Correction: Experiences of doctoral students enrolled in a research fellowship program to support doctoral training in Africa (2014 to 2018): The Consortium for Advanced Research Training in Africa odyssey.

[This corrects the article DOI: 10.1371/journal.pone.0252863.].

The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21).

Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.

Experiences of membership in munno mubulwadde (your friend indeed) - a novel community-based health insurance scheme in Luwero district in rural central Uganda.

BACKGROUND: Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme. METHODS: We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach. RESULTS: Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment. CONCLUSION: Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings.

Managing transitions from external assistance: cross-national learning about sustaining effective coverage.

The often-prominent role of external assistance in health financing in low- and middle-income countries raises the question of how such resources can enable the sustained or even expanded coverage of key health services and initiatives even after donor funding is no longer available. In response to this question, this paper analyses the process and outcomes of donor transitions in health-where countries or regions within countries are no longer eligible to receive grants or concessional loans from external sources based on eligibility criteria or change in donor policy. The comparative analysis of multiple donor transitions in four countries-China, Georgia, Sri Lanka and Uganda-identifies 16 factors related to policy actors, policy process, the content of donor-funded initiatives and the broader political-economic context that were associated with sustained coverage of previously donor supported interventions. From a contextual standpoint, these factors relate to favourable economic and political environments for domestic systems to prioritize coverage for donor-supported interventions. Clear and transparent transition processes also enabled a smoother transition. How the donor-supported initiatives and services were organized within the context of the overall health system was found to be critically important, both before and during the transition process. This includes a targeted approach to integrate, strengthen and align key elements of the governance, financing, input management and service delivery arrangements with domestic systems. The findings of this analysis have important implications for how both donors and country policy makers can better structure external assistance that enables sustained coverage regardless of the source of funding. In particular, donors can better support sustained coverage through supporting long-term structural and institutional reform, clear co-financing policies, ensuring alignment with local salary scales and engaging with communities to ensure a continued focus on equitable access post-transition.

Guidelines for the establishment and functioning of Animal Ethics Commitees (Institutional Animal Care and Use Committees) in Africa.

Animals are used for scientific purposes across Africa to benefit humans, animals or the environment. Nonetheless, ethical and regulatory oversight remains limited in many parts of the continent. To strengthen this governance framework, the Pan-African Network for Laboratory Animal Science and Ethics brought together experts from 12 African countries to create an Africa-centric practical guide to facilitate the establishment and appropriate functioning of Institutional Animal Ethics Committees across Africa. The Guidelines are based on universal principles for the care and use of sentient animals for scientific purposes, with consideration of the cultural, religious, political and socio-economic diversity in Africa. They focus on 11 key elements, including responsibilities of institutions and of the Institutional Official; composition of the Committee; its responsibilities, functioning and authority; ethical application and review processes; oversight and monitoring of animal care and use and of training and competence; quality assurance; and the roles of other responsible parties. The intent is for African institutions to adopt and adapt the guidelines, aligning with existing national legislation and standards where relevant, thus ensuring incorporation into practice. More broadly, the Guidelines form an essential component of the growing discourse in Africa regarding moral considerations of, and appropriate standards for, the care and use of animals for scientific purposes. The increased establishment of appropriately functioning animal ethics committees and robust ethical review procedures across Africa will enhance research quality and culture, strengthen societal awareness of animals as sentient beings, improve animal well-being, bolster standards of animal care and use, and contribute to sustainable socio-economic development.

"Here, your only relative is money " why slum social networks do not facilitate neighborhood community development: insights through a sanitation lens.

