Leonard Bufumbo

Willingness to participate in preventive HIV vaccine trials in a community-based cohort in south western Uganda.

Objectives  To assess willingness to participate in HIV vaccine trials and possible barriers to participation.

Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal

BACKGROUND Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uniject™, has potential to be a valuable innovation in family planning (FP) because it may overcome logistic and safety challenges in delivering intramuscular DMPA (DMPA IM). However, SPs acceptability is unknown. We measured acceptability of SP among DMPA IM users. STUDY DESIGN This open-label observational study was conducted in clinics in three districts in Senegal and community-based distribution services in two districts in Uganda. Experienced DMPA IM users were offered SP by community health workers (CHWs) or clinic-based providers. SP decliners were asked to discuss their reasons. Those who received SP were interviewed pre- and postinjection and 3 months later, when they were asked if they would select SP over DMPA IM if it were available. RESULTS One hundred twenty women in Uganda and 242 in Senegal received SP (117 and 240 were followed up, respectively). Nine Ugandan and seven Senegalese SP decliners were interviewed. Three months after receiving SP, 84% [95% confidence interval (CI)=75%-93%] of Ugandan participants and 80% (95% CI=74%-87%) of Senegalese participants said they would select SP over DMPA IM. Main reasons for selecting SP were fewer side effects, liking the method, fast administration, less pain and method effectiveness. Thirty-four adverse events were reported but were not serious. No pregnancies were reported. CONCLUSION Current DMPA IM users in Senegal and Uganda accepted SP, and most preferred SP over DMPA IM. SP can be safely introduced into FP programs and administered by trained CHWs, with expectation of client uptake. IMPLICATIONS We found SP acceptable and safe in diverse settings among current intramuscular DMPA users, including those who received SP from CHWs. This provides evidence that SP would be used and could therefore reduce unmet family planning needs if introduced into family planning programs.

Barriers to starting ART and how they can be overcome: individual and operational factors associated with early and late start of treatment

Objective  Despite expanding access to antiretroviral therapy (ART) in Sub‐Saharan Africa, there are few data on patients’ perceptions about starting ART to explore issues affecting decisions to start ART in eligible individuals during the ART roll out.

Keeping community health workers in Uganda motivated: key challenges, facilitators, and preferred program inputs

In Uganda, community-based health programs using volunteers should focus on strengthening support systems to address transportation and stockout issues and on improving links with the health structure while reinforcing effort recognition, status, and acquisition of new skills. In Uganda, community-based health programs using volunteers should focus on strengthening support systems to address transportation and stockout issues and on improving links with the health structure while reinforcing effort recognition, status, and acquisition of new skills. Introduction: In the face of global health worker shortages, community health workers (CHWs) are an important health care delivery strategy for underserved populations. In Uganda, community-based programs often use volunteer CHWs to extend services, including family planning, in rural areas. This study examined factors related to CHW motivation and level of activity in 3 family planning programs in Uganda. Methods: Data were collected between July and August 2011, and sources comprised 183 surveys with active CHWs, in-depth interviews (IDIs) with 43 active CHWs and 5 former CHWs, and service statistics records. Surveys included a discrete choice experiment (DCE) to elicit CHW preferences for selected program inputs. Results: Service statistics indicated an average of 56 visits with family planning clients per surveyed CHW over the 3-month period prior to data collection. In the survey, new skills and knowledge, perceived impact on the community, and enhanced status were the main positive aspects of the job reported by CHWs; the main challenges related to transportation. Multivariate analyses identified 2 correlates of CHWs being highly vs. less active (in terms of number of client visits): experiencing problems with supplies and not collaborating with peers. DCE results showed that provision of a package including a T-shirt, badge, and bicycle was the program input CHWs preferred, followed by a mobile phone (without airtime). IDI data reinforced and supplemented these quantitative findings. Social prestige, social responsibility, and aspirations for other opportunities were important motivators, while main challenges related to transportation and commodity stockouts. CHWs had complex motivations for wanting better compensation, including offsetting time and transportation costs, providing for their families, and feeling appreciated for their efforts. Conclusion: Volunteer CHW programs in Uganda and elsewhere need to carefully consider appropriate combinations of financial and nonfinancial inputs for optimal results.

