Rakai Health Sciences Program

Image 1.

Sepsis survivors worldwide face a high risk of death after hospitalization. In sub-Saharan Africa, where nearly 40% of all sepsis cases occur, post-discharge mortality is a major contributor to poor sepsis outcomes. In this context, stratification of sepsis survivors at high risk for post-discharge mortality is needed to guide targeted follow-up care. We sought to determine the performance of Karnofsky Performance Status (KPS)-based risk stratification for predicting post-discharge mortality among adults surviving sepsis hospitalization in Uganda. Analysis of two prospective observational cohorts in Uganda. Two public hospitals in Entebbe and Tororo, Uganda. Adults (≥ 18 yr) hospitalized with sepsis, defined by signs of infection and quick Sepsis-related Organ Failure Assessment score greater than or equal to 1, who were discharged or transferred alive from the hospital. None. KPS was assessed on the day of discharge or transfer by study clinicians. Vital status was ascertained at 30 and 60 days post-discharge in the Entebbe ( n = 217) and Tororo ( n = 251) cohorts, respectively. In both cohorts, higher KPS scores at discharge or transfer were significantly associated with reduced odds of post-discharge mortality after adjustment for demographics, inpatient physiologic severity, high-burden co-infections and duration of hospitalization (adjusted odds ratios, 0.95 [95% CI, 0.93-0.98] and 0.96 [95% CI, 0.94-0.98] in Entebbe and Tororo, respectively). Adding KPS to a baseline risk model including the above variables significantly improved post-discharge mortality prediction in both cohorts; predictive discrimination and calibration were also improved. KPS assessed at hospital discharge significantly improves prediction of post-discharge mortality among acute sepsis survivors in sub-Saharan Africa. Incorporating KPS into discharge planning may help guide targeted interventions to improve sepsis survivorship in low- and middle-income countries.

The World Health Organization (WHO) recently released revised guidelines on self-care interventions for health and well-being, which, in 2022, included recommendations supporting equitable access to information about and availability of pre-exposure prophylaxis (PrEP) as a self-care strategy. Successful implementation of PrEP as an HIV prevention strategy extends beyond providing access to medication. It hinges on individuals adopting self-care strategies to ensure adherence to PrEP in their daily lives. This paper aims to explore self-care strategies that bolster adherence to oral PrEP among female sex workers in two rural Ugandan settings. Through in-depth interviews with 20 female sex workers residing in fishing communities or Trans-Africa highway towns, we used deductive thematic analysis to explore people-centred and health system-centred perspectives on women’s PrEP-related self-care strategies. A people-centred perspective on self-care illustrated a range of self-care strategies to support PrEP adherence conducted by women individually (medication reminders; pairing PrEP with daily habits), and with support from others in familial and social networks (verbal reminders to take tablets; information sharing; shared clinic visits; shared pill-taking routines). A health system-centred perspective illustrated the importance of support from health services and professionals. Examples included information provision; NGO clinics as friendly, safe, non-judgemental spaces; PrEP distribution through home-based care outreach strategies; in-bulk PrEP provision for work-related travel periods; formal integration of female sex workers into the system as peer health workers. By considering both person-centred and health system-centred perspectives on self-care, we can pinpoint strategies for health systems to assist female sex workers and their communities in preventing the acquisition and transmission of HIV.

Background: Insights into SARS-CoV-2 in Uganda were limited throughout the epidemic due to incomplete access to diagnostic testing and limited formal surveillance systems. From September 2021 to August 2022, we conducted a household-based surveillance

Abstract Background:Uganda is consistently one of the highest burden countries for mother-to-child transmission of HIV (MTCT). This study assessed Uganda’s progress toward elimination of MTCT and factors associated with MTCT. Methods:Mother-infant pairs (MIP) were recruited at immunization clinics at randomly sampled public and private health facilities in Uganda during 2017-2019. Using a multistage sampling method, a national representative sample of MIP aged 4-12 weeks were recruited and followed longitudinally for 18 months or until the infant acquired HIV. Early MTCT was defined as an infant with confirmed HIV infection at enrollment and was calculated using logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for associated factors. Poisson regression was used to estimate incidence rate and incidence rate ratio (IRR) for infants acquiring HIV at any time during the study after enrollment (late MTCT) and associated factors. Results:Early MTCT was 2.2% (95% CI: 1.3–3.6) and late MTCT rate was 5.2 per 1000 person-years (95% CI: 2.5-10.9). In the adjusted model, only detectable maternal HIV viral load (≥1,000 copies/mL) was significantly associated with early MTCT (aOR: 6.8, 95% CI: 2.3-19.9). Similarly, ever having a detectable viral load (at any visit) was significantly associated with late MTCT (IRR: 6.2, 95% CI: 1.2-31.7). Conclusion:Uganda’s program has made large strides to eliminate MTCT. Identifying and addressing elevated maternal HIV viral load, especially during pregnancy and the early breastfeeding period could further reduce the number of new childhood infections in Uganda.

In engineering projects, coordination between project managers and engineering teams is essential to ensure timely and cost-effective project execution. However, a communication gap between these stakeholders often leads to delays, rework, and increased costs. This research analyzes the causes and impacts of this gap in engineering project management and proposes practical and technological solutions, including: Developing a standardized communication framework between management and engineering teams. Utilizing AI-based predictive analysis to foresee project risks. Implementing interactive training workshops to bridge knowledge gaps. Introducing the role of the "Engineering Manager" as a link between engineering and management. Developing interactive dashboards for real-time project tracking.

