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High prevalence of sexually transmitted infections (STIs) combined with poor antimicrobial stewardship are drivers of STI antimicrobial resistance (AMR) especially in resource-limited settings where syndromic case management (SCM) is the norm. We characterized patterns of antibiotic use prior to clinic attendance and study enrollment in Ugandan men with urethral discharge syndrome (UDS), evaluated in-clinic prescribing, and the performance characteristics of SCM. Participants were recruited from government clinics participating in an existing gonococcal surveillance program in Kampala, Uganda. Questionnaires including antimicrobial use prior to attendance, prior episodes of UDS, penile swabs, and blood samples were collected. Bivariable and multivariable logistic regression models were used to estimate odds ratios (OR) for preselected factors likely to be associated with antibiotic use. In-clinic antibiotic treatment data were extracted from clinical notes, and the performance of SCM against laboratory-based STI diagnoses was evaluated. Between October 2019 and November 2020, 100(40%) of 250 men with UDS reported taking antibiotics in the 14days prior to attending the clinic. Of these 210(84%) had at least one curable STI and 20% had a reactive point-of-care HIV test. Multivariable analysis demonstrated significant associations between recent antimicrobial use and duration of UDS symptoms <6 days (OR 2.98(95%CI 1.07,8.36), p = 0.038), and sex with women only (OR 0.08(95%CI 0.01,0.82),p = 0.038). The sensitivity of SCM ranged from 80.0% to 94.4%; specificity was low between 5.6% and 33.1%. The positive predictive value of SCM ranged from 2.4(95%CI 0.7,6.0) for trichomoniasis to 63.4(95%CI 56.5,69.9) for gonorrhea. Pre-enrollment antibiotic use was common in this population at high risk of STI and HIV. Combined with the poor specificity of SCM for male UDS, extensive antibiotic use is a likely driver of STI-AMR in Ugandan men. Interventions to improve antimicrobial stewardship and deliver affordable diagnostics to augment SCM and decrease overtreatment of STI syndromes are required.

Background Universal health coverage (UHC) embedded within the United Nations Sustainable Development Goals, is defined by the World Health Organization as all individuals having access to required health services, of sufficient quality, without suffering financial hardship. Effective strategies for financing healthcare are critical in achieving this goal yet remain a challenge in Sub-Saharan Africa (SSA). This systematic review aims to determine reported health financing mechanisms in SSA within the published literature and summarize potential learnings. Methods A systematic review was conducted aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. On 19 to 30 July 2019, MEDLINE, EMBASE, Web of Science, Global Health Database, the Cochrane Library, Scopus and JSTOR were searched for literature published from 2005. Studies describing health financing approaches for UHC in SSA were included. Evidence was synthesised in form of a table and thematic analysis. Results Of all records, 39 papers were selected for inclusion. Among the included studies, most studies were conducted in Kenya ( n  = 7), followed by SSA as a whole ( n  = 6) and Nigeria ( n  = 5). More than two thirds of the selected studies reported the importance of equitable national health insurance schemes for UHC. The results indicate that a majority of health care revenue in SSA is from direct out-of-pocket payments. Another common financing mechanism was donor funding, which was reported by most of the studies. The average quality score of all studies was 81.6%, indicating a high appraisal score. The interrater reliability Cohen’s kappa score, κ=0.43 ( p  = 0.002), which showed a moderate level of agreement. Conclusions Appropriate health financing strategies that safeguard financial risk protection underpin sustainable health services and the attainment of UHC. It is evident from the review that innovative health financing strategies in SSA are needed. Some limitations of this review include potentially skewed interpretations due to publication bias and a higher frequency of publications included from two countries in SSA. Establishing evidence-based and multi-sectoral strategies tailored to country contexts remains imperative.

