Fredrick Makumbi

Expanding access to voluntary HIV counselling and testing in sub-Saharan Africa: alternative approaches for improving uptake, 2001-2007.

The changing face of the HIV/AIDS epidemic has resulted in new opportunities to increase access to voluntary HIV counselling and testing (VCT), especially during the past 7 years (2001–2007). As access to HIV treatment becomes more widely available in sub‐Saharan Africa, the need for enhanced access to VCT would become even greater. When given the opportunity, many more adults in sub‐Saharan African would accept VCT, and many clearly express the desire to learn their HIV sero‐status. However, in most parts of sub‐Saharan Africa, fewer than one in 10 people know their HIV status. Stigma, fear of receiving an HIV‐positive status, lack of confidentiality, long distances to VCT sites, and long delays in returning HIV test results limit people’s access to traditional VCT systems. Alternative VCT delivery models, such as mobile VCT, routine offer of VCT and home‐based VCT increase access to and uptake of VCT. We recommend that these alternative models be implemented in more settings and on a much larger scale in sub‐Saharan Africa, where VCT uptake rates remain low.

Voluntary HIV counseling and testing acceptance, sexual risk behavior and HIV incidence in Rakai, Uganda

Objective:To assess the acceptance of voluntary HIV counseling and testing (VCT) and the effects of VCT on sexual risk behavior and HIV acquisition in Rakai, Uganda. Methods:In a rural cohort, 10 694 consenting adults were interviewed, provided blood for HIV testing and were offered free VCT by community resident counselors. The proportions receiving VCT and the adjusted risk ratio (adj. RR) of VCT acceptance were estimated by log binomial regression. Risk behaviors and HIV incidence per 100 person-years (PY) in HIV-negative acceptors and non-acceptors of VCT were assessed prospectively. Results:Although 93% initially requested HIV results, 62.2% subsequently accepted VCT. VCT acceptance was lower among persons with no prior VCT [Adj. RR = 0.88; 95% confidence interval (CI), 0.85–0.90], individuals with primary education (adj. RR = 0.94; 95% CI, 0.90–0.99) or higher (adj. RR = 0.91; 95% CI, 0.87–0.97), individuals who were HIV-positive (adj. RR = 0.72; 95% CI, 0.68–0.76), and persons reporting condom use in the past 6 months (inconsistent users, adj. RR = 0.95; 95% CI, 0.90–0.99; consistent users, adj. RR = 0.88; 95% CI, 0.82–0.95). VCT acceptance was higher among the currently married (adj. RR = 1.14; 95% CI, 1.08–1.20) and previously married (adj. RR = 1.11; 95% CI, 1.04–1.18). Receipt of results was not significantly associated with age, gender, and self-perception of HIV risk. There were no significant differences in sexual risk behaviors, or in HIV incidence between acceptors (1.6/100 PY) and non-acceptors (1.4/100 PY) of VCT. Conclusion:In this rural cohort where VCT services are free and accessible, there is self-selection of individuals accepting VCT, and no impact of VCT on subsequent risk behaviors or HIV incidence.

Limitations of rapid HIV-1 tests during screening for trials in Uganda: diagnostic test accuracy study

Objective To evaluate the limitations of rapid tests for HIV-1. Design Diagnostic test accuracy study. Setting Rural Rakai, Uganda. Participants 1517 males aged 15-49 screened for trials of circumcision for HIV prevention. Main outcome measures Sensitivity, specificity, negative predictive values, and positive predictive values of an algorithm using three rapid tests for HIV, compared with the results of enzyme immunoassay and western blotting as the optimal methods. Results Rapid test results were evaluated by enzyme immunoassay and western blotting. Sensitivity was 97.7%. Among 639 samples where the strength of positive bands was coded if the sample showed positivity for HIV, the algorithm had low specificity (94.1%) and a low positive predictive value (74.0%). Exclusion of 37 samples (5.8%) with a weak positive band improved the specificity (99.6%) and positive predictive value (97.7%). Conclusion Weak positive bands on rapid tests for HIV should be confirmed by enzyme immunoassay and western blotting before disclosing the diagnosis. Programmes using rapid tests routinely should use standard serological assays for quality control. Trial registration Clinical Trials NCT00425984.

HIV-1 viral subtype differences in the rate of CD4+ T-cell decline among HIV seroincident antiretroviral naive persons in Rakai district, Uganda.

