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Severely immunocompromised human immunodeficiency virus (HIV)-infected individuals have high mortality shortly after starting antiretroviral therapy (ART). We investigated predictors of early mortality and \"late presenter\" phenotypes. The Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children ≥5 years of age with CD4 counts <100 cells/µL initiating ART in Uganda, Zimbabwe, Malawi, and Kenya. Baseline predictors of mortality through 48 weeks were identified using Cox regression with backwards elimination (exit P > .1). Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P < .04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P = .02). Of five late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/µL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/µL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/µL), but low symptom burden and maintained fat mass. The remaining groups had 4%-6% mortality. Clinical and laboratory features identified groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up. ISRCTN43622374.

Introduction Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost‐effectiveness of this enhanced‐prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. Methods The REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. Results Enhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US $300 and US$ 500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US $157 per QALY in the CD4 <200 cells/mm3 population providing enhanced‐prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$ 113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US $722 per QALY). Results were sensitive to prices of the enhanced‐prophylaxis components. Enhanced‐prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced‐prophylaxis still conveyed health gains in CrAg‐negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost‐effective unless the price of CrAg testing fell below US$ 2.30. Conclusions The REALITY enhanced‐prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost‐effective. Efforts should continue to ensure that components are accessed at lowest available prices.

Many HIV?positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced?prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm[sup.3] . We investigated the cost?effectiveness of this enhanced?prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm[sup.3] or <100 cells/mm[sup.3] at ART initiation and all individuals regardless of CD4 count. The REALITY trial enrolled from June 2013 to April 2015. A decision?analytic model was developed to estimate the cost?effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard?prophylaxis, enhanced?prophylaxis, standard?prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced?prophylaxis (CrAg?positive) or standard?prophylaxis (CrAg?negative), the second to enhanced?prophylaxis (CrAg?positive) or enhanced?prophylaxis without fluconazole (CrAg?negative) and the third to standard?prophylaxis with fluconazole (CrAg?positive) or without fluconazole (CrAg?negative). The model estimated costs, life?years and quality?adjusted life?years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. The REALITY enhanced?prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost?effective. Efforts should continue to ensure that components are accessed at lowest available prices.

Purpose Libraries globally automate their operations and services using integrated library systems (ILS) to increase operational efficiency and meet the ever-evolving demands of their users. Open source ILS (OS ILS) has become more popular globally. The purpose of this paper is to better understand the diffusion of OS ILS in academic libraries in Uganda. Design/methodology/approach Rogers’ diffusion of innovation (DoI) supplemented by the fit-viability theory was used as a theoretical framework. A questionnaire was developed based on extant literature and distributed electronically to representative members of a Ugandan university library association. Findings The diffusion of OS ILS in Ugandan academic libraries approximates the S-curve expected based on DoI. Ugandan academic libraries are adopting OS ILS for more flexibility to meet changing needs at what is perceived as an affordable cost but not all are fully satisfied. Koha is the most adopted OS ILS and is also being considered by all libraries without any ILS or a proprietary ILS. The information and communication technology (ICT) infrastructure, organizational procurement policies and national procurement legislation, human resource capacity and limited finances are barriers to diffusion. The total cost of ownership and technical skills required are of particular concern for OS ILS. Research limitations/implications The research was limited to a single African country and the recommendations may not be transferable to other African countries. Future research can expand the survey, the countries studied and/or address the methodological limitations of this study. Practical implications When embarking upon library automation using OS ILS or migrating to an OS ILS solution libraries should consider their ICT infrastructure, local support community, available training and be realistic about the costs. Local library associations should provide guidance on OS ILS selection, ongoing training, and opportunities for knowledge sharing. LIS schools should consider expanding their curriculum to include library automation and, in Uganda incorporate training on Koha as OS ILS. Libraries and library associations should advocate to reduce restrictive organizational procurement policies and national procurement legislation. Originality/value Studies on country-level diffusion of ILS are comparatively few, particularly in African countries. This is the first country-level study of OS ILS diffusion in Uganda. This study can positively impact future patterns of diffusion for optimal deployment of OS ILS software by informing academic libraries, university management, library association, LIS schools, and policymakers in Uganda and across the African continent, and encouraging academics and researchers to teach and study library automation using OS ILS.

Background Female Anopheles mosquitoes are the primary vectors for malaria transmission within communities, significantly contributing to the high burden of malaria in Africa overall and Uganda specifically. Many tropical plants have insect-repellent properties and have traditionally been used in their native regions to prevent mosquito bites. Methods A cross-sectional ethnobotanical survey was conducted between January 2025 and May 2025 in five districts of the West Nile Subregion: Adjumani, Moyo, Madi-Okollo, Pakwach, and Obongi. Semi-structured questionnaires were used to collect data on indigenous knowledge about mosquito repellents from 57 respondents, who were selected through purposive and snowball sampling techniques. The ethnobotanical data were analyzed using descriptive statistics, the informant consensus factor, and preference ranking. Results A total of 42 plant species from 40 genera and 25 families were documented as being used to repel mosquitoes. The plants most commonly used for this purpose were: Azadirachta indica  A.Juss. (9) , Boswellia papyrifera (Caill.) (7), Aeschynomene american a L. (6), Mesosphaerum suaveolens (L.) Kuntze. (6), and Ocimum gratissimum L. (5). The most common indigenous method for repelling mosquitoes involves burning either dry cow dung (32%) or dry goat droppings (20%). Most of the plant species belong to the families Fabaceae (10), Lamiaceae (4), and Asteraceae (3). The majority of the plant species used were trees (43%) and herbs (42%), with leaves (42%) and seeds (12%) being the most frequently used plant parts. Except for Cymbopogon citratus (DC.) Stapf and M. suaveolens, which are used as live plants for repelling mosquitoes, all other plant species used were prepared by burning or smoking indoors. Conclusions Communities in the West Nile Subregion, especially those living along the River Nile, possess rich indigenous knowledge and practices used to repel mosquitoes in their efforts to control deadly malaria.

Alternaria is a plant pathogen and human allergen. Alternaria alternata is one of the most abundant fungal spores in the air. The purpose of this study was to examine whether Alternaria spp. spore concentrations can be used to predict the abundance and spatio-temporal pattern of A. alternata spores in the air. This was investigated by testing the hypothesis that A. alternata dominates airborne Alternaria spp. spores and varies spatio-temporally. Secondarily, we aimed at investigating the relationship between airborne Alternaria spp. spores and the DNA profile of A. alternata spores between two proximate (~ 7 km apart) sites. These were examined by sampling Alternaria spp. spores using Burkard 7-day and cyclone samplers for the period 2016–2018 at Worcester and Lakeside campuses of the University of Worcester, UK. Daily Alternaria spp. spores from the Burkard traps were identified using optical microscopy whilst A. alternata from the cyclone samples was detected and quantified using quantitative polymerase chain reaction (qPCR). The results showed that either A. alternata or other Alternaria species spores dominate the airborne Alternaria spore concentrations, generally depending on weather conditions. Furthermore, although Alternaria spp. spore concentrations were similar for the two proximate sites, A. alternata spore concentrations significantly varied for those sites and it is highly likely that the airborne samples contained large amounts of small fragments of A. alternata. Overall, the study shows that there is a higher abundance of airborne Alternaria allergen than reported by aerobiological networks and the majority is likely to be from spore and hyphal fragments.