Elly Katabira

HIV prevention transformed: the new prevention research agenda

We have entered a new era in HIV prevention whereby priorities have expanded from biomedical discovery to include implementation, effectiveness, and the effect of combination prevention at the population level. However, gaps in knowledge and implementation challenges remain. In this Review we analyse trends in the rapidly changing landscape of HIV prevention, and chart a new path for HIV prevention research that focuses on the implementation of effective and efficient combination prevention strategies to turn the tide on the HIV pandemic.

Enabling Dynamic Partnerships through Joint Degrees between Low- and High-Income Countries for Capacity Development in Global Health Research: Experience from the Karolinska Institutet/Makerere University Partnership

Enabling Dynamic Partnerships through Joint Degrees between Low- and High-Income Countries for Capacity Development in Global Health Research : Experience from the Karolinska Institutet/Makerere University Partnership

Validation of World Health Organisation HIV/AIDS Clinical Staging in Predicting Initiation of Antiretroviral Therapy and Clinical Predictors of Low CD4 Cell Count in Uganda

Introduction The WHO clinical guidelines for HIV/AIDS are widely used in resource limited settings to represent the gold standard of CD4 counts for antiviral therapy initiation. The utility of the WHO-defined stage 1 and 2 clinical factors used in WHO HIV/AIDS clinical staging in predicting low CD4 cell count has not been established in Uganda. Although the WHO staging has shown low sensitivity for predicting CD4<200cells/mm3, it has not been evaluated at for CD4 cut-offs of <250cells/mm3 or <350 cells/mm3. Objective To validate the World Health Organisation HIV/AIDS clinical staging in predicting initiation of antiretroviral therapy in a low-resource setting and to determine the clinical predictors of low CD4 cell count in Uganda. Results Data was collected on 395 participants from the Joint Clinical Research Centre, of whom 242 (61.3%) were classified as in stages 1 and 2 and 262 (68%) were females. Participants had a mean age of 36.8 years (SD 8.5). We found a significant inverse correlation between the CD4 lymphocyte count and WHO clinical stages. The sensitivity the WHO clinical staging at CD4 cell count of 250 cells/mm3 and 350cells/mm3 was 53.5% and 49.1% respectively. Angular cheilitis, papular pruritic eruptions and recurrent upper respiratory tract infections were found to be significant predictors of low CD4 cell count among participants in WHO stage 1 and 2. Conclusion The WHO HIV/AIDS clinical staging guidelines have a low sensitivity and about half of the participants in stages 1 and 2 would be eligible for ART initiation if they had been tested for CD4 count. Angular cheilitis and papular pruritic eruptions and recurrent upper respiratory tract infections may be used, in addition to the WHO staging, to improve sensitivity in the interim, as access to CD4 machines increases in Uganda.

Palliative Care Research in Africa: Consensus Building for a Prioritized Agenda

CONTEXTnPalliative care research in Africa is in its relative infancy, with dedicated financial support extremely limited. Therefore, setting research priorities to optimize use of limited resources is imperative.nnnOBJECTIVESnTo develop a prioritized research agenda for palliative care in Africa.nnnMETHODSnWe used a two-stage process involving palliative care professionals and researchers: 1) generation of an initial topic list at a consultative workshop of experts and 2) prioritization of that list using a consensus development process, the nominal group technique.nnnRESULTSnPhase 1: 41 topics were generated across five groups, with several topics nominated in more than one group. Phase 2: 16 topics and three broad thematic areas were identified. The two most prioritized topics within each of the three themes were the following: Theme 1: patient, family, and volunteers-1) care outcomes and the impact of palliative care as perceived by patients and caregivers and 2) palliative care needs of children; Theme 2: health providers-1) impact of palliative care training on care and practice and 2) integration of palliative care and antiretroviral therapy services; and Theme 3: health systems-1) palliative care needs assessments at the micro-, meso-, and macro-levels and 2) integration of palliative care into health systems and educational curricula.nnnCONCLUSIONnConsensus-based palliative care topics determined by the study can assist researchers in optimizing limited research capacities by focusing on these prioritized areas. Subsequent to the identification and publication of the research agenda, concrete steps will be undertaken by the African Palliative Care Research Network and other partners to help implement it.

