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author:("patch, Robin")
1.  Abbreviated HIV counselling and testing and enhanced referral to care in Uganda: a factorial randomised controlled trial 
The lancet global health  2013;1(3):e137-e145.
Summary
Background
HIV counselling and testing and linkage to care are crucial for successful HIV prevention and treatment. Abbreviated counselling could save time; however, its effect on HIV risk is uncertain and methods to improve linkage to care have not been studied.
Methods
We did this factorial randomised controlled study at Mulago Hospital, Uganda. Participants were randomly assigned to abbreviated or traditional HIV counselling and testing; HIV-infected patients were randomly assigned to enhanced linkage to care or standard linkage to care. All study personnel except counsellors and the data officer were masked to study group assignment. Participants had structured interviews, given once every 3 months. We compared sexual risk behaviour by counselling strategy with a 6·5% non-inferiority margin. We used Cox proportional hazards analyses to compare HIV outcomes by linkage to care over 1 year and tested for interaction by sex. This trial is registered with ClinicalTrials.gov (NCT00648232).
Findings
We enrolled 3415 participants; 1707 assigned to abbreviated counselling versus 1708 assigned to traditional. Unprotected sex with an HIV discordant or status unknown partner was similar in each group (232/823 [27·9%] vs 251/890 [28·2%], difference −0·3%, one-sided 95% CI 3·2). Loss to follow-up was lower for traditional counselling than for abbreviated counselling (adjusted hazard ratio [HR] 0·61, 95% CI 0·44–0·83). 1003 HIV-positive participants were assigned to enhanced linkage (n=504) or standard linkage to care (n=499). Linkage to care did not have a significant effect on mortality or receipt of co-trimoxazole. Time to treatment in men with CD4 cell counts of 250 cells per μL or fewer was lower for enhanced linkage versus standard linkage (adjusted HR 0·60, 95% CI 0·41–0·87) and time to HIV care was decreased among women (0·80, 0·66–0·96).
Interpretation
Abbreviated HIV counselling and testing did not adversely affect risk behaviour. Linkage to care interventions might decrease time to enrolment in HIV care and antiretroviral treatment and thus might affect secondary HIV transmission and improve treatment outcomes.
Funding
US National Institute of Mental Health.
doi:10.1016/S2214-109X(13)70067-6
PMCID: PMC4129546  PMID: 25104262
2.  Decreases in self-reported alcohol consumption following HIV counseling and testing at Mulago Hospital, Kampala, Uganda 
BMC Infectious Diseases  2014;14:403.
Background
Alcohol use has a detrimental impact on the HIV epidemic, especially in sub-Saharan Africa. HIV counseling and testing (HCT) may provide a contact opportunity to intervene with hazardous alcohol use; however, little is known about how alcohol consumption changes following HCT.
Methods
We utilized data from 2056 participants of a randomized controlled trial comparing two methods of HCT and subsequent linkage to HIV care conducted at Mulago Hospital in Kampala, Uganda. Those who had not previously tested positive for HIV and whose last HIV test was at least one year in the past were eligible. Participants were asked at baseline when they last consumed alcohol, and prior three month alcohol consumption was measured using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) at baseline and quarterly for one year. Hazardous alcohol consumption was defined as scoring ≥3 or ≥4 for women and men, respectively. We examined correlates of alcohol use at baseline, and of hazardous and non-hazardous drinking during the year of follow-up using multinomial logistic regression, clustered at the participant level to account for repeated measurements.
Results
Prior to HCT, 30% were current drinkers (prior three months), 27% were past drinkers (>3 months ago), and 44% were lifetime abstainers. One-third (35%) of the current drinkers met criteria for hazardous drinking. Hazardous and non-hazardous self-reported alcohol consumption declined after HCT, with 16% of baseline current drinkers reporting hazardous alcohol use 3 months after HCT. Independent predictors (p < 0.05) of continuing non-hazardous and hazardous alcohol consumption after HCT were sex (male), alcohol consumption prior to HCT (hazardous), and HIV status (negative). Among those with HIV, non-hazardous drinking was less likely among those taking antiretroviral therapy (ART).
