.18-3.35) compared to women under the age of 21, and decreased in single or divorced women compared to women in partnerships (AOR 0.42; 0.22-0.77) and in women having less COVID-19-related knowledge (AOR 0.40; 0.27-0.58). In conclusion, prevention behavior adherence seemed challenging, and psycho-emotional stress was ubiquitous among our cohort. To avoid adverse consequences in maternal and neonatal health, campaigns for hygiene but also women's emotional state should be a major focus of community healthcare in exceptional times such as the SARS-CoV-2 pandemic.

HIV-Related Stigma Among Youth Living With HIV in Western Uganda.

We present an explanatory theory for HIV-related stigma from the perspectives of youth living with HIV/AIDS (YLWHA) in Western Uganda, on which the fight against this relentless stigma in this age group and locality can be founded. A constant comparative method was used to analyze textual data from in-depth interviews with 35 YLWHA, selected from three health facilities. A stigma process model for YLWHA was developed with the stigmatizing feelings and behaviors as the core category. Concepts delineating causes, consequences, and moderators of HIV-related stigma emerged from the data to complete the stigma process. The specific focus on YLWHA and contextual characteristics adds new dimensions to the understanding of HIV-related stigma that are scant in existing HIV-related stigma models. In light of our findings, research is necessary to identify context-specific strategies to overcome the deep-rooted causes of stigmatizing views and behaviors in all social spheres of YLWHA within Western Uganda.

Care and support for youth living with HIV/AIDS in secondary schools: perspectives of school stakeholders in western Uganda.

BACKGROUND: Although schools have been identified as significant settings in the response to the HIV/AIDS pandemic, limited research is available on how they can accommodate Youth Living with HIV/AIDS (YLWHA), especially in resource limited countries. In this study, we explored strategies by school stakeholders (school staff, parents/caretakers, and students) in western Uganda to care for and support YLWHA in their schools. METHODS: The article utilizes data collected between May and October, 2019 from a qualitative inquiry based on focus group discussions and interviews with 88 school stakeholders purposively selected from 3 secondary schools in western Uganda. Textual data was analyzed thematically involving both inductive and deductive coding. RESULTS: We identified 7 overarching interrelated themes in which participants reported strategies to care for and support YLWHA: counselling and guidance; social support networks and linkages; knowledge and skills; anti-stigma and anti-discrimination measures; disclosure of HIV status; treatment and management of HIV/AIDS; and affirmative actions for YLWHA. Stakeholders' strategies often differed regarding what was considered appropriate, the approach and who to take lead in supporting YLWHA. CONCLUSIONS: Despite the limited care and support strategies specific for YLWHA currently available in schools, our study points to optimism and high potential given stakeholders' identified avenues for improvement. We posit that promoting HIV/AIDS-care and support in schools is a gradual process requiring each school to develop a strong knowledge base about HIV/AIDS and support needs of YLWHA, develop a coherent and school-wide approach, and collaborate extensively with external stakeholders who are significant in supporting YLWHA.

The incidence of HIV and associated risk factors among pregnant women in Kabarole District, Uganda.

OBJECTIVES: The study attempted to determine the incidence of HIV among pregnant women in Kabarole District, Uganda, and to identify socio-demographic and behavioral risk factors for seroconversion during pregnancy. METHODS: We carried out a retrospective cohort study among women for whom a documented HIV-negative test result from the first pregnancy trimester could be confirmed using available records, and who were HIV-retested in the third trimester or during delivery. In total, 1610 pregnant women from three different healthcare settings took part in the study. We captured the results of repeated HIV tests and conducted semi-structured interviews to explore participants' socio-demographic characteristics and sexual risk behavior. For HIV incidence rates, we calculated the number of seroconversions per 100 person-years. We used Fisher's exact test to test for potential associations. Penalized maximum likelihood logistic regression and Poisson regression were applied to adjust for potential confounders. RESULTS: The overall HIV incidence rate among participants was 2.9/100 women-years. Among socio-demographic characteristics, the multivariable analysis showed a significant association of marital status with HIV incidence in pregnancy (IRR 8.78, 95%CI [1.13-68.33]). Risky sexual behaviors including higher number of sexual partners in pregnancy (IRR 2.78 [1.30-5.94]), unprotected sex with unknown persons (IRR 14.25 [4.52-44.93]), alcohol abuse (IRR 12.08 [4.18-34.90]) and sex under the influence of drugs or alcohol (IRR 6.33 [1.36-29.49]) were significantly associated with seroconversion in pregnancy (similar results in logistic regression). CONCLUSIONS: HIV incidence was three times higher among our pregnant study population compared to the general female population in Uganda. This underlines the importance of HIV prevention and repeat testing during pregnancy. Identified risk groups should be considered for pre-exposure prophylaxis.

