Francis Bajunirwe

Non-communicable diseases in sub-Saharan Africa: what we know now

BACKGROUND Sub-Saharan Africa (SSA) has a disproportionate burden of both infectious and chronic diseases compared with other world regions. Current disease estimates for SSA are based on sparse data, but projections indicate increases in non-communicable diseases (NCDs) caused by demographic and epidemiologic transitions. We review the literature on NCDs in SSA and summarize data from the World Health Organization and International Agency for Research on Cancer on the prevalence and incidence of cardiovascular diseases, diabetes mellitus Type 2, cancer and their risk factors. METHODS We searched the PubMed database for studies on each condition, and included those that were community based, conducted in any SSA country and reported on disease or risk factor prevalence, incidence or mortality. RESULTS We found few community-based studies and some countries (such as South Africa) were over-represented. The prevalence of NCDs and risk factors varied considerably between countries, urban/rural location and other sub-populations. The prevalence of stroke ranged from 0.07 to 0.3%, diabetes mellitus from 0 to 16%, hypertension from 6 to 48%, obesity from 0.4 to 43% and current smoking from 0.4 to 71%. Hypertension prevalence was consistently similar among men and women, whereas women were more frequently obese and men were more frequently current smokers. CONCLUSIONS The prevalence of NCDs and their risk factors is high in some SSA settings. With the lack of vital statistics systems, epidemiologic studies with a variety of designs (cross-sectional, longitudinal and interventional) capable of in-depth analyses of risk factors could provide a better understanding of NCDs in SSA, and inform health-care policy to mitigate the oncoming NCD epidemic.

Supervised versus unsupervised intake of six-dose artemether-lumefantrine for treatment of acute, uncomplicated Plasmodium falciparum malaria in Mbarara, Uganda: a randomised trial

BACKGROUND The six-dose regimen of artemether-lumefantrine is effective and is among combination therapies prioritised to replace antimalarials that no longer work in Africa. However, its effectiveness has not been assessed in the field, and could be compromised by poor adherence, incorrect timing of doses, and insufficient intake of fatty foods with every dose. Our aim, therefore, was to assess the effectiveness of artemether-lumefantrine prescribed under routine outpatient conditions, compared with its efficacy when given under supervision to inpatients with acute uncomplicated falciparum malaria. METHODS We did a randomised trial to compare the efficacy, safety, and pharmacokinetics of artemether-lumefantrine when given in a supervised (all doses observed with fatty-food intake; n=313) or unsupervised (first dose supervised followed by outpatient treatment with nutritional advice; n=644) setting to patients of all ages (weight >10 kg) with acute, uncomplicated falciparum malaria in Mbarara, Uganda. Our primary endpoint was 28 day, PCR-adjusted, parasitological cure rate. Analysis was by intention to treat and evaluability analysis. FINDINGS 38 patients were lost to follow-up and one withdrew consent. Day-28 cure rates were 97.7% (296 of 303) and 98.0% (603 of 615) in the supervised and unsupervised groups, respectively. We recorded 15 non-severe, drug-related adverse events, all of which resolved. INTERPRETATION Artemether-lumefantrine has a high cure rate irrespective of whether given under supervision with food or under conditions of routine clinic practice. If used as first-line treatment, artemether-lumefantrine could make a substantial contribution to malaria control in Africa, though cost is an issue.