INTRODUCTION: Though social networks which are deemed vehicles of community development exist in slum areas, underdevelopment still persists in these areas. We explored the nature and role of social networks in facilitating community development in the slums of Kampala through a sanitation lens. METHODS: Qualitative Social Network Analysis (SNA) was done to understand the nature of slum social networks primarily through the analysis of sanitation behavior. Data were collected through six Focus Group Discussions (FGD), six In-depth Interviews (IDIs), and 18 Key Informant Interviews (KII) with Government, civil society and private stakeholders. We used both inductive and deductive thematic analysis. RESULTS: Four themes emerged in our analysis; i); Unsupportive environments, uncooperative neighbours and uncertainty of tenure: participants reported slums as unsupportive of community development due to a shortage of space, poverty and unplanned services. Tenants perceived landlords as exploitative and predatory and wished the tables are turned. This notion of cyclic exploitation did not encourage collective action for community good. Short-term economic survival trumped long-term community interests ii) Patronage and poor service delivery: varying degrees of patronage led to multiple forms of illegalities and violations such as tax evasion. Due to vested interests and corruption among public officials, the slum population was lethargic. iii) Intersecting realities of poverty and unemployment: slum dwellers lived on the margins daily. Hence, poor living conditions were a secondary concern. iv) Social relations for personal development: Slum social networks were driven by individual interests rather than community good. Slum dwellers prioritized connections with people of common socio-economic interests. As such social networks were instrumental only if they 'added value'. CONCLUSION: Social networks in slums are only concerned about survival needs. Slums require responses that address the complexity of slum formation and broader livelihood challenges, as well as re-assessing the meaning of community. We posit that more needs to be done in understanding the meaning and workings of a sociology beyond physical societies. Poverty is a modifier of social systems and processes and should be a concern for all stakeholders involved in slum development.

Decolonizing global health: an agenda for research.

This editorial outlines the background to the BMC Health Services Research collection on decolonizing global health. The discourse on decolonizing global health is gaining increasing momentum. These persistent 'voices' have coalesced into a 'movement'. Several commentators have critiqued the way global health continues to be structured and practiced. The colonial roots of global health dominance have come under an unprecedentedly intense spotlight amid pressure for reform.

The impact of donor transition on continuity of maternal and newborn health service delivery in Rwenzori sub-region of Uganda: a qualitative country case study analysis.

BACKGROUND: The transition of donor-supported health programmes to country ownership is gaining increasing attention due to reduced development assistance for health globally. It is further accelerated by the ineligibility of previously Low-Income Countries' elevation into Middle-income status. Despite the increased attention, little is known about the long-term impact of this transition on the continuity of maternal and child health service provision. Hence, we conducted this study to explore the impact of donor transition on the continuity of maternal and newborn health service provision at the sub-national level in Uganda between 2012 and 2021. METHODS: We conducted a qualitative case study of the Rwenzori sub-region in mid-western Uganda which benefited from a USAID project to reduce maternal and newborn deaths between 2012 and 2016. We purposively sampled three districts. Data were collected between January and May 2022 among subnational key informants (n = 26), national level key informants at the Ministry of Health [3], national level donor representatives [3] and subnational level donor representatives [4] giving a total of 36 respondents. Thematic analysis was deductively conducted with findings structured along the WHO's health systems building blocks (Governance, Human resources for health, Health financing, Health information systems, medical products, Vaccines and Technologies and service delivery) framework. RESULTS: Overall, continuity of maternal and newborn health service provision was to a greater extent maintained post-donor support. The process was characterised by a phased implementation approach. The embedded learning offered the opportunity to plough back lessons into intervention modification which reflected contextual adaptation. The availability of successor grants from other donors (such as Belgian ENABEL), counterpart funding from the government to bridge the gaps left behind, absorption of USAID-project salaried workforce (such as midwives) onto the public sector payroll, harmonisation of salary structures, the continued use of infrastructure (such as newborn intensive care units), and support for MCH services under PEPFAR support post-transition contributed to the maintenance of coverage. The demand creation for MCH services pre-transition ensured patient demand post-transition. Challenges to the maintenance of coverage were drug stockouts and sustainability of the private sector component among others. CONCLUSION: A general perception of the continuity of maternal and newborn health service provision post-donor transition was observed with internal (government counterpart funding) and external enablers (successor donor funding) contributing to this performance. Opportunities for the continuity of maternal and newborn service delivery performance post-transition exist when harnessed well within the prevailing context. The ability to learn and adapt, the presence of government counterpart funding and commitment to carry on with implementation were major ingredients signalling a crucial role of government in the continuity of service provision post-transition.

Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition.

Introduction Donor transition for HIV/AIDS programmes remains sensitive, marking a significant shift away from the traditional investment model of large-scale, vertical investments to control the epidemic and achieve rapid scaling-up of services. In late 2015, the United States President's Emergency Plan for AIDS Relief (PEPFAR) headquarters instructed their country missions to implement 'geographic prioritisation' (GP), whereby PEPFAR investments would target geographic areas with high HIV burden and reduce or cease support in areas with low burden.Methods Using Gaventa's power cube framework, we compare how power is distributed and manifested using qualitative data collected in an evaluation of the GP's impact in Kenya and Uganda.Results We found that the GP was designed with little space for national and local actors to shape either the policy or its implementation. While decision-making processes limited the scope for national-level government actors to shape the GP, the national government in Kenya claimed such a space, proactively pressuring PEPFAR to change particular aspects of its GP plan. Subnational level actors were typically recipients of top-down decision-making with apparently limited scope to resist or change GP. While civil society had the potential to hold both PEPFAR and government actors accountable, the closed-door nature of policy-making and the lack of transparency about decisions made this difficult.Conclusion Donor agencies should exercise power responsibly, especially to ensure that transition processes meaningfully engage governments and others with a mandate for service delivery. Furthermore, subnational actors and civil society are often better positioned to understand the implications and changes arising from transition. Greater transparency and accountability would increase the success of global health programme transitions, especially in the context of greater decentralisation, requiring donors and country counterparts to be more aware and flexible of working within political systems that have implications for programmatic success.

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll.

BACKGROUND: Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017. METHODS: We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers. RESULTS: At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future. CONCLUSIONS: Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.

Understanding Uganda's early adoption of novel differentiated HIV treatment services: a qualitative exploration of drivers of policy uptake.

BACKGROUND: Although differentiated service delivery (DSD) for HIV treatment was endorsed by the WHO in its landmark 2016 guidelines to lessen patients' need to frequently visit clinics and hence to reduce unnecessary burdens on health systems, uptake has been uneven globally. This paper is prompted by the HIV Policy Lab's annual report of 2022 which reveals substantial variations in programmatic uptake of differentiated HIV treatment services across the globe. We use Uganda as a case study of an 'early adopter' to explore the drivers of programmatic uptake of novel differentiated HIV treatment services. METHODS: We conducted a qualitative case-study in Uganda. In-depth interviews were held with national-level HIV program managers (n = 18), district health team members (n = 24), HIV clinic managers (n = 36) and five focus groups with recipients of HIV care (60 participants) supplemented with documentary reviews. Our thematic analysis of the qualitative data was guided by the Consolidated Framework for Implementation Research (CFIR)'s five domains (inner context, outer setting, individuals, process of implementation). RESULTS: Our analysis reveals that drivers of Uganda's 'early adoption' of DSD include: having a decades-old HIV treatment intervention implementation history; receiving substantial external donor support in policy uptake; the imperatives of having a high HIV burden; accelerated uptake of select DSD models owing to Covid-19 'lockdown' restrictions; and Uganda's participation in clinical trials underpinning WHO guidance on DSD. The identified processes of implementation entailed policy adoption of DSD (such as the role of local Technical Working Groups in domesticating global guidelines, disseminating national DSD implementation guidelines) and implementation strategies (high-level health ministry buy-in, protracted patient engagement to enhance model uptake, devising metrics for measuring DSD uptake progress) for promoting programmatic adoption. CONCLUSION: Our analysis suggests early adoption derives from Uganda's decades-old HIV intervention implementation experience, the imperative of having a high HIV burden which prompted innovations in HIV treatment delivery as well as outer context factors such as receiving substantial external assistance in policy uptake. Our case study of Uganda offers implementation research lessons on pragmatic strategies for promoting programmatic uptake of differentiated treatment HIV services in other countries with a high HIV burden.