Traditional male circumcision in Uganda: a qualitative focus group discussion analysis.

Background The growing body of evidence attesting to the effectiveness of clinical male circumcision in the prevention of HIV/AIDS transmission is prompting the majority of sub-Saharan African governments to move towards the adoption of voluntary medical male circumcision (VMMC). Even though it is recommended to consider collaboration with traditional male circumcision (TMC) providers when planning for VMMC, there is limited knowledge available about the TMC landscape and traditional beliefs. Methodology and Main Findings During 2010–11 over 25 focus group discussions (FGDs) were held with clan leaders, traditional cutters, and their assistants to understand the practice of TMC in four ethnic groups in Uganda. Cultural significance and cost were among the primary reasons cited for preferring TMC over VMMC. Ethnic groups in western Uganda circumcised boys at younger ages and encountered lower rates of TMC related adverse events compared to ethnic groups in eastern Uganda. Cutting styles and post-cut care also differed among the four groups. The use of a single razor blade per candidate instead of the traditional knife was identified as an important and recent change. Participants in the focus groups expressed interest in learning about methods to reduce adverse events. Conclusion This work reaffirmed the strong cultural significance of TMC within Ugandan ethnic groups. Outcomes suggest that there is an opportunity to evaluate the involvement of local communities that still perform TMC in the national VMMC roll-out plan by devising safer, more effective procedures through innovative approaches.

Pregnancy in HIV clinical trials in Sub Saharan Africa: failure of consent or contraception?

Objective Higher than expected pregnancy rates have been observed in HIV related clinical trials in Sub-Saharan Africa. We designed a qualitative study to explore the factors contributing to high pregnancy rates among participants in two HIV clinical trials in Sub-Saharan Africa. Methods Female and male participants enrolled in one of two clinical HIV trials in south-west Uganda were approached. The trials were a phase III microbicide efficacy trial among HIV negative women using vaginal gel (MDP); and a trial of primary prevention prophylaxis for invasive cryptococcal disease using fluconazole among HIV infected men and women in Uganda (CRYPTOPRO). 14 focus group discussions and 8 in-depth interviews were conducted with HIV positive and negative women and their male partners over a six month period. Areas explored were their experiences about why and when one should get pregnant, factors affecting use of contraceptives, HIV status disclosure and trial product use. Results All respondents acknowledged being advised of the importance of avoiding pregnancy during the trial. Factors reported to contribute to pregnancy included; trust that the investigational product (oral capsules/vaginal gel) would not harm the baby, need for children, side effects that led to inconsistent contraceptive use, low acceptance of condom use among male partners. Attitudes towards getting pregnant are fluid within couples over time and the trials often last for more than a year. Researchers need to account for high pregnancy rates in their sample size calculations, and consider lesser used female initiated contraceptive options e.g. diaphragm or female condoms. In long clinical trials where there is a high fetal or maternal risk due to investigational product, researchers and ethics committees should consider a review of participants contraceptive needs/pregnancy desire review after a fixed period, as need for children, partners and health status of participants may alter over time.

On the road again: concurrency and condom use among Uganda truck drivers.

Long-distance truck drivers have been shown to be a critical population in the spread of HIV in Africa. In 2009, surveys with 385 Ugandan long-distance truck drivers measured concurrency point prevalence with two methods; it ranged from 37.4% (calendar-method) to 50.1% (direct question). The majority (84%) of relationships reported were long-term resulting in a long duration of overlap (average of 58 months) across concurrent partnerships. Only 7% of these men reported using any condoms with their spouses during the past month. Among all non-spousal relationships, duration of relationship was the factor most strongly associated with engaging in unprotected sex in the past month in a multivariable analyses controlling for partner and relationship characteristics. Innovative intervention programs for these men and their partners are needed that address the realities of truck drivers’ lifestyles.