Peer-group support intervention improves the psychosocial well-being of AIDS orphans: Cluster randomized trial

Accumulating evidence suggests that AIDS orphanhood status is accompanied by increased levels of psychological distress such as anxiety, depression, intense guilt, shame, and anger. However, few studies have examined the possible reduction of psychological distress in AIDS orphans through the help of interventions that promote well-being. The objective of the study was to evaluate the effects of a school-based peer-group support intervention combined with periodic somatic health assessments and treatment on the psychosocial well-being of AIDS orphans in the Mbarara District of southwestern Uganda. In a cluster randomized controlled design, 326 AIDS orphans aged 10-15 years were assigned to either peer-group support intervention combined with monthly somatic healthcare (n=159) or control group (n=167) for follow-up assessment. Baseline and 10 week follow-up psychological assessments were conducted in both groups using self-administered Beck Youth Inventories. Complete data were available for 298 orphans. After adjusting for baseline scores, follow-up scores for the intervention group in comparison with controls showed significant improvement in depression, anger, and anxiety but not for self-concept. This study demonstrated that peer-group support intervention decreased psychological distress, particularly symptoms of depression, anxiety and anger. Thus, the use of peer-group support interventions should be incorporated into existing school health programs.

Supervised versus unsupervised antimalarial treatment with six-dose artemether-lumefantrine:pharmacokinetic and dosage-related findings from a clinical trial in Uganda

BackgroundA six-dose antimalarial regimen of artemether-lumefantrine (A/L) may soon become one of the most widely used drug combination in Africa, despite possible constraints with adherence and poor absorption due to inadequate nutrition, and a lack of pharmacokinetic and effectiveness data.MethodsWithin a trial of supervised versus unsupervised A/L treatment in a stable Ugandan Plasmodium falciparum transmission setting, plasma lumefantrine concentrations were measured in a subset of patients on day 3 (C [lum]day3) and day 7 (C [lum]day7) post-inclusion. Predictors of lumefantrine concentrations were analysed to show how both C [lum]day7 and the weight-adjusted lumefantrine dose affect 28-day recrudescence and re-infection risks. The implications of these novel findings are discussed in terms of the emergence of lumefantrine-resistant strains in Africa.ResultsC [lum]day3 and C [lum]day7 distributions among 241 supervised and 238 unsupervised patients were positively skewed. Unsupervised treatment and decreasing weight-adjusted lumefantrine dose were negatively associated with C [lum]day3. Unsupervised treatment and decreasing age showed strong negative associations with C [lum]day7. Both models were poorly predictive (R-squared < 0.25). There were no recrudescences in either arm, but decreasing lumefantrine dose per Kg resulted in up to 13-fold higher adjusted risks of re-infection. Re-infections occurred only among patients with C [lum]day7 below 400 ng/mL (p < 0.001).ConclusionMaintaining the present six-dose regimen and ensuring high adherence and intake are essential to maximize the public health benefits of this valuable drug combination.

Quality of life and social support among patients receiving antiretroviral therapy in Western Uganda

Abstract Quality of life (QOL) among patients with HIV/AIDS has been shown to improve once treatment with antiretroviral therapy (ART) has been initiated. We conducted a cross-sectional study in Western Uganda to examine the factors associated with QOL among patients who had received ART for the duration of at least six months. We interviewed 330 patients attending the HIV/AIDS clinic at two government-supported hospitals in Western Uganda. We measured QOL using a culturally adapted version of the Medical Outcomes Study (MOS-HIV) tool and calculated the physical health summary (PHS) and mental health summary (MHS) scores. In addition, data were collected on sociodemographic factors, three-day self-reported adherence, social support, sexual behavior, CD4 count and viral load. Informational social support was significantly positively correlated with PHS (p=0.001) and MHS (p=0.002). Affectionate support was also significantly positively correlated to PHS (p=0.05) and MHS (p=0.03) but tangible support was not (PHS p value=0.85 and MHS p value=0.31). In the univariate analysis, older age, rural dwelling, alcohol use, CD4 count less than 200, and ART duration of less than one year were significantly associated with lower PHS scores. Lower PHS scores were also associated with sexual inactivity. In multivariate analysis, higher scores on informational social support and CD4≥200 were associated with higher PHS score and past or recent alcohol consumption was associated with lower scores on MHS. Optimizing ART to restore CD4 count and provision of informational and affectionate social support but not tangible support, to HIV/AIDS patients may improve their QOL.