Cancer Pain Management in Resource-Limited Settings: A Practice Review

Pain in cancer is a common and burdensome symptom with different causes but in a significant number of cases it is undiagnosed and undertreated because of lack of skills for its assessment. Pain has significant negative impact on the patient and, therefore, it needs to be managed urgently and appropriately. In resource-limited settings, there are several barriers and challenges to pain management but even in these circumstances pain can be well managed with planned and innovative use of resources and if the World Health Organization public health system approach is used to ensure opioid availability.

Cognitive Dysfunction among HIV Positive and HIV Negative Patients with Psychosis in Uganda

Background Cognitive impairment is an established phenomenon in HIV infected individuals and patients that have psychosis. However there is need to establish the severity of the impairment if patients are co morbid with both conditions. Aim To compare cognitive function among HIV positive individuals and HIV negative individuals with psychosis. Methods We recruited patients with psychosis at two national referral hospitals. A standardized demographics questionnaire and psychiatric, physical, and laboratory assessments were conducted. Types of psychosis were diagnosed using the Mini International Neuropsychiatric Inventory-PLUS while cognitive functioning was determined using the Mini mental state examination (MMSE) and a neuropsychological test battery. Follow-up assessments on cognitive function and severity of psychiatric illness were performed at 3 and 6 months. Pairwise comparison and multivariable logistic regression analysis were used to determine the differences between the HIV positive and HIV negative individuals. Results There were 156 HIV positive and 322 HIV negative participants. The mean age was 33 years for the HIV positive group and 29 years for the HIV negative group (p<0.001). The HIV positive individuals were almost three times (ORu200a=u200a2.62 CI 95% 1.69–4.06) more likely to be cognitively impaired on the MMSE as well as the following cognitive tests:- WHO-UCLA Auditory Verbal Learning Test (OR 1.79, 95% CI 1.09–2.92), Verbal Fluency (OR 3.42, 95% CI 2.24–5.24), Color Trails 1 (OR 2.03, 95% CI 1.29–3.02) and Color Trails 2 (OR 3.50 95% 2.00–6.10) all pu200a=u200a0.01. There was improvement in cognitive function at follow up; however the impairment remained higher for the HIV positive group (p<0.001). Conclusion Cognitive impairment in psychosis was worsened by HIV infection. Care plans to minimize the effect of this impairment should be structured for the management of individuals with HIV and psychosis.

The frequency and precipitating factors for breakthrough seizures among patients with epilepsy in Uganda

BackgroundEpilepsy is one of the major brain disorders worldwide. Breakthrough seizures carry a heavy burden of epilepsy, with increased morbidity and risk of premature mortality. Several factors have been suggested to precipitate break through seizures but these have not been studied in our setting. The study sought to determine the prevalence of breakthrough seizures, as well as precipitating factors in adults with epilepsy attending Mulago hospital.MethodsThis study was conducted in Mulago Hospital, using a cross sectional study design between August and December 2009. Subjects with epilepsy and had been receiving anti-epileptics treatment for at least 6xa0months prior to the study were consecutively enrolled.ResultsA total of 256 patients with epilepsy were recruited. Prevalence of breakthrough seizures among epilepsy patients attending Mulago hospital was 75.3%. Factors found to be significantly associated with breakthrough seizures were non compliance to anti-epileptic therapy (pu2009<u20090.0001); duration of treatment (pu2009<u20090.0001); infections (pu2009<u20090.044) and menses among female study participants (pu2009<u20090.0001). The level of education, sleep deprivation, alcohol and substance abuse, and flickering lights were not associated with breakthrough seizures.ConclusionsBreakthrough seizures are high in Mulago National referral hospital, with drug non-compliance the commonest cause. The attending physicians need to identify precipitating factors among patients attending Mulago hospital and have them addressed appropriately during patient care.

Integration of antenatal syphilis screening in an urban HIV clinic: a feasibility study