Background:Data on the effect of HIV-1 viral subtype on CD4+ T-cell decline are limited. Methods:We assessed the rate of CD4+ T-cell decline per year among 312 HIV seroincident persons infected with different HIV-1 subtypes. Rates of CD4+ decline by HIV-1 subtype were determined by linear mixed effects models, using an unstructured convariance structure. Results:A total of 59.6% had D, 15.7% A, 18.9% recombinant viruses (R), and 5.8% multiple subtypes (M). For all subtypes combined, the overall rate of CD4+ T-cell decline was −34.5 [95% confidence interval (CI), −47.1, −22.0] cells/μL per yr, adjusted for age, sex, baseline CD4+ counts, and viral load. Compared with subtype A, the adjusted rate of CD4 cell loss was −73.7/μL/yr (95% CI, −113.5, −33.8, P < 0.001) for subtype D, −43.2/μL/yr (95% CI, −90.2, 3.8, P = 0.072) for recombinants, and −63.9/μL/yr (95% CI, −132.3, 4.4, P = 0.067) for infection with multiple HIV subtypes. Square-root transformation of CD4+ cell counts did not change the results. Conclusions:Infection with subtype D is associated with significantly faster rates of CD4+ T-cell loss than subtype A. This may explain the more rapid disease progression for subtype D compared with subtype A.

Survival of infants born to HIV-positive mothers by feeding modality in Rakai Uganda.

Background Data comparing survival of formula-fed to breast-fed infants in programmatic settings are limited. We compared mortality and HIV-free of breast and formula-fed infants born to HIV-positive mothers in a program in rural, Rakai District Uganda. Methodology/Principal Findings One hundred eighty two infants born to HIV-positive mothers were followed at one, six and twelve months postpartum. Mothers were given infant-feeding counseling and allowed to make informed choices as to whether to formula-feed or breast-feed. Eligible mothers and infants received antiretroviral therapy (ART) if indicated. Mothers and their newborns received prophylaxis for prevention of mother-to-child HIV transmission (pMTCT) if they were not receiving ART. Infant HIV infection was detected by PCR (Roche Amplicor 1.5) during the follow-up visits. Kaplan Meier time-to-event methods were used to compare mortality and HIV-free survival. The adjusted hazard ratio (Adjusted HR) of infant HIV-free survival was estimated by Cox regression. Seventy-five infants (41%) were formula-fed while 107 (59%) were breast-fed. Exclusive breast-feeding was practiced by only 25% of breast-feeding women at one month postpartum. The cumulative 12-month probability of infant mortality was 18% (95% CI = 11%–29%) among the formula-fed compared to 3% (95% CI = 1%–9%) among the breast-fed infants (unadjusted hazard ratio (HR)  = 6.1(95% CI = 1.7–21.4, P-value<0.01). There were no statistically significant differentials in HIV-free survival by feeding choice (86% in the formula-fed compared to 96% in breast-fed group (Adjusted RH = 2.8[95%CI = 0.67–11.7, P-value = 0.16] Conclusions/Significance Formula-feeding was associated with a higher risk of infant mortality than breastfeeding in this rural population. Our findings suggest that formula-feeding should be discouraged in similar African settings.

Effectiveness of syphilis treatment using Azithromycin and/or benzathine penicillin in Rakai, Uganda

Objective: The goal of this study was to assess azithromycin and/or benzathine penicillin for treatment of syphilis. Methods: In a population-based study, participants with serologic syphilis (TRUST with TPHA confirmation) were offered 2.4 MU benzathine penicillin intramuscularly. Intervention arm participants received 1 g presumptive oral azithromycin. We assessed cure rates with penicillin or azithromycin given alone and in combination. Cure assessed after 10 months was defined as seroreversion or a 4-fold decrease in titer. The rate ratio (RR) of cure and 95% confidence intervals (95% CIs) were estimated by log binomial regression. Results: Among 952 cases with syphilis, 18% received penicillin alone, 17% azithromycin only, and 65% dual treatment. The overall cure rate was 61%. Cure rates were lower in males compared with females (RR, 0.89; 95% CI, 0.80–0.99) and in subjects with initial titers ≥1:4 compared with ≤1:2 (RR, 0.77; 95% CI, 0.69–0.86). There was no significant differences in cure rates among HIV-positive and HIV-negative persons. With initial titers ≤1:2, there were no differences in cure rates by treatment regimen. However, with initial titers ≥1:4, significantly higher cure rates were observed with azithromycin alone (adjusted RR, 1.38; 95% CI, 0.97–1.96), and with dual treatment of azithromycin and benzathine penicillin (RR, 1.38; 95% CI, 1.03–1.87) compared with penicillin alone. Conclusion: Azithromycin alone or in combination with penicillin achieved higher cure rates than penicillin alone in cases with a high initial TRUST titer. In low-titer infections, the 3 drug combinations were equally effective. HIV status did not affect cure rates.