Community acceptability of use of rapid diagnostic tests for malaria by community health workers in Uganda

BackgroundMany malarious countries plan to introduce artemisinin combination therapy (ACT) at community level using community health workers (CHWs) for treatment of uncomplicated malaria. Use of ACT with reliance on presumptive diagnosis may lead to excessive use, increased costs and rise of drug resistance. Use of rapid diagnostic tests (RDTs) could address these challenges but only if the communities will accept their use by CHWs. This study assessed community acceptability of the use of RDTs by Ugandan CHWs, locally referred to as community medicine distributors (CMDs).MethodsThe study was conducted in Iganga district using 10 focus group discussions (FGDs) with CMDs and caregivers of children under five years, and 10 key informant interviews (KIIs) with health workers and community leaders. Pre-designed FGD and KII guides were used to collect data. Manifest content analysis was used to explore issues of trust and confidence in CMDs, stigma associated with drawing blood from children, community willingness for CMDs to use RDTs, and challenges anticipated to be faced by the CMDs.ResultsCMDs are trusted by their communities because of their commitment to voluntary service, access, and the perceived effectiveness of anti-malarial drugs they provide. Some community members expressed fear that the blood collected could be used for HIV testing, the procedure could infect children with HIV, and the blood samples could be used for witchcraft. Education level of CMDs is important in their acceptability by the community, who welcome the use of RDTs given that the CMDs are trained and supported. Anticipated challenges for CMDs included transport for patient follow-up and picking supplies, adults demanding to be tested, and caregivers insisting their children be treated instead of being referred.ConclusionUse of RDTs by CMDs is likely to be acceptable by community members given that CMDs are properly trained, and receive regular technical supervision and logistical support. A well-designed behaviour change communication strategy is needed to address the anticipated programmatic challenges as well as community fears and stigma about drawing blood. Level of formal education may have to be a criterion for CMD selection into programmes deploying RDTs.

Acceptance of HIV testing among women attending antenatal care in south-western Uganda: risk factors and reasons for test refusal.

Abstract A problem commonly encountered in programs for prevention of mother-to-child-transmission (PMTCT) of HIV in sub-Saharan Africa is low rates of HIV test acceptance among pregnant women. In this study, we examined risk factors and reasons for HIV test refusal among 432 women attending three antenatal care clinics offering PMTCT in urban and semi-urban parts of the Mbarara district, Uganda. Structured interviews were performed following pre-test counselling. Three-hundred-eighty women were included in the study, 323 (85%) of whom accepted HIV testing. In multivariate analysis, testing site (Site A: OR = 1.0; Site B: OR = 3.08; 95%CI: 1.12–8.46; Site C: OR = 5.93; 95%CI: 2.94–11.98), age between 30 and 34 years (<20 years: OR = 1.0; 20–24 years: OR = 1.81; 95%CI: 0.58–5.67; 25–29 years: OR = 2.15; 95%CI: 0.66–6.97; 30–34 years: OR = 3.88; 95%CI: 1.21–13.41), mistrust in reliability of the HIV test (OR = 20.60; 95%CI: 3.24–131.0) and not having been tested for HIV previously (OR = 2.15; 95%CI: 1.02–4.54) were associated with test refusal. Testing sites operating for longer durations had higher rates of acceptance. The most common reasons claimed for test refusal were: lack of access to antiretroviral therapy (ART) for HIV-infected women (88%; n=57), a need to discuss with partner before decision (82%; n=57) and fear of partners reaction (54%; n=57). Comparison with previous periods showed that the acceptance rate increased with the duration of the program. Our study identified risk factors for HIV test refusal among pregnant women in Uganda and common reasons for not accepting testing. These findings may suggest modifications and improvements in the performance of HIV testing in this and similar populations.