Experiences and effects of HIV-related stigma among youth living with HIV/AIDS in Western Uganda: A photovoice study.

HIV-related stigma has been identified as a significant stressor affecting Quality of Life of Youth Living With HIV/AIDS (YLWHA). Gaining a contextualized understanding of how this stigma is experienced by YLWHA in Western Uganda is crucial in addressing it in this group and setting. In this study, we explored the lived experiences of YLWHA with HIV-related stigma. Photovoice was used to gain insight into the lived experiences of HIV-related stigma in 11 YLWHA (15-19 years), purposively selected from a hospital-based peer support group. Group interview transcripts, notes and photographs were subjected to phenomenological hermeneutic analysis. Encounters with enacted, anticipated and internalized stigmas and their myriad sequels were prevalent in the photos and narratives of participants. Our findings were categorized and presented in 5 main themes that were identified through the analysis: being devalued, experiencing fear, experiencing injustices, feeling lonely, and lacking future perspectives. HIV-related stigmas were experienced in various socio-ecological domains but predominantly in homes and schools that ought to be supportive surroundings for youths. A multilevel approach, targeting the entire society where the root causes of stigma can be found and specific contexts like schools and homes where youth are confronted with stigma on a daily basis is proposed for a wholistic intervention.

Experiences and perceptions of youth living with HIV in Western Uganda on school attendance: barriers and facilitators.

BACKGROUND: The globally recognized socio-economic benefits of education have stirred many countries in Sub-Saharan Africa like Uganda to promote universal access to schooling by removing fiscal barricades for those in primary and secondary schools. However, the proportion of Youth Living With HIV/AIDS (YLWHA) missing school, studying with difficulties and dropping out of school in Uganda has been observed to be higher than that of other youth. This study aimed at understanding the barriers and facilitators for YLWHA in Uganda to attend school. METHODS: We conducted a qualitative inquiry with 35 purposively selected YLWHA aged 12 to 19 years, including 16 females at three accredited Antiretroviral Therapy (ART) treatment centres in Kabarole district in Western Uganda. Individual semi-structured interviews were tape-recorded, transcribed verbatim and subjected to thematic inductive analysis. RESULTS: We identified five main themes in which barriers to attend school were reported and four main themes in which facilitators were reported by participants. The main themes for barriers were: 1) management of ART and illnesses, 2) fear, negative thoughts and self-devaluation, 3) lack of meaningful and supportive relationships, 4) reactionary attitudes and behaviours from others at school, 5) financial challenges. The main themes for facilitators were: 1) practical support at school, home and community, 2) counselling, encouragement and spirituality, 3) individual coping strategies, 4) hopes, dreams and opportunities for the future. CONCLUSION: Most of the barriers reported arose from HIV-related stigma and financial challenges whose genesis transcends school boundaries. While YLWHA reported measures to cope, and support from other people, these were non-sustainable and on a limited scale due to disclosure apprehension at school and the indiscretion of those who learnt about their status. To promote supportive school environments for YLWHA, integrated curricular and extracurricular interventions are necessary to increase HIV knowledge, dispel misconceptions about HIV and consequently transform the school community from a stigmatizing one to a supportive one.

Youth living with HIV/AIDS in secondary schools: perspectives of peer educators and patron teachers in Western Uganda on stressors and supports.