Disclosure of HIV results among discordant couples in Rakai, Uganda: a facilitated couple counselling approach

Abstract Disclosure of HIV sero-positive results among HIV-discordant couples in sub-Saharan Africa is generally low. We describe a facilitated couple counselling approach to enhance disclosure among HIV-discordant couples. Using unique identifiers, 293 HIV-discordant couples were identified through retrospective linkage of married or cohabiting consenting adults individually enrolled into a cohort study and into two randomised trials of male circumcision in Rakai, Uganda. HIV-discordant couples and a random sample of HIV-infected concordant and HIV-negative concordant couples (to mask HIV status) were invited to sensitisation meetings to discuss the benefits of disclosure and couple counselling. HIV-infected partners were subsequently contacted to encourage HIV disclosure to their HIV-uninfected partners. If the index positive partner agreed, the counsellor facilitated the disclosure of HIV results, and provided ongoing support. The proportion of disclosure was determined. Eighty-one per cent of HIV-positive partners in discordant relationships disclosed their status to their HIV-uninfected partners in the presence of the counsellor. The rates of disclosure were 81.3% in male HIV-positive and 80.2% in female HIV-positive discordant couples. Disclosure did not vary by age, education or occupation. In summary, disclosure of HIV-positive results in discordant couples using facilitated couple counselling approach is high, but requires a stepwise process of sensitisation and agreement by the infected partner.

Associations between HIV Antiretroviral Therapy and the Prevalence and Incidence of Pregnancy in Rakai, Uganda.

Background. Use of antiretroviral therapy (ART) may be associated with higher pregnancy rates. Methods. The prevalence and incidence of pregnancy was assessed in 712 HIV+ pre-ART women of reproductive age (WRA) (15–45) and 244 HIV+ WRA initiating ART. Prevalence rate ratios (PRR), incidence rate ratios (IRR), and 95% confidence interval (CI) were assessed. Results. The incidence of pregnancy was 13.1/100 py among women in pre-ART care compared to 24.6/100 py among women on ART (IRR = 0.54; 95% CI 0.37, 0.81, p < 0.0017). The prevalence of pregnancy at ART initiation was 12.0% with CD4 counts 100–250 compared with 3.2% with CD4 <100 (PRR = 3.24, CI 1.51–6.93), and the incidence of pregnancy while on ART was highest in women with a good immunologic response. Desire for more children was a very important factor in fertility. Conclusion. ART was associated with increased pregnancy rates in HIV+ women, particularly those with higher CD4 counts and good immunologic response to therapy, suggesting a need to strengthen reproductive health services for both women and their partners that could address their fertility decisions/intentions particularly after ART initiation.

WHO HIV clinical staging or CD4 cell counts for antiretroviral therapy eligibility assessment? An evaluation in rural Rakai district, Uganda.

The ability of WHO clinical staging to predict CD4 cell counts of 200 cells/μl or less was evaluated among 1221 patients screened for antiretroviral therapy (ART). Sensitivity was 51% and specificity was 88%. The positive predictive value was 64% and the negative predictive value was 81%. Clinical criteria missed half the patients with CD4 cell counts of 200 cells/μl or less, highlighting the importance of CD4 cell measurements for the scale-up of ART provision in resource-limited settings.

Modifiable Socio-Behavioural Factors Associated with Overweight and Hypertension among Persons Aged 35 to 60 Years in Eastern Uganda

Background Few studies have examined the behavioural correlates of non-communicable, chronic disease risk in low-income countries. The objective of this study was to identify socio-behavioural characteristics associated with being overweight or being hypertensive in a low-income setting, so as to highlight possible interventions and target groups. Methods A population based survey was conducted in a Health and Demographic Surveillance Site (HDSS) in eastern Uganda. 1656 individuals aged 35 to 60 years had their Body Mass Index (BMI) and blood pressure (BP) assessed. Seven lifestyle factors were also assessed, using a validated questionnaire. Logistic regression was used to identify socio-behavioural factors associated with being overweight or being hypertensive. Results Prevalence of overweight was found to be 18% (25.2% of women; 9.7% of men; p<0.001) while prevalence of obesity was 5.3% (8.3% of women; 2.2% of men). The prevalence of hypertension was 20.5%. Factors associated with being overweight included being female (OR 3.7; 95% CI 2.69–5.08), peri-urban residence (OR 2.5; 95% CI 1.46–3.01), higher socio-economic status (OR 4.1; 95% CI 2.40–6.98), and increasing age (OR 1.8; 95% CI 1.12–2.79). Those who met the recommended minimum physical activity level, and those with moderate dietary diversity were less likely to be overweight (OR 0.5; 95% CI 0.35–0.65 and OR 0.7; 95% CI 0.49–3.01). Factors associated with being hypertensive included peri-urban residence (OR 2.4; 95%CI 1.60–3.66), increasing age (OR 4.5; 95% CI 2.94–6.96) and being over-weight (OR 2.8; 95% CI 1.98–3.98). Overweight persons in rural areas were significantly more likely to be hypertensive than those in peri-urban areas (p = 0.013). Conclusions Being overweight in low-income settings is associated with sex, physical activity and dietary diversity and being hypertensive is associated with being overweight; these factors are modifiable. There is need for context-specific health education addressing disparities in lifestyles at community levels in rural Africa.