Adherence and Treatment Response Among HIV-1-Infected Adults Receiving Antiretroviral Therapy in a Rural Government Hospital in Southwestern Uganda:

Background. Large-scale, government-based antiretroviral therapy (ART) programs in rural areas of resource-poor countries remain largely unevaluated. Methods. We conducted a retrospective review of all patients receiving ART (n = 399) to assess survival and retention in care and a prospective evaluation of patients on ART for at least 6 months (n = 175). We used 3-day self-report to measure adherence. Results. The probability (95% confidence interval [CI]) of surviving and remaining in care was 0.76 (0.72, 0.81) at 1 year. Men and patients with advanced disease were more likely to die or be lost to follow-up. At baseline, 149 (85%) reported 100% adherence. Nonadherence was associated with lack of suppression of viral replication (odds ratio [OR] = 4.5; 95% CI: 1.8, 11.5). Missing a scheduled clinic visit and lack of disclosure of HIV status were associated with nonadherence. Conclusion. Viral suppression was high, but counseling to include HIV disclosure to family and keeping scheduled clinic appointments may improve long-term adherence and treatment outcomes.

Brain drain in sub-Saharan Africa: contributing factors, potential remedies and the role of academic medical centres

A double jeopardy exists in resource-limited settings (RLS) in sub-Saharan Africa (SSA): there are a disproportionately greater number of acutely ill patients, but a paucity of healthcare workers (HCW) to care for them. SSA has 25% of the global disease burden but only 3% of the worlds HCW. Thirty-two SSA countries do not meet the WHO minimum of 23 HCW per 10000 population. Contributing factors include insufficient supply, inadequate distribution and migration. Potential remedies include international workforce policies, non-governmental organisations, national and international medical organisations’ codes of conduct, inter-country collaborations, donor-directed policies and funding to train more people in-country, and health system strengthening and task-shifting. Collaborations among academic institutions from resource-rich and poor countries can help address HCW supply, distribution and migration. It is now opportune to harness bright, committed people from academic centres in resource-rich and poor settings to create long-term, collaborative relationships focused on training, clinical skills and locally relevant research endeavours, who mutually strive for HCW retention, less migration, and ultimately sufficient HCW to provide optimal care in all RLS.

Comparison of Self-Reported Alcohol Consumption to Phosphatidylethanol Measurement among HIV-Infected Patients Initiating Antiretroviral Treatment in Southwestern Uganda

Background Alcohol consumption among HIV-infected patients may accelerate HIV disease progression or reduce antiretroviral therapy adherence. Self-reported alcohol use is frequently under-reported due to social desirability and recall bias. The aim of this study was to compare self-reported alcohol consumption to phosphatidylethanol (PEth), a biomarker of alcohol consumption, and to estimate the correlation between multiple measures of self-reported alcohol consumption with PEth. Methods The Uganda AIDS Rural Treatment Outcomes (UARTO) cohort is located in southwestern Uganda and follows patients on ART to measure treatment outcomes. Patients complete standardized questionnaires quarterly including questions on demographics, health status and alcohol consumption. Baseline dried blood spots (DBS) were collected and retrieved to measure PEth. Results One hundred fifty samples were tested, and 56 (37.3%) were PEth positive (≥8 ng/mL). Of those, 51.7% did not report alcohol use in the past month. Men were more likely to under-report compared to women, OR 2.9, 95% CI = 1.26, 6.65) and those in the higher economic asset categories were less likely to under-report compared to those in the lowest category (OR = 0.41 95% CI: 0.17, 0.94). Among self-reported drinkers (n = 31), PEth was highly correlated with the total number of drinking days in the last 30 (Spearman R = 0.73, p<0.001). Conclusions Approximately half of HIV infected patients initiating ART and consuming alcohol under-report their use of alcohol. Given the high prevalence, clinicians should assess all patients for alcohol use with more attention to males and those in lower economic asset categories who deny alcohol use. Among those reporting current drinking, self-reported drinking days is a useful quantitative measure.