In Uganda, adolescent girls', and young women's (AGYW-15-24 years) current HIV prevalence is fourfold compared with their male counterparts due to compounded social, economic, and environmental factors. Using the Protective Motivation Theory (PMT), we explored HIV-acquisition risk sources and perceived protective factors from AGYW and caregivers' perspective. During 2018, we conducted a qualitative study guided by PMT to explore factors influencing HIV acquisition among AGYW. We purposively sampled two groups of key informants, AGYW at high-risk for HIV acquisition (uninfected) and AGYW living with HIV, varied by age and place of residence (urban/rural). We conducted 34 focus group discussions with AGYW, nine with AGYW parents, and 25 key informant interviews. Data were analyzed using the framework method based on the PMT and developed from participants' narratives. AGYW were knowledgeable about HIV, HIV acquisition risk factors, and HIV prevention interventions. Nonetheless, few AGYW knew about pre-exposure prophylaxis (PrEP). Imbalance in power relations between the genders explained inability of AGYW making safe healthy decisions, with social norms giving men power over women. Parents modelling positively influenced HIV risk behavior. Many AGYW viewed staying in school a protective factor both while at school and further for life. AGYW identified alcohol use, desire for material possessions, discounting HIV disease severity, social norms, and poverty as barriers to engaging in self-protective behaviors. Several AGYW believed that access to AGYW-focused programs would facilitate healthy sex-positive, protective behaviors. While PMT focuses on individual factors confirmed by our findings, we found HIV risk behavior to be influenced by complex contextual factors including poverty, gender inequality and cultural norms. Distinct HIV risk factors among AGYW require policy and comprehensive targeted interventions addressing violence, alcohol consumption, increased economic opportunities, educational opportunities, safe-sex practices, and PrEP scale-up which may prevent HIV in AGYW and facilitate HIV epidemic control.

ObjectiveTo refine a standard questionnaire on sexual practices, experiences and health-related outcomes to improve its cross-cultural applicability and interpretability. We aimed to explore participants’ willingness and ability to answer the draft questionnaire items, and determine whether items were interpreted as intended across diverse geographic and cultural environments.MethodsWe conducted cognitive interviews (n = 645) in three iterative waves of data collection across 19 countries during March 2022–March 2023, with participants of diverse sex, gender, age and geography. Interviewers used a semi-structured field guide to elicit narratives from participants about their questionnaire item interpretation and response processes. Local study teams completed data analysis frameworks, and we conducted joint analysis meetings between data collection waves to identify question failures.FindingsOverall, we observed that participants were willing to respond to even the most sensitive questionnaire items on sexual biography and practices. We identified issues with the original questionnaire that (i) affected the willingness (acceptability) and ability (knowledge barriers) of participants to respond fully; and/or (ii) prevented participants from interpreting the questions as intended, including poor wording (source question error), cultural portability and very rarely translation error. Our revisions included adjusting item order and wording, adding preambles and implementation guidance, and removing items with limited cultural portability.ConclusionWe have demonstrated that a questionnaire exploring sexual practices, experiences and health-related outcomes can be comprehensible and acceptable by the general population in diverse global contexts, and have highlighted the importance of rigorous processes for the translation and cognitive testing of such a questionnaire.

BackgroundHIV treatment programs in Africa have implemented centralized testing for routine viral load monitoring (VLM), which may result in specimen processing delays inhibiting timely return of viral load results. Decentralized, point-of-care (PoC) VLM is a promising tool for expediting HIV clinical decision-making but remains unavailable in most African settings. We qualitatively explored the perceived feasibility and appropriateness of PoC VLM to address gaps along the viral load monitoring continuum in rural Uganda.MethodsBetween May and September 2022, we conducted 15 in-depth interviews with HIV clinicians (facility in-charges, clinical officers, nurses, counselors) and six focus group discussions with 47 peer health workers from three south-central Ugandan districts. Topics explored centralized VLM implementation and opportunities/challenges to optimizing routine VLM implementation with PoC testing platforms. We explored perspectives on PoC VLM suitability and feasibility using iterative thematic analysis. Applying the Framework Method, we then mapped salient constraints and enablers of PoC VLM to constructs from the Consolidated Framework for Implementation Research.ResultsClinicians and peers alike emphasized centralized viral load monitoring’s resource-intensiveness and susceptibility to procedural/infrastructural bottlenecks (e.g., supply stockouts, testing backlogs, community tracing of clients with delayed VLM results), inhibiting timely clinical decision-making. Participants reacted enthusiastically to the prospect of PoC VLM, anticipating accelerated turnarounds in specimen processing, shorter and/or fewer client encounters with treatment services, and streamlined efficiencies in HIV care provision (including expedited VLM-driven clinical decision-making). Anticipated constraints to PoC VLM implementation included human resource requirements for processing large quantities of specimens (especially when machinery require repair), procurement and maintenance costs, training needs in the existing health workforce for operating point-of-care technology, and insufficient space in lower-tier health facilities to accommodate installation of new laboratory equipment.ConclusionsAnticipated implementation challenges, primarily clustering around resource requirements, did not diminish enthusiasm for PoC VLM monitoring among rural Ugandan clinicians and peer health workers, who perceived PoC platforms as potential solutions to existing inefficiencies within the centralized VLM ecosystem. Prioritizing PoC VLM rollout in facilities with available resources for optimal implementation (e.g., adequate physical and fiscal infrastructure, capacity to manage high specimen volumes) could help overcome anticipated barriers to decentralizing viral load monitoring.