Facilitators and Barriers to Uptake of the Med Safety Mobile App for Adverse Drug Reaction Reporting by Health Workers in Uganda: A Qualitative Study.

INTRODUCTION: Adverse drug reactions (ADRs) are an important public health challenge worldwide; however, pharmacovigilance systems are plagued by under-reporting. Mobile technologies, including mobile applications such as Med Safety, could strengthen ADR reporting. We explored the acceptability, and factors that could influence uptake of, Med Safety for ADR reporting by health workers in Uganda. METHODS: The study took place between July and September 2020 in 12 HIV clinics in Uganda and employed a qualitative exploratory research design. We conducted 22 in-depth interviews and 3 mixed-gender focus group discussions (49 participants) with a diverse range of health workers. We analysed the data using a thematic approach. RESULTS: There was goodwill among the health workers to adopt Med Safety for ADR reporting and the majority would recommend the app to other health workers. Training with practice increased acceptability of the app. Uptake of the app was favoured by the younger, technology proficient, health worker demographic; the app's offline and two-way risk communication functionalities; availability of free internet hotspots at some health facilities; goodwill and willingness of health workers to report ADRs; and the cumbersome nature of conventional ADR reporting tools. Potential barriers to the uptake of Med Safety were the perceived lengthy processes of initial app registration and completion of multiple screens during ADR reporting; challenges with health workers' smartphones (incompatibility with application, no space for more applications, low battery charge); high cost of internet data; poor internet connectivity; difficulty in recognising ADRs, language barrier and poor feedback to ADR reporters. CONCLUSION: There was goodwill among the health workers to adopt Med Safety for ADR reporting and the majority would recommend the app to other health workers. Training with practice increased acceptability of the app and should be integral in all future app roll-out campaigns. The identified facilitators and barriers could be used to appropriately guide future research and implementation to promote the uptake of Med Safety for pharmacovigilance in low- and middle-income countries.

Containing COVID-19 and the social costs on human rights in African countries.

Multiple social interventions were introduced to contain the COVID-19 pandemic across Africa, limiting social engagement, school and workplace attendance, and travel. In anticipation of negative economic consequences and social impact, many governments introduced cash transfers, social pensions, food aid, and utility and tax waivers. However, people living precariously and/or under conditions of structural vulnerability were often unable to access to this support. A rapid review was undertaken on COVID-19 and the effects of interventions on human rights in African countries, examining primary studies, editorial notes, opinion papers, and literature reviews, with focus on qualitative approaches and discussions. In examining the links between health, human rights and non-pharmaceutical interventions on vulnerable populations, the review identified that: (1) people who were vulnerable were excluded from or not adequately represented in policy responses to COVID-19; (2) the precarious socio-economic conditions of these populations were not adequately addressed by dominant policy responses; and (3) only partial support was offered to those whose relationship with the state was ambiguous or conditional, so compromising human rights. Interactions between health, human rights, and underlying social and economic conditions amplified poor health and impoverishment of those who were already vulnerable. The challenge is to find a balance between stopping the spread of COVID-19 and the protection of human rights; to implement population-specific responses to supplement uniform public health responses; and to address causes (structural vulnerability) rather than symptoms. There is a need to plan rather than react to pandemics, and to co-construct interventions with rather than delivering instructions to populations. These recommendations serve as instruments to be considered when designing new policies, to incorporate a human rights perspective in responses to current and future pandemics.

Patient experiences of sexual dysfunction after transition to dolutegravir-based HIV treatment in mid-Western Uganda: a qualitative study.

