Suchergebnisse

Abstract Background It has been almost a decade since HIV was declared a national disaster in Kenya. Antiretroviral therapy (ART) provision has been a mainstay of HIV treatment efforts globally. In Kenya, the government started ART provision in 2003 with significantly scale-up after 2006. This study aims to demonstrate changes in population-level HIV mortality in two high HIV prevalence slums in Nairobi with respect to the initiation and subsequent scale-up of the national ART program. Methods We used data from 2070 deaths of people aged 15–54 years that occurred between 2003 and 2010 in a population of about 72,000 individuals living in two slums covered by the Nairobi Urban Health and Demographic Surveillance System. Only deaths for which verbal autopsy was conducted were included in the study. We divided the analysis into two time periods: the "early" period (2003–2006) which coincides with the initiation of ART program in Kenya, and the "late" period (2007–2010) which coincides with the scale up of the program nationally. We calculated the mortality rate per 1000 person years by gender and age for both periods. Poisson regression was used to predict the risk of HIV mortality in the two periods while controlling for age and gender. Results Overall, HIV mortality declined significantly from 2.5 per 1,000 person years in the early period to 1.7 per 1,000 person years in the late period. The risk of dying from HIV was 53 percent less in the late period compared to the period before, controlling for age and gender. Women experienced a decline in HIV mortality between the two periods that was more than double that of men. At the same time, the risk of non-HIV mortality did not change significantly between the two time periods. Conclusions Population-level HIV mortality in Nairobi's slums was significantly lower in the approximate period coinciding with the scale-up of ART provision in Kenya. However, further studies that incorporate ART coverage data in mortality estimates are needed. Such information will enhance our understanding of the full impact of ART scale-up in reducing adult mortality among marginalized slum populations in Kenya.

Background: It has been almost a decade since HIV was declared a national disaster in Kenya. Antiretroviral therapy (ART) provision has been a mainstay of HIV treatment efforts globally. In Kenya, the government started ART provision in 2003 with significantly scale-up after 2006. This study aims to demonstrate changes in population-level HIV mortality in two high HIV prevalence slums in Nairobi with respect to the initiation and subsequent scale-up of the national ART program. Methods: We used data from 2070 deaths of people aged 15-54 years that occurred between 2003 and 2010 in a population of about 72,000 individuals living in two slums covered by the Nairobi Urban Health and Demographic Surveillance System. Only deaths for which verbal autopsy was conducted were included in the study. We divided the analysis into two time periods: the "early" period (2003-2006) which coincides with the initiation of ART program in Kenya, and the "late" period (2007-2010) which coincides with the scale up of the program nationally. We calculated the mortality rate per 1000 person years by gender and age for both periods. Poisson regression was used to predict the risk of HIV mortality in the two periods while controlling for age and gender. Results: Overall, HIV mortality declined significantly from 2.5 per 1,000 person years in the early period to 1.7 per 1,000 person years in the late period. The risk of dying from HIV was 53 percent less in the late period compared to the period before, controlling for age and gender. Women experienced a decline in HIV mortality between the two periods that was more than double that of men. At the same time, the risk of non-HIV mortality did not change significantly between the two time periods. Conclusions: Population-level HIV mortality in Nairobi's slums was significantly lower in the approximate period coinciding with the scale-up of ART provision in Kenya. However, further studies that incorporate ART coverage data in mortality estimates are needed. Such information will enhance our understanding of the full impact of ART scale-up in reducing adult mortality among marginalized slum populations in Kenya.

Health facilities require teams of health workers with complementary skills and responsibilities to efficiently provide quality care. In low-income countries, failure to attract and retain health workers in rural areas reduces population access to health services and undermines facility performance, resulting in poor health outcomes. It is important that governments consider health worker preferences in crafting policies to address attraction and retention in underserved areas. We investigated preferences for job characteristics among final year medical, nursing, pharmacy, and laboratory students at select universities in Uganda. Participants were administered a cadre-specific discrete choice experiment that elicited preferences for attributes of potential job postings they were likely to pursue after graduation. Job attributes included salary, facility quality, housing, length of commitment, manager support, training tuition, and dual practice opportunities. Mixed logit models were used to estimate stated preferences for these attributes. Data were collected from 246 medical students, 132 nursing students, 50 pharmacy students and 57 laboratory students. For all student-groups, choice of job posting was strongly influenced by salary, facility quality and manager support, relative to other attributes. For medical and laboratory students, tuition support for future training was also important, while pharmacy students valued opportunities for dual practice. In Uganda, financial and non-financial incentives may be effective in attracting health workers to underserved areas. Our findings contribute to mounting evidence that salary is not the only important factor health workers consider when deciding where to work. Better quality facilities and supportive managers were important to all students. Similarities in preferences for these factors suggest that team-based, facility-level strategies for attracting health workers may be appropriate. Improving facility quality and training managers to be more supportive of facility staff may be particularly cost-effective, as investments are borne once while benefits accrue to a range of health workers at the facility.