Background The World Health Organisation approved boosted atazanavir as a preferred second line protease inhibitor in 2010. This is as an alternative to the current boosted lopinavir. Atazanavir has a lower genetic barrier than lopinavir. We compared the virological outcomes of patients during the roll out of routine viral load monitoring, who had switched to boosted second- line regimens of either atazanavir or lopinavir. Methods This was a cross-sectional study involving adult patients at the Infectious Diseases Institute Kampala, Uganda started on a standard WHO recommended second-line regimen containing either boosted atazanavir or boosted lopinavir between 1 Dec 2014 and 31 July 2015.. Mantel -Haenszel chi square was used to test for the statistical significance of the odds of being suppressed (VL < 400 copies/ml) when on boosted atazanavir compared to boosted lopinavir after stratifying by duration on antiretroviral therapy (ART). Multivariate logistic regression analysis used to determine if the type of boosted protease inhibitor (bPI) was associated with virological outcome. Results Ninety (90) % on ATV/r and 83% on LPV/r had a VL less than 1000 copies/ml. The odds of being suppressed using the same viral load cut-off while on boosted atazanavir compared to boosted lopinavir was not statistically significant after stratifying for duration on ART ( p  = 0.09). In a multivariate analysis the type of bPI used was not a predictor of virological outcome ( p  = 0.60). Conclusions Patients using the WHO recommended second-line of boosted atazanavir have comparable virological suppression to those on boosted lopinavir.

We evaluated the efficacy of a brief motivational intervention (MI) counseling in reducing alcohol consumption among persons living with HIV/AIDS in Kampala, Uganda. Persons living with HIV/AIDS with Alcohol Use Disorders Identification Tool (AUDIT) score ≥3 points were randomized to either standardized positive prevention counseling alone or in combination with alcohol brief MI counseling. The mean change in AUDIT-C scores over 6 months was compared by treatment arm. The mean (standard deviation [SD]) AUDIT-C scores were 6.3 (2.3) and 6.8 (2.3) for control and MI arms (P = .1) at baseline, respectively, and change in mean AUDIT-C score was not statistically different between arms over the 6 months (P = .8). However, there was a statistically significant decrease in mean AUDIT-C score (−1.10; 95% confidence interval: −2.19 to −0.02, P = .046) among women in the MI arm. There was a nondifferential reduction in alcohol consumption overall, but MI appeared effective among women only. Studies with more than 1 counseling session and evaluation of gender differences in treatment response are needed.

The effect of long-term exposure to antiretroviral therapy (ART) on hypertension in sub-Saharan Africa remains unclear. We aimed to determine the prevalence and incidence of hypertension in people living with HIV (PLWH) with more than 10 years of ART in Uganda. The analysis was performed within a cohort of adult PLWH with more than 10 years of ART at an HIV clinic in Kampala, Uganda. Participants were eligible for this analysis if they had ≥2 follow-up visits. Hypertension was defined as two consecutive systolic blood pressure (SBP) measures greater than 140 mmHg and/or diastolic blood pressure (DBP) greater than 90 mmHg, and/or documented diagnosis and/or the initiation of antihypertensives. We determined the proportion of PLWH with hypertension at baseline and used multivariable logistic regression to determine the factors associated with prevalent hypertension. To determine the incidence of hypertension, follow-up began from the cohort baseline date and was censored at the last clinic visit or date of the event, whichever occurred earlier. Multivariable Poisson regression was used to determine the adjusted incidence rate ratios (aIRR) of hypertension according to demographic, ART, and clinical characteristics. Of the 1000 ALT participants, 970 (97%) had ≥2 follow-up visits, and 237 (24.4%) had hypertension at baseline. The odds of prevalent hypertension were 1.18 for every 5-year increase in age (adjusted odds ratio (aOR) 1.18, 95% CI 1.10-1.34) and were higher among males (aOR 1.70, 95% CI 1.20-2.34), participants with diabetes mellitus (aOR 2.37, 95% CI 1.10-4.01), obesity (aOR 1.99, 95% CI 1.08-3.60), high cholesterol (aOR 1.47, 95% CI 1.16-2.01), and those with prior exposure to stavudine (aOR 2.10, 95% CI 1.35-3.52), or nevirapine (aOR 1.90, 95% CI 1.25-3.01). Of the 733 participants without hypertension at baseline, 116 (15.83%) developed hypertension during 4671.3 person-years of follow-up (incidence rate 24.8 per 1000 person-years; 95% CI 20.7-29.8). The factors associated with incident hypertension were obesity (adjusted incidence rate ratio (aIRR) 1.80, 95% CI 1.40-2.81), older age (aIRR 1.12 per 5-year increase in age, 95% CI 1.10,1.25), and renal insufficiency (aIRR1.80, 95% CI 1.40-2.81). The prevalence and incidence of hypertension were high in this heavily treated PLWH cohort. Therefore, with increasing ART coverage, HIV programs in SSA should strengthen the screening for hypertension in heavily treated PLWH.