BACKGROUND: The literature on dolutegravir (DTG)-based HIV treatment has focused on assessing therapeutic efficacy particularly with regard to viral load suppression. However, little empirical attention has been devoted to understanding the effects of DTG on quality of life, in particular sexual health and functioning in PLHIV. This study focused on understanding patient experiences of sexual dysfunction, after transition to DTG-based regimens in Rwenzori region in Mid-Western Uganda. METHODS: We adopted a qualitative exploratory research design. Between August and September 2021, we conducted sixteen in-depth interviews and six focus group discussions (48 participants) with patients reporting 'new' sexual dysfunction after transition to DTG-based regimens at seven health facilities in mid-Western Uganda. Data were analyzed by thematic approach. RESULTS: Decreased libido was reported in both sexes of patients within weeks of transition to DTG-based regimens. Diminished interest in sex was more frequently reported among women while men complained of a marked reduction in the frequency of sex. Women reported loss of psycho-social attraction to their long-term male partners. Erectile dysfunction was common among men in this sample of patients. Patients described their experiences of sexual dysfunction as an affront to their socially-constructed gender identities. Patients described tolerating sexual adverse drug reactions (ADRs) as a necessary tradeoff for the extension in life granted through antiretroviral therapy. A number of women reported that they had separated from their spouses as a result of perceived drug-induced sexual dysfunction. Marital strife and conflict arising from frustration with sexual-partner dysfunction was frequently reported by participants in both sexes. Several participants indicated experiencing insecurity in their heterosexual relationships due to difficulties in sexual functioning. CONCLUSION: Sexual dysfunction following transition to DTG-based regimens is common in both sexes of PLHIV, who indicated that they had no prior experience of difficulties in sexual health. Our findings demonstrate that sexual ADRs negatively impact self-esteem, overall quality of life and impair gender relations. DTG-related sexual health problems merit increased attention from HIV clinicians. Further research is warranted to assess the prevalence of DTG-associated sexual dysfunction in patients in Uganda.

Implementation of a peer support intervention to promote the detection, reporting and management of adverse drug reactions in people living with HIV in Uganda: a protocol for a quasi-experimental study.

INTRODUCTION: Patients have contributed <1% of spontaneous adverse drug reaction (ADR) reports in Uganda's pharmacovigilance database. Peer support combined with mobile technologies could empower people living with HIV (PLHIV) to report ADRs and improve ADR management through linkage to care. We seek to test the feasibility and effect of a peer support intervention on ADR reporting by PLHIV receiving combination antiretroviral therapy (cART) in Uganda; identify barriers and facilitators to the intervention; and characterise ADR reporting and management. METHODS AND ANALYSIS: This is a quasi-experimental study to be implemented over 4 months at 12 intervention and 12 comparison cART sites from four geographical regions of Uganda. Per region, two blocks each with a tertiary, secondary and primary care cART site will be selected by simple random sampling. Blocks per region will be randomly assigned to intervention and comparison arms.Study units will include cART sites and PLHIV receiving cART. PLHIV at intervention sites will be assigned to peer supporters to empower them to report ADRs directly to the National Pharmacovigilance Centre (NPC). Peer supporters will be expert clients from among PLHIV and/or recognised community health workers.Direct patient reporting of ADRs to NPC will leverage the Med Safety App and toll-free unstructured supplementary service data interface to augment traditional pharmacovigilance methods.The primary outcomes are attrition rate measured by number of study participants who remain in the study until the end of follow-up at 4 months; and number of ADR reports submitted to NPC by PLHIV as measured by questionnaire and data abstraction from the national pharmacovigilance database at baseline and 4 months. ETHICS AND DISSEMINATION: The study received ethical approval from: School of Health Sciences Research and Ethics Committee at Makerere University (MAKSHSREC-2020-64) and Uganda National Council for Science and Technology (HS1206ES). Results will be shared with PLHIV, policy-makers, the public and academia. TRIAL REGISTRATION NUMBER: ISRCTN75989485.

Provider perspectives on the acceptability and tolerability of dolutegravir-based anti-retroviral therapy after national roll-out in Uganda: a qualitative study.