As Youth Living With HIV/AIDS (YLWHA) continue to survive and live with HIV chronically due to effective Antiretroviral Therapy (ART), it is paramount to work toward maximising their psychosocial wellbeing. The school where these YLWHA are expected to spend most of their time is an excellent environment to investigate this. In this study, we explore perspectives of Peer Educators (PEs) in secondary schools of one district in Western Uganda on how YLWHA are perceived in school, on their daily stressors and their way of coping with their HIV-positive serostatus given the support of the schools. We conducted eight focus groups with a total of 59 students who were members of Peer Educators Clubs (PECs) as well as 8 in-depth interviews with patron teachers of PECs in eight secondary schools of Kabarole district, selected through a stratified random sampling method. Focus groups and interviews were tape-recorded, transcribed and analysed thematically both inductively and deductively. Stressors and support in schools, as identified by the PEs were categorised into three interrelated thematic domains; psychological wellbeing of YLWHA, disclosure of HIV status by YLWHA, and health and treatment adherence. Stigma was found to be a key stressor and an intermediary in all the three thematic domains Stressors affecting psychological wellbeing were fear of death and uncertainty of the future compounded by financial and academic challenges. Stressors affecting disclosure centred around lack of privacy, confidentiality and fear of loss of friends. Stressors affecting treatment adherence included lack of privacy while taking drugs, unintended disclosure while obtaining drugs or seeking permission to attend clinic appointments and fear of drug adverse effects due to poor nutrition. A supportive school environment involved the availability of a school nurse, counselling services and PECs. We conclude that the school environment brings more stressors than supports for YLWHA. The daily stressors related to HIV stigma, uncertainty, disclosure, privacy and confidentiality render schooling a hassle for YLWHA. Interventions that promote resilient school communities are necessary to foster disclosure in a non-discriminatory and stigma-free environment. This calls for concerted efforts from all school stakeholders.

Challenges and support for quality of life of youths living with HIV/AIDS in schools and larger community in East Africa: a systematic review.

BACKGROUND: Youths living with HIV/AIDS (YLWHA) experience innumerable challenges within schools and the larger community. Nonetheless, these environments are potential sources of support for such youths. This review provides a synthesis of evidence about these challenges and support available for YLWHA to inform the design and implementation of interventions that support the wellbeing of youths living with HIV/AIDS in an East African context. METHODS: We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Cochrane central registry of systematic reviews and randomized control trials for studies conducted in East Africa and published in English in the last 10 years (March 2007 to March 2017). We also searched Google Scholar and reference lists of all included studies. We purposed to include both qualitative and quantitative data but no quantitative data merited inclusion. We analyzed qualitative data using a framework thematic analysis. RESULTS: We included 16 primary studies conducted in clinic and community settings that used qualitative or mixed methods. Three overarching themes-psychosocial wellbeing, treatment and health, and disclosure of HIV status together with a sub-theme of stigma that was important across the three overarching themes-were the basis for analysis. In each overarching theme, a duality of challenges versus support was reported. Psychosocial wellbeing included subthemes of challenges in schools and larger community, financial challenges, domestic violence, sexual and reproductive health challenges, and psychosocial support. CONCLUSION: YLWHA experience numerous challenges and support needs, some of which occur in schools and affect their QoL. The effects of these challenges are poor health and educational outcomes as well as school dropout. The schools in which youths spend most of their formative years have not provided adequate support for YLWHA. This review identified that although most of the challenges that studies identified arose from within schools and that a few supportive approaches were available, none of the studies explored how these supportive approaches would work in schools. It was additionally identified that stigma complicates challenges of living with HIV/AIDS necessitating interventions for the wellbeing of YLWHA to understand and address HIV-stigma and its ramifications. Such interventions ought to be sustainable in schools, culturally appropriate, and multidisciplinary in order to promote the general health of all students.

Prevention of mother-to-child transmission of HIV: Postpartum adherence to Option B+ until 18 months in Western Uganda.

Since 2012, the WHO recommends Option B+ for the prevention of mother-to-child transmission of HIV. This approach entails the initiation of lifelong antiretroviral therapy in all HIV-positive pregnant women, also implying protection during breastfeeding for 12 months or longer. Research on long-term adherence to Option B+ throughout breastfeeding is scarce to date. Therefore, we conducted a prospective observational cohort study in Fort Portal, Western Uganda, to assess adherence to Option B+ until 18 months postpartum. In 2013, we recruited 67 HIV-positive, Option B+ enrolled women six weeks after giving birth and scheduled them for follow-up study visits after six, twelve and 18 months. Two adherence measures, self-reported drug intake and amount of drug refill visits, were combined to define adherence, and were assessed together with feeding information at all study visits. At six months postpartum, 51% of the enrolled women were considered to be adherent. Until twelve and 18 months postpartum, adherence for the respective follow-up interval decreased to 19% and 20.5% respectively. No woman was completely adherent until 18 months. At the same time, 76.5% of the women breastfed for ≥12 months. Drug adherence was associated with younger age (p<0.01), lower travel costs (p = 0.02), and lower number of previous deliveries (p = 0.04). Long-term adherence to Option B+ seems to be challenging. Considering that in our cohort, prolonged breastfeeding until ≥12 months was widely applied while postpartum adherence until the end of breastfeeding was poor, a potential risk of postpartum vertical transmission needs to be taken seriously into account for Option B+ implementation.