Abstract Background Health facilities require teams of health workers with complementary skills and responsibilities to efficiently provide quality care. In low-income countries, failure to attract and retain health workers in rural areas reduces population access to health services and undermines facility performance, resulting in poor health outcomes. It is important that governments consider health worker preferences in crafting policies to address attraction and retention in underserved areas. Methods We investigated preferences for job characteristics among final year medical, nursing, pharmacy, and laboratory students at select universities in Uganda. Participants were administered a cadre-specific discrete choice experiment that elicited preferences for attributes of potential job postings they were likely to pursue after graduation. Job attributes included salary, facility quality, housing, length of commitment, manager support, training tuition, and dual practice opportunities. Mixed logit models were used to estimate stated preferences for these attributes. Results Data were collected from 246 medical students, 132 nursing students, 50 pharmacy students and 57 laboratory students. For all student-groups, choice of job posting was strongly influenced by salary, facility quality and manager support, relative to other attributes. For medical and laboratory students, tuition support for future training was also important, while pharmacy students valued opportunities for dual practice. Conclusions In Uganda, financial and non-financial incentives may be effective in attracting health workers to underserved areas. Our findings contribute to mounting evidence that salary is not the only important factor health workers consider when deciding where to work. Better quality facilities and supportive managers were important to all students. Similarities in preferences for these factors suggest that team-based, facility-level strategies for attracting health workers may be appropriate. Improving facility quality and training managers to be more supportive of facility staff may be particularly cost-effective, as investments are borne once while benefits accrue to a range of health workers at the facility.

AbstractIntroductionPopulation‐based biomarker surveys are the gold standard for estimating HIV prevalence but are susceptible to substantial non‐participation (up to 30%). Analytical missing data methods, including inverse‐probability weighting (IPW) and multiple imputation (MI), are biased when data are missing‐not‐at‐random, for example when people living with HIV more frequently decline participation. Heckman‐type selection models can, under certain assumptions, recover unbiased prevalence estimates in such scenarios.MethodsWe pooled data from 142,706 participants aged 15–49 years from nationally representative cross‐sectional Population‐based HIV Impact Assessments in seven countries in sub‐Saharan Africa, conducted between 2015 and 2018 in Tanzania, Uganda, Malawi, Zambia, Zimbabwe, Lesotho and Eswatini. We compared sex‐stratified HIV prevalence estimates from unadjusted, IPW, MI and selection models, controlling for household and individual‐level predictors of non‐participation, and assessed the sensitivity of selection models to the copula function specifying the correlation between study participation and HIV status.ResultsIn total, 84.1% of participants provided a blood sample to determine HIV serostatus (range: 76% in Malawi to 95% in Uganda). HIV prevalence estimates from selection models diverged from IPW and MI models by up to 5% in Lesotho, without substantial precision loss. In Tanzania, the IPW model yielded lower HIV prevalence estimates among males than the best‐fitting copula selection model (3.8% vs. 7.9%).ConclusionsWe demonstrate how HIV prevalence estimates from selection models can differ from those obtained under missing‐at‐random assumptions. Further benefits include exploration of plausible relationships between participation and outcome. While selection models require additional assumptions and careful specification, they are an important tool for triangulating prevalence estimates in surveys with substantial missing data due to non‐participation.