BackgroundSyphilis infection during pregnancy leads to avoidable morbidity and mortality and remains a significant problem in sub-Saharan Africa. Despite global initiatives to increase the proportion of pregnant women screened, implementation has been slow. We sought to investigate the feasibility of adding syphilis screening within an integrated antenatal HIV clinic.MethodsPregnant women attending the HIV antenatal clinic were sequentially enrolled and consenting participants answered a questionnaire on sexual behavior and previous pregnancies, provided sociodemographic data, and were tested using rapid plasmin reagin (RPR). If positive, participants were treated with benzathine penicillin. All were given a partner notification slip and were followed up after delivery to determine birth outcomes.Results584 of 606 (95.7%) women approached and consented to test for syphilis. 570 women were enrolled (median age 29 (IQR 25–32) with a median (IQR) CD4 of 372 (257–569) cells/μL). Of the 5.1% (29/570) with a positive RPR, all were asymptomatic, were successfully contacted, and treated with benzathine penicillin without adverse reactions. Overall, 61 (12.1%) of the participants had an adverse birth outcome. In the bivariate analysis, only age was significantly different between those with and without a positive RPR (RRu2009=u20091.15, 95% CI 1.065-1.248; pu2009<u20090.001). Partners of only 10 (34.5%) participants returned for treatment.ConclusionsStructural interventions such as opt-out testing for syphilis within integrated HIV-antenatal care clinics are feasible and capitalize on the excellent care programs that have already been established for HIV care. Novel approaches are required for partner notification.

Prevalence of stroke in children admitted with sickle cell anaemia to Mulago Hospital

BackgroundStroke is a major complication of sickle cell anaemia (SCA). It occurs commonly in childhood with about 10xa0% of children with sickle cell anaemia getting affected by this complication. In Uganda, there is paucity of data on the prevalence of stroke in children admitted in a tertiary institution. We determined the prevalence of stroke amongst children with SCA admitted to Mulago National Referral Hospital in Uganda and described the ir co-morbidities.MethodsWe conducted a retrospective record review of children with SCA admitted from August 2012 to August 2014 to the Paediatric Haematology Ward of Mulago Hospital in Kampala, Uganda. The target population was SCA children age 6xa0months-17xa0years of age. A descriptive analysis was used to summarize the demographic characteristics and clinical diagnosis.ResultsThere were 2,176 children with SCA admitted who were included in this study. There were 147 children with stroke. Their mean age 6.1, (SD 3), with a male to female ratio was 1:1 (71 males and 76 females). The M: F ratio of non-stroke children was 1.1:1 (1084 males and 945 females) with a mean age of 5.2, (SD 3). The prevalence of stroke was 6.8xa0% (147 of 2176). Amongst the children with stroke, 72.1 % (106 ofxa0147) had co-morbidities which included severe anaemia 21.7 % (23 of 106), bacteraemia and vaso-occlusive crisis 17 % (18 of 106), pneumonia 8.4 % (9 of 106) and malaria 6.6xa0% (7 of 106).ConclusionThe prevalence of stroke in hospitalized Ugandan children with SCA was 6.8xa0%. Children with stroke were often admitted with other medical conditions such as severe anaemia, bacteraemia and vaso-occlusion.

Vitamin D deficiency and its characteristics among patients with acute stroke at a national referral hospital in Kampala Uganda

BackgroundVitamin D deficiency has been associated with acute stroke and other cardiovascular diseases in the developed world. Low 25-hydroxyvitamin D (25OHD) has been described in some populations in Sub-Saharan Africa (SSA) in spite of adequate sunshine all year round. There is no information on the magnitude of vitamin D deficiency among patients with stroke and other cardiovascular diseases in Uganda or SSA. The aim of this study was to determine the burden and characteristics of vitamin D deficiency among patients with acute stroke, the most common form of cardiovascular events in SSA.MethodsWe conducted a cross-sectional study between October 2012 and March 2013. We consecutively recruited 142 subjects with acute stroke admitted to the medical wards of Mulago hospital. We administered a pre-tested questionnaire to the study participants, and did a detailed physical examination and laboratory evaluation. Serum levels of 25OHD were determined using an electrochemiluminescence assay. Data were analyzed using STATA version 12 software.ResultsThe prevalence of vitamin D deficiency (25OHDu2009<u200920xa0ng/ml) was 15xa0%. Longer hours of sunshine exposure decreased the likelihood vitamin D deficiency significantly (adjusted OR 0.85, pu2009=u20090.03). Higher HDL cholesterol had a significant inverse association with vitamin D deficiency (adjusted OR 0.15, pu2009=u20090.02). In addition, the likelihood of vitamin D deficiency increased with rising age (adjusted OR 1.03, pu2009=u20090.05).ConclusionsThere was a relatively low burden of vitamin D deficiency among patients with acute stroke in Uganda. With increasing longevity and indoor lifestyles vitamin D deficiency may assume a greater role in stroke and other cardiovascular diseases in tropical sub Saharan Africa. Future studies on the mechanisms of vitamin D deficiency and its relationship to outcomes among patients with stroke may be necessary.