Decreased emergence of HIV-1 drug resistance mutations in a cohort of Ugandan women initiating option B+ for PMTCT.

BACKGROUND: Since 2012, WHO guidelines for the prevention of mother-to-child transmission (PMTCT) of HIV-1 in resource-limited settings recommend the initiation of lifelong antiretroviral combination therapy (cART) for all pregnant HIV-1 positive women independent of CD4 count and WHO clinical stage (Option B+). However, long-term outcomes regarding development of drug resistance are lacking until now. Therefore, we analysed the emergence of drug resistance mutations (DRMs) in women initiating Option B+ in Fort Portal, Uganda, at 12 and 18 months postpartum (ppm). METHODS AND FINDINGS: 124 HIV-1 positive pregnant women were enrolled within antenatal care services in Fort Portal, Uganda. Blood samples were collected at the first visit prior starting Option B+ and postpartum at week six, month six, 12 and 18. Viral load was determined by real-time RT-PCR. An RT-PCR covering resistance associated positions in the protease and reverse transcriptase HIV-1 genomic region was performed. PCR-positive samples at 12/18 ppm and respective baseline samples were analysed by next generation sequencing regarding HIV-1 drug resistant variants including low-frequency variants. Furthermore, vertical transmission of HIV-1 was analysed. 49/124 (39.5%) women were included into the DRM analysis. Virological failure, defined as >1000 copies HIV-1 RNA/ml, was observed in three and seven women at 12 and 18 ppm, respectively. Sequences were obtained for three and six of these. In total, DRMs were detected in 3/49 (6.1%) women. Two women displayed dual-class resistance against all recommended first-line regimen drugs. Of 49 mother-infant-pairs no infant was HIV-1 positive at 12 or 18 ppm. CONCLUSION: Our findings suggest that the WHO-recommended Option B+ for PMTCT is effective in a cohort of Ugandan HIV-1 positive pregnant women with regard to the low selection rate of DRMs and vertical transmission. Therefore, these results are encouraging for other countries considering the implementation of lifelong cART for all pregnant HIV-1 positive women.

Option B+ for prevention of vertical HIV transmission has no influence on adverse birth outcomes in a cross-sectional cohort in Western Uganda.

BACKGROUND: While most Sub-Saharan African countries are now implementing the WHO-recommended Option B+ protocol for prevention of vertical HIV transmission, there is a lack of knowledge regarding the influence of Option B+ exposure on adverse birth outcomes (ABOs). Against this background, we assessed ABOs among delivering women in Western Uganda. METHODS: A cross-sectional, observational study was performed within a cohort of 412 mother-newborn-pairs in Virika Hospital, Fort Portal in 2013. The occurrence of stillbirth, pre-term delivery, and small size for gestational age (SGA) was analysed, looking for influencing factors related to HIV-status, antiretroviral drug exposure and duration, and other sociodemographic and clinical parameters. RESULTS: Among 302 HIV-negative and 110 HIV-positive women, ABOs occurred in 40.5%, with stillbirth in 6.3%, pre-term delivery in 28.6%, and SGA in 12.2% of deliveries. For Option B+ intake (n = 59), no significant association was found with stillbirth (OR 0.48, p = 0.55), pre-term delivery (OR 0.97, p = 0.92) and SGA (OR 1.5, p = 0.3) compared to seronegative women. Women enrolled on antiretroviral therapy (ART) before conception (n = 38) had no different risk for ABOs than women on Option B+ or HIV-negative women. Identified risk factors for stillbirth included lack of formal education, poor socio-economic status, long travel distance, hypertension and anaemia. Pre-term delivery risk was increased with poor socio-economic status, primiparity, Malaria and anaemia. The occurrence of SGA was influenced by older age and Malaria. CONCLUSION: In our study, women on Option B+ showed no difference in ABOs compared to HIV-negative women and to women on ART. We identified several non-HIV/ART-related influencing factors, suggesting an urgent need for improving early risk assessment mechanisms in antenatal care through better screening and triage systems. Our results are encouraging with regard to continued universal scale-up of Option B+ and ART programmes.

Frequency and distribution patterns of opportunistic infections associated with HIV/AIDS in Uganda.