AbstractIntroductionHazardous alcohol use (HAU), defined as a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others, is associated with an elevated risk of human immunodeficiency virus (HIV) infection and poor health outcomes. We describe the association between people living with HIV (PLHIV) who report HAU and key HIV indicators. Gaps in current literature in estimating HAU on HIV outcomes at the regional level of Eastern and Southern Africa still exist and our analysis aims to address this issue.MethodsWe used weighted pooled data (2015–2017) from the nationally representative Population‐based HIV Impact Assessments among adults who provided written consent aged 18–59 years from Eswatini, Malawi, Namibia, Tanzania, Zambia and Zimbabwe. We estimated differences in the prevalence of HIV infection and The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90‐90‐90 indicators between PLHIV by HAU status using log‐binomial regression, stratified by sex. HAU was determined using the Alcohol Use Identification Test—Consumption.ResultsAmong the 9755 women and 4444 men who tested HIV positive, 6.6% of women and 21.8% of men engaged in HAU. Women who reported HAU were more likely to be HIV positive (adjusted prevalence ratio [aPR] = 1.31, 95% CI: 1.18–1.46) compared to those who did not report HAU. For the UNAIDS 90‐90‐90 targets, women who engaged in HAU were more likely to be unaware of their HIV‐positive status (aPR = 1.22, 95% CI: 1.01–1.47) and not on antiretroviral therapy (ART) (aPR = 1.73, 95% CI: 1.26–2.37). Men who engaged in HAU were more likely to be unaware of their HIV‐positive status (aPR = 1.56, 95% CI 1.39–1.76) and not on ART (aPR = 1.72, 95% CI: 1.30–2.29). No difference in viral load suppression, defined as <1000 copies/ml of HIV RNA, was seen by sex.ConclusionsPLHIV who engage in HAU were more likely to have suboptimal outcomes along the HIV care continuum when compared to those who did not engage in HAU. Targeted interventions, such as alcohol screening for HAU in HIV testing and treatment settings and HIV prevention efforts in alcohol‐based venues, may help countries reach HIV epidemic control by 2030.

The global plan to eradicate hepatitis C virus (HCV) led by the World Health Organization outlines the use of highly effective direct‐acting antiviral drugs (DAAs) to achieve elimination by 2030. Identifying individuals with active disease and investigation of the breadth of diversity of the virus in sub‐Saharan Africa (SSA) is essential as genotypes in this region (where very few clinical trials have been carried out) are distinct from those found in other parts of the world. We undertook a population‐based, nested case‐control study in Uganda and obtained additional samples from the Democratic Republic of Congo (DRC) to estimate the prevalence of HCV, assess strategies for disease detection using serological and molecular techniques, and characterize genetic diversity of the virus. Using next‐generation and Sanger sequencing, we aimed to identify strains circulating in East and Central Africa. A total of 7,751 Ugandan patients were initially screened for HCV, and 20 PCR‐positive samples were obtained for sequencing. Serological assays were found to vary significantly in specificity for HCV. HCV strains detected in Uganda included genotype (g) 4k, g4p, g4q, and g4s and a newly identified unassigned g7 HCV strain. Two additional unassigned g7 strains were identified in patients originating from DRC (one partial and one full open reading frame sequence). These g4 and g7 strains contain nonstructural (ns) protein 3 and 5A polymorphisms associated with resistance to DAAs in other genotypes. Clinical studies are therefore indicated to investigate treatment response in infected patients. Conclusion: Although HCV prevalence and genotypes have been well characterized in patients in well‐resourced countries, clinical trials are urgently required in SSA, where highly diverse g4 and g7 strains circulate. ; Supported by the Medical Research Council (MRC) (MC_UU_12014/1) and Wellcome Trust (102789/Z/13/A) (to E.T.). M.S. is funded by the Wellcome Trust Sanger Institute (WT098051), the National Institute for Health Research Cambridge Biomedical Research Centre, the African Partnership for Chronic Disease Research (MRC UK partnership grant number MR/K013491/1), and the UK MRC (G0901213‐92157, G0801566). P.K. is funded by the UK MRC and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement. J.S. is funded by the MRC Confidence in Concept award to the University of Glasgow (MC PC 16045). G.M. is a Gates Cambridge Scholar supported by the Gates Cambridge Trust.