In people living with HIV, adherence to antiretroviral therapy (ART) is essential for achieving and sustaining viral suppression and reducing mortality. In young people living with HIV, ART adherence and retention remain a challenge with unsatisfactory viral suppression rates despite facility-based intensive adherence counseling that is the standard of care. Few studies have evaluated mHealth adherence interventions among young people living with HIV in resource-limited settings. This was a randomized parallel trial. Young people aged between15-24 living with HIV, initiating ART, or on ART for not more than 6 months at three ART clinics were recruited and randomized to a ratio of 1:1 to either standard of care or the intervention \"Call for Life-Interactive Voice Response\" with standard of care, between 12th August 2020 and 1st June 2022. The intervention is mobile technology-based software, that has interactive voice response functionalities, with a web-based interface, that allows interaction through the use of voice and tones via a dial pad. The primary outcome was viral suppression defined as HIV RNA below 1,000 copies per mL at 12 months with retention in care and viral suppression at month 6 as a secondary outcome. Descriptive statistics were used for participant characteristics. Primary outcomes and factors associated with viral load failure were assessed using the log-binomial model. All calculations were done using statistical software release 16.0. A total of 206 participants were recruited and randomized; the mean age was 22.5(SD±1.9) years and 81% (167/206) were female. The intervention had 78.6% (81/103), females, while the standard of care had 83.5% (86/103). Viral suppression at 12 months in the intervention arm was 73.6% (67/91) versus 51.9% (40/77) in the standard of care arm, p=0.01. Retention in care was 88.4% (91/103) in the intervention vs. 74.7% (77/103) in the standard of care arm p=0.01. This is the first study in Uganda to demonstrate that mHealth has the potential to improve medication adherence and retention in care among youth living with HIV in Uganda. NCT04718974 Registry: clinical Trials.gov.

Sexually Transmitted Infections (STIs) rank in the top 5 disease categories for which adults in developing countries seek healthcare services. Community pharmacies offer clients convenience, proximity, extended opening hours, privacy, and efficiency, which could make them desirable locations for HIV and STI screening and treatment. We examined the feasibility of using point-of-care (POC) STI tests for screening HIV and other STIs at community pharmacies. We conducted a prospective cohort study of persons seeking medication and other services at 18 purposively selected community pharmacies in Kampala, Uganda. Study participants comprised two broad categories: i) Symptomatic persons aged 18 years who presented with at least one STI sign or symptom and were purchasing treatment for themselves; ii) persons presenting with no STI symptom who had come to purchase any other medication, including family planning services such as emergency contraception. POC tests were used to test HIV, Chlamydia trachomatis (Ct), Neisseria gonorrhoeae (Ng), Trichomonas vaginalis (Tv), and Syphilis. Test results were returned on-site or via telephone within 48 to 72 hours. Descriptive statistics were used to estimate the prevalence of STIs. Of the 450 participants enrolled, 235 (52.2%) were symptomatic, 215 (47.8%) were asymptomatic, and 280 (62.2%) were females. STI testing was feasible, with an acceptability rate of 99.8%. 135 (30%) of participants had at least one STI; HIV prevalence was 39 (8.7%), Syphilis prevalence was 14 (3.1%), 50 (11.1%) tested positive for Ng, 39 (8.7%) were positive for Ct while. The prevalence of Tv was 25 (8.9%) (tested among women). A total of 107 (23.8%) participants had used an antibiotic in the preceding month. Our research underscores the potentially pivotal role of community pharmacies in deploying POC diagnostics for STIs and antimicrobial stewardship by decreasing unnecessary antibiotic dispensation across Africa.