BACKGROUND: We conducted a study to assess the frequency and distribution patterns of selected opportunistic infections (OIs) and opportunistic cancers (OCs) in different geographical areas before and after HAART in Uganda. METHODS: This was a cross-sectional serial review of observation data for adult HIV positive patients (≥15 years) enrolled with the AIDS support organization (TASO) in Uganda covering the period from January 2001 to December 2013. Both AIDS defining OIs/OCs and non-AIDS defining OIs were analyzed. The study period was structured into three time periods: "pre- HAART" (2001-2003), "early-HAART" (2004-2008) and "late-HAART" (2009-2013). Descriptive statistics were used to summarize the data by time period, age, gender and geographical location. Chi squared test used to test the significance of the differences in proportions. RESULTS: A total of 108,619 HIV positive patients were included in the analysis. 64% (64,240) were female with median age of 33 years (IQR 27-40). The most frequent OIs before HAART were oral candida (34.6%) diarrhoeal infection (<1 month) (30.6%), geohelminths (26.5%), Mycobacterium tuberculosis (TB) (17.7%), malaria (15.1%) and bacterial pneumonia (11.2%). In early HAART (2004-2008), the most frequent OIs were geohelminths (32.4%), diarrhoeal infection (25.6%), TB (18.2%) and oral candida (18.1%). In late HAART (2009-2013), the most frequent OIs were geohelminths (23.5%) and diarrhoeal infection (14.3%). By gender, prevalence was consistently higher in women (p < 0.05) before and after HAART for geohelminths, candidiasis, diarrhoeal infection, bacterial pneumonia and genital ulcer disease but consistently higher in men for TB and Kaposi's sarcoma (p < 0.05). By age, prevalence was consistently higher in older age groups (>30 years) before and after HAART for oral candida and TB (p < 0.05) and higher in young age groups (<30 years) for malaria and genital ulcers (p < 0.05). By geographical location, prevalence was consistently higher in Eastern and Northern Uganda before and after HAART for diarrheal infection and geohelminths (p < 0.0001). CONCLUSIONS: The frequency and pattern of OIs before and after HAART differs by gender, age and geographical location. Prevalence of geohelminths and diarrhea infection(<1 month) remains high especially in Northern and Eastern Uganda even after HAART and should therefore be given special attention in HIV/AIDS care programmes in these settings.

Forecast analysis of any opportunistic infection among HIV positive individuals on antiretroviral therapy in Uganda.

BACKGROUND: Predicting future prevalence of any opportunistic infection (OI) among persons infected with the human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) in resource poor settings is important for proper planning, advocacy and resource allocation. We conducted a study to forecast 5-years prevalence of any OI among HIV-infected individuals on HAART in Uganda. METHODS: Monthly observational data collected over a 10-years period (2004-2013) by the AIDS support organization (TASO) in Uganda were used to forecast 5-years annual prevalence of any OI covering the period 2014-2018. The OIs considered include 14 AIDS-defining OIs, two non-AIDS defining OIs (malaria & geohelminths) and HIV-associated Kaposi's sarcoma. Box-Jenkins autoregressive integrated moving average (ARIMA) forecasting methodology was used. RESULTS: Between 2004 and 2013, a total of 36,133 HIV patients were enrolled on HAART of which two thirds (66 %) were female. Mean annual prevalence for any OI in 2004 was 57.6 % and in 2013 was 27.5 % (X(2) trend = 122, b = -0.0283, p <0.0001). ARIMA (1, 1, 1) model was the most parsimonious and best fit for the data. The forecasted mean annual prevalence of any OI was 26.1 % (95 % CI 21.1-31.0 %) in 2014 and 15.3 % (95 % CI 10.4-20.3 %) in 2018. CONCLUSIONS: While the prevalence of any OI among HIV positive individuals on HAART in Uganda is expected to decrease overall, it's unlikely that OIs will be completely eliminated in the foreseeable future. There is therefore need for continued efforts in prevention and control of opportunistic infections in all HIV/AIDS care programmes in these settings.

Prevention of Mother-to-Child Transmission of HIV in Option B+ Era: Uptake and Adherence During Pregnancy in Western Uganda.