The global plan to eradicate hepatitis C virus (HCV) led by the World Health Organization outlines the use of highly effective direct‐acting antiviral drugs (DAAs) to achieve elimination by 2030. Identifying individuals with active disease and investigation of the breadth of diversity of the virus in sub‐Saharan Africa (SSA) is essential as genotypes in this region (where very few clinical trials have been carried out) are distinct from those found in other parts of the world. We undertook a population‐based, nested case‐control study in Uganda and obtained additional samples from the Democratic Republic of Congo (DRC) to estimate the prevalence of HCV, assess strategies for disease detection using serological and molecular techniques, and characterize genetic diversity of the virus. Using next‐generation and Sanger sequencing, we aimed to identify strains circulating in East and Central Africa. A total of 7,751 Ugandan patients were initially screened for HCV, and 20 PCR‐positive samples were obtained for sequencing. Serological assays were found to vary significantly in specificity for HCV. HCV strains detected in Uganda included genotype (g) 4k, g4p, g4q, and g4s and a newly identified unassigned g7 HCV strain. Two additional unassigned g7 strains were identified in patients originating from DRC (one partial and one full open reading frame sequence). These g4 and g7 strains contain nonstructural (ns) protein 3 and 5A polymorphisms associated with resistance to DAAs in other genotypes. Clinical studies are therefore indicated to investigate treatment response in infected patients. Conclusion: Although HCV prevalence and genotypes have been well characterized in patients in well‐resourced countries, clinical trials are urgently required in SSA, where highly diverse g4 and g7 strains circulate.

Background and rationale for the study: The global plan to eradicate hepatitis C (HCV) led by the World Health Organisation (WHO) outlines the use of highly effective direct‐acting antiviral drugs (DAAs) to achieve elimination by 2030. Identifying individuals with active disease and investigation of the breadth of diversity of the virus sub‐Saharan Africa (SSA) is essential as genotypes in this region (where very few clinical trials have been carried out) are distinct from those found in other parts of the world. We undertook a population‐based nested case‐control study in Uganda and obtained additional samples from the Democratic Republic of Congo (DRC), to estimate the prevalence of HCV, assess strategies for disease detection using serological and molecular techniques, and characterise genetic diversity of the virus. Using next generation (NGS) and Sanger sequencing, we aimed to identify strains circulating in East and Central Africa. Main results: 7751 Ugandan patients were initially screened for HCV and 20 PCR positive samples obtained for sequencing. Serological assays were found to vary significantly in specificity for HCV. HCV strains detected in Uganda included genotypes (g) 4k, 4p, 4q and 4s and a new unassigned genotype 7 HCV strain. Two additional unassigned g7 strains were identified in patients originating from DRC (one partial and one full ORF sequence). These g4 and 7 strains contain NS3 and NS5A polymorphisms associated with resistance to DAAs in other genotypes. Clinical studies are therefore indicated to investigate treatment response in infected patients. Conclusion: While HCV prevalence and genotypes have been well characterised in patients in well‐resourced countries, clinical trials are urgently required in SSA where highly diverse g4 and 7 strains circulate.

The global plan to eradicate hepatitis C virus (HCV) led by the World Health Organization outlines the use of highly effective direct-acting antiviral drugs (DAAs) to achieve elimination by 2030. Identifying individuals with active disease and investigation of the breadth of diversity of the virus in sub-Saharan Africa (SSA) is essential as genotypes in this region (where very few clinical trials have been carried out) are distinct from those found in other parts of the world. We undertook a population-based, nested case-control study in Uganda and obtained additional samples from the Democratic Republic of Congo (DRC) to estimate the prevalence of HCV, assess strategies for disease detection using serological and molecular techniques, and characterize genetic diversity of the virus. Using next-generation and Sanger sequencing, we aimed to identify strains circulating in East and Central Africa. A total of 7,751 Ugandan patients were initially screened for HCV, and 20 PCR-positive samples were obtained for sequencing. Serological assays were found to vary significantly in specificity for HCV. HCV strains detected in Uganda included genotype (g) 4k, g4p, g4q, and g4s and a newly identified unassigned g7 HCV strain. Two additional unassigned g7 strains were identified in patients originating from DRC (one partial and one full open reading frame sequence). These g4 and g7 strains contain nonstructural (ns) protein 3 and 5A polymorphisms associated with resistance to DAAs in other genotypes. Clinical studies are therefore indicated to investigate treatment response in infected patients. Conclusion: Although HCV prevalence and genotypes have been well characterized in patients in well-resourced countries, clinical trials are urgently required in SSA, where highly diverse g4 and g7 strains circulate.