BackgroundDiscrepancies between what is transcribed and the actual interview recordings were noticed in qualitative research reports. This study aimed at the development of a new transcription software (Jiegnote), and the evaluation of its effectiveness in the optimization of the transcription process, to minimize transcription completion time, and errors in qualitative research.MethodsThe study was a mixed methods project implemented from September to November 2020. The qualitative aspect of the study was phenomenological in perspective whereas the quantitative consisted of a randomized controlled trial (RCT) with a parallel design.ResultsAt the time of the study, the Jiegnote software was a working prototype. We enrolled a total of 26 participants; 14 participants had their data analyzed in the RCT part of the study, 13 participated in the in-depth interviews, and 22 in the answering of Semi Structured Questionnaires. Upon the execution of an independent t test, results showed that, there was no statistical significance between the intervention and control means. On considering the total average transcription completion time and the type of language in which an audio case was recorded, the effect size evaluation implied that the Jiegnote software had a small impact (Hedges' g = 0.413438) in reducing the total average time taken to translate and transcribe audio cases that were recorded in a local language (Luganda), and a large impact (Hedges' g = 1.190919) in reducing the total average time taken to transcribe audio cases that were recorded in a foreign language (English). On considering the total average number of transcription errors and the type of language in which an audio case is recorded, the effect size evaluation implied that the Jiegnote software had a small impact (Hedges' g = 0.213258) in reducing the total average time taken to translate and transcribe audio cases that were recorded in a local language (Luganda). This was further observed (Hedges' g = 0.039928) in the transcription of cases that were recorded in a foreign language (English). On considering the in-depth interview data outcomes, participants responded that the Jiegnote software media looping functions (algorithm) enabled them to accomplish their transcription tasks in a shorter time and with fewer errors compared to the traditional methods.ConclusionThe study demonstrates utilities associated with intrapreneurship and technological innovation in an organization setting whereby, the Jiegnote technology that was developed by the researchers, had some impact on the optimization of the qualitative research value chain. This was observed through the effect size (impact) evaluations that were conducted to investigate the superiority of the Jiegnote software against the traditional transcription methods, in minimizing the average number of errors committed, and time taken to complete a transcription process.

BackgroundSexually transmitted infections (STIs) are a global health challenge. Testing is not routinely performed in low- and middle-income countries (LMICs), which bear a disproportionate burden of STIs. Self-collected penile-meatal swabs (SCPMS) are an alternative to urine for STI testing, but data from LMICs are limited.MethodsBetween October 2019 and September 2020, recruited participants with urethral discharge syndrome at government health facilities in Kampala, Uganda, provided urine and SCPMS. Samples were retrospectively analysed for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) using Aptima assays. Paired SCPMS and urine samples with discordant STI results were analysed using real-time PCR assays.ResultsOf the 250 participants, 66.8% (n=167), 22.8% (n=57), 12.8% (n=32) and 2.4% (n=6) tested positive for NG, CT, MG and TV, respectively, on testing of their SCPMS and urine samples. The overall agreement between urine and SCPMS for all STIs using the Aptima assays was 98.7% (987/1000). After adjudication with PCR assays, the agreement between urine and SCPMS for NG, CT, MG and TV was 100% (250/250), 97.6% (244/250), 99.6% (249/250), and 99.6% (249/250), respectively. There was no significant difference between SCPMS and urine (p=0.9996). For paired samples with one STI (n=164) or ≥2 STIs (n=39), concordance was 100% (656/656) and 97.2% (175/180), respectively. There was no association between number of STIs and agreement between sample types (p=0.8606).ConclusionsThis study revealed a high level of agreement between SCPMS and urine for detection of STIs in symptomatic Ugandan men, even in the presence of multiple concurrent STIs. SCPMS may be a suitable alternative to urine, with ease of collection, transporting, and processing of samples.

In conflict-affected settings, access to health care for displaced populations is constrained by barriers including geographical, cultural, communication, logistical, financial and insecurity. A six year humanitarian crises in the North West and South West regions of Cameroon has caused 27% of health facilities to be non-functional. The eleven year crisis in North-East Nigeria, has caused the closure of 26% of health facilities. These closure of health facilities and population displacement led to health care delivery using humanitarian funding by multiple different agencies. However, there is a paucity of evidence on the selection and design of the primary health care delivery models used in humanitarian settings. To ensure efficient use of resources and quality of services, model of care selection should be evidence based and informed by the specific humanitarian context. This research protocol aims to explore how primary health care models are selected by humanitarian organizations. We will conduct a cross sectional quantitative survey to map the range of primary health care delivery models used by humanitarian organisations in Cameroon and Nigeria. Using in-depth interviews and focus group discussions with staff from humanitarian organizations and internally displaced persons, we will explore the factors influencing the selection of primary health care models in these settings and determine the coverage and gaps in services across the different primary health care models. Quantitative data will be analysed in a descriptive manner and qualitative data will be analysed thematically. Different models of care have been reported to be used by humanitarian organisations in conflict-affected settings, yet evidence on how different models are selected is lacking. A detailed understanding of the rationale for selection, the design and quality considerations of the strategies used to deliver health care will be obtained using a survey, in-depth interviews and focus group discussions.