Since 2012, lifelong antiretroviral therapy for all HIV-positive pregnant women ("Option B+") is recommended by WHO for the prevention of mother-to-child transmission of HIV (PMTCT). Many sub-Saharan African countries have since introduced this regimen, but to date, longer-term outcome evaluations are scarce. We conducted an observational study in Fort Portal Municipality, Uganda, to describe uptake and adherence of Option B+ during pregnancy. HIV-positive women approaching antenatal care (ANC) services in two hospitals were enrolled and followed-up at monthly routine ANC visits until delivery. At each visit, next to sociodemographic and clinical data, we assessed drug adherence through pill counts. In total, 124 HIV-positive pregnant women were enrolled in our study; from these, 80.8% had not been aware of their positive serostatus before. Forty-five PMTCT clients (36.3%) never returned to ANC after their first visit. Protective factors (p < 0.05) for immediate loss to care included previous HIV status knowledge, status disclosure before or at first ANC visit, and tertiary education. Among those clients starting Option B+, the median adherence during pregnancy was 95.7% pill intake. Rather low adherence (<80%) was observed in 21.1% of clients, while more than half achieved an adherence level of ≥95%, with 40.8% of all clients being 100% adherent. The cohort's median adherence remained stable throughout the course of pregnancy. Healthcare providers should place high emphasis on individual PMTCT counseling at first ANC encounter, and pay special attention to those women previously unaware of their HIV status. However, after initial uptake, high adherence seems to be feasible for Option B+.

Trends and Predictors of Mortality Among HIV Positive Patients in the Era of Highly Active Antiretroviral Therapy in Uganda.

Knowledge of mortality trends and predictors among HIV-positive patients in the era of highly active antiretroviral therapy (HAART) in resource poor settings is still limited. The aim of this study was to describe trends and predictors of mortality among HIV-positive patients in the era of HAART in Uganda. Data from 2004 to 2013 for adult HIV-positive patients (≥15 years) obtaining care and treatment from the AIDS Support Organization in Uganda were reviewed for mortality. Descriptive statistics were analyzed by frequencies and cross tabulations. Calendar period was used as a proxy measure for HAART exposure and a time plot of the proportion of HIV-positive patients reporting dead per year was used to describe the trends. Logistic regression was used to determine the predictors of mortality at bivariate and multivariate levels, respectively. We included in the analysis 95,857 HIV positive patients; 64% were female with median age of 33 years (interquartile range 27-40). Of these 36,133 (38%) were initiated on ART and a total of 4279 (4.5%) died; 19.5% (835/4279) of those who died had an opportunistic infection. Overall, mortality first increased between 2004 and 2006 and thereafter substantially declined (X(2) trend=211.9, P<0.001). Mortality was relatively higher in Eastern Uganda compared to other geographical areas. Male gender, older age (>45 years), being from Eastern or Northern Uganda, having none or primary education, being unemployed, advanced immunodeficiency (CD4 count <100 cell/µL or WHO stage III or IV) and underweight (<45 kg weight) at HAART initiation and calendar period 2004-2008 were significant predictors of mortality (P<0.001). Overall, the expanding coverage of HAART is associated with a declining trend in mortality among HIV positive patients in Uganda. However, mortality trends differed significantly by geographical area and men remain potentially at higher risk of death probably because of delayed initiation on ART. There is urgent need for men targeted interventions for improved ART performance.

Lack of effect of intermittent preventive treatment for malaria in pregnancy and intense drug resistance in western Uganda.

BACKGROUND: Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is widely implemented in sub-Saharan Africa for the prevention of malaria in pregnancy and adverse birth outcomes. However, in areas of intense SP resistance, the efficacy of IPTp may be compromised. METHODS: A cross-sectional study among 915 delivering women (728 analysable live singleton deliveries) was conducted in Fort Portal, western Uganda, to assess associations of reported IPTp use, Plasmodium falciparum infection, maternal anaemia, low birth weight, and preterm delivery, and to estimate the degree of SP resistance as reflected by pfdhfr/pfdhps mutations. RESULTS: Plasmodium falciparum infection was detected by PCR in 8.9 % and by microscopy of placental blood samples in 4.0 %. Infection was significantly associated with stillbirth, early neonatal death, anaemia, low birth weight, and pre-term delivery. Eighty percent of the women had taken at least one dose of IPTp, and more than half had taken two doses. As compared to women without chemoprophylaxis against malaria, IPTp had no significant influence on the presence of P. falciparum infection (13.8 vs. 9.6 %, P = 0.31). Nor was it associated with reductions in anaemia, low birth weight or preterm delivery. P. falciparum with intense SP resistance (pfdhfr/pfdhps quintuple or sextuple mutations) were observed in 93 % (pfdhps 581G, 36 %), and the additional high resistance allele pfhdr 164L in 36 %. CONCLUSIONS: In Fort Portal, Uganda, reported use of IPTp with SP does not provide an observable benefit. The molecular markers of P. falciparum indicate high grade SP resistance reaching the threshold set by WHO for the discontinuation of IPTp with SP. Alternative approaches for the prevention of malaria in pregnancy are urgently needed.