BACKGROUND: The World Health Organization recommends dolutegravir (DTG) as the for first-line and second-line antiretroviral therapy (ART) worldwide. However, little is known about the acceptability and tolerability of DTG-based ART at routine points-of-care in Uganda. We set out to explore the perceptions of clinicians in ART clinics regarding the acceptability and tolerability of DTG-based ART since national roll-out in March 2018 in Uganda. METHODS: We adopted a qualitative exploratory design involving 49 participants. Between September 2020 and February 2021, we conducted 22 in-depth interviews with clinicians in the ART clinics of 12 purposively selected health facilities across Uganda. The selection of study sites ensured diversity in facility ownership-type (public/private), level of service delivery (tertiary/secondary/primary) and the four major geographic sub-regions of Uganda. We conducted three focus group discussions with 27 clinicians in the participating facilities. Data were analyzed by thematic approach. RESULTS: Clinicians in ART clinics acknowledged that DTG-based ART is well tolerated by the majority of their patients who appreciate the reduced pill burden, perceived less side effects and superior viral load suppression. However, they reported that a number of their patients experience adverse drug reactions (ADRs) after being transitioned to DTG. Hyperglycemia is, by far, the most commonly reported suspected ADR associated with DTG-based regimens and was cited in all but two participating facilities. Insomnia, weight gain and reduced libido are among the other frequently cited suspected ADRs. In addition, clinicians in ART clinics perceived some of the suspected ADRs as resulting from drug interactions between dolutegravir and isoniazid. Weak diagnostic capacities and shortage of associated commodities (e.g. glucometers and test kits) were reported as impediments to understanding the full extent of ADRs associated DTG-based ART. CONCLUSION: While DTG-based regimens were perceived by clinicians in ART clinics to be well tolerated by the majority of their patients, they also reported that a number of patients experience suspected ADRs key among which were hyperglycemia, insomnia and reduced libido. Based on the perspectives of clinicians, we recommend that future studies examine the prevalence of dolutegravir-induced hyperglycemia in patients in Uganda.

Community-funded integrated care outreach clinics as a capacity building strategy to expand access to health care in remote areas of Uganda.

Most Ugandans live in rural, medically underserved communities where geography and poverty lead to reduced access to healthcare. We present a novel low-cost approach for supplemental primary care financing through 1) pooling community wealth to cover overhead costs for outreach clinic activities and 2) issuing microfinance loans to motorcycle taxi entrepreneurs to overcome gaps in access to transportation. The intervention described here, which leverages community participation as a means to extend the reach of government health service delivery, was developed and implemented by Health Access Connect (HAC), a non-governmental organization based in Uganda. HAC began its work in August 2015 in the Lake Victoria region and now serves over 40 sites in Uganda across 5 districts, helping government health-care workers to provide over 1,300 patient services per month (and over 35,000 since the program's inception) with an average administrative cost of $6.24 per patient service in 2020. In this article, we demonstrate how integrated and appropriately resourced monthly outreach clinics, based on a microfinance-linked model of wealth pooling and government cooperation, can expand the capacity of government-provided healthcare to reach more patients living in remote communities. This scalable, sustainable, and flexible model is responsive to shifting needs of patients and health systems and presents an alternative approach to healthcare financing in low-resource settings. More rigorous evaluation of health outcomes stemming from such community-based models of service delivery is warranted.

Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda.

BACKGROUND: The notion of health-system resilience has received little empirical attention in the current literature on the Covid-19 response. We set out to explore health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. METHODS: We conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, we conducted qualitative interviews with district health team leaders (n = 9), ART clinic managers (n = 36), representatives of PEPFAR implementing organizations (n = 6).In addition, six focus group discussions were held with recipients of HIV care (48 participants). Qualitative data were analyzed using thematic approach. RESULTS: Five broad strategies for distributing antiretrovirals during 'lockdown' emerged in our analysis: accelerating home-based delivery of antiretrovirals,; extending multi-month dispensing from three to six months for stable patients; leveraging the Community Drug Distribution Points (CDDPs) model for ART refill pick-ups at outreach sites in the community; increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings. District health teams reported leveraging Covid-19 outbreak response funding to deliver ART refills to homesteads in rural communities. CONCLUSION: While Covid-19 'lockdown' restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.

Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda.

INTRODUCTION: In 2015, the President's Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda. METHODS: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners. RESULTS: In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing. DISCUSSION: Loss of external support for outreach raises concerns for countries' ability to reach the 90-90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected. CONCLUSION: Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level.