Conclusions
HCT may be an opportune time to intervene with alcohol consumption. Those with HIV experienced greater declines in alcohol consumption after HCT, and non-hazardous drinking decreased for those with HIV initiating ART. HCT and ART initiation may be ideal times to intervene with alcohol consumption. Screening and brief intervention (SBI) to reduce alcohol consumption should be considered for HCT and HIV treatment venues.
doi:10.1186/1471-2334-14-403
PMCID: PMC4223423  PMID: 25038830
Alcohol; Africa; HIV; HIV counseling and testing; Antiretroviral therapy; Screening and brief intervention
3.  Injecting Risk Behavior among Traveling Young Injection Drug Users: Travel Partner and City Characteristics 
Young injection drug users (IDUs), a highly mobile population, engage in high levels of injecting risk behavior, yet little is understood about how such risk behavior may vary by the characteristics of the cities to which they travel, including the existence of a syringe exchange program (SEP), as well as travel partner characteristics. In 2004–2005, we conducted a 6-month prospective study to investigate the risk behavior of 89 young IDUs as they traveled, with detailed information gathered about 350 city visits. In multivariable analyses, travel to larger urban cities with a population of 500,000–1,000,000 was significantly associated with injecting drugs (adjusted odds ratio (AOR) = 3.71; 95 % confidence interval (CI), 1.56–8.82), ancillary equipment sharing (AES; AOR = 7.05; 95 % CI, 2.25–22.06) and receptive needle sharing (RNS; AOR = 5.73; 95 % CI, 1.11–27.95), as compared with visits to smaller cities with populations below 50,000. Region of the country, and the existence of a SEP within the city visited, were not independently associated with injecting drugs, AES, or RNS during city visits. Traveling with more than one injecting partner was associated with injecting drugs during city visits (AOR = 2.77; 95 % CI, 1.46–5.27), when compared with traveling alone. Additionally, both non-daily and daily/almost daily alcohol use during city visits were associated with AES (AOR = 3.37; 95 % CI, 1.42–7.68; AOR = 3.03; 95 % CI, 1.32–6.97, respectively) as compared with no alcohol consumption. Traveling young IDUs are more likely to inject when traveling with other IDUs and to engage in higher risk injection behavior when they are in large cities. Risk behavior occurring in city visits, including equipment sharing and alcohol consumption, suggests further need for focused interventions to reduce risk for viral infection among this population.
doi:10.1007/s11524-012-9718-2
PMCID: PMC3665972  PMID: 22744293
Young IDUs; Travelers; Injecting risk; Ancillary equipment sharing; Receptive needle sharing; City characteristics; Travel partners
4.  Alcohol consumption as a barrier to prior HIV testing in a population-based study in rural Uganda 
AIDS and behavior  2013;17(5):1713-1723.
Early receipt of HIV care and ART is essential for improving treatment outcomes, but is dependent first upon HIV testing. Heavy alcohol consumption is common in sub-Saharan Africa, a barrier to ART adherence, and a potential barrier to HIV care. We conducted a population-based study of 2,516 adults in southwestern Uganda from November-December 2007, and estimated the relative risk of having never been tested for HIV using sex-stratified Poisson models. More men (63.9%) than women (56.9%) had never been tested. In multivariable analysis, compared to women who had not consumed alcohol for at least 5 years, women who were current heavy drinkers and women who last drank alcohol 1-5 years prior, were more likely to have never been tested. Alcohol use was not associated with prior HIV testing among men. HIV testing strategies may thus need to specifically target women who drink alcohol.
doi:10.1007/s10461-012-0282-2
PMCID: PMC3769173  PMID: 22878790
alcohol; HIV testing; Uganda; barriers; sub-Saharan Africa
5.  Self-report of alcohol use increases when specimens for alcohol biomarkers are collected in persons with HIV in Uganda 
doi:10.1097/QAI.0b013e318267c0f1
PMCID: PMC3495104  PMID: 23138732
Alcohol; self-report; phosphatidylethanol; biomarker; bias; sub-Saharan Africa
6.  Contraceptive Use and Associated Factors among Women Enrolling into HIV Care in Southwestern Uganda 
Background. Preventing unintended pregnancies among women living with HIV is an important component of prevention of mother-to-child HIV transmission (PMTCT), yet few data exist on contraceptive use among women entering HIV care. Methods. This was a retrospective study of electronic medical records from the initial HIV clinic visits of 826 sexually active, nonpregnant, 18–49-year old women in southwestern Uganda in 2009. We examined whether contraceptive use was associated with HIV status disclosure to one's spouse. Results. The proportion reporting use of contraception was 27.8%. The most common method used was injectable hormones (51.7%), followed by condoms (29.6%), and oral contraceptives (8.7%). In multivariable analysis, the odds of contraceptive use were significantly higher among women reporting secondary education, higher income, three or more children, and younger age. There were no significant independent associations between contraceptive use and HIV status disclosure to spouse. Discussion. Contraceptive use among HIV-positive females enrolling into HIV care in southwestern Uganda was low. Our results suggest that increased emphasis should be given to increase the contraception uptake for all women especially those with lower education and income. HIV clinics may be prime sites for contraception education and service delivery integration.
doi:10.1155/2012/340782
PMCID: PMC3469089  PMID: 23082069
7.  Potential for false positive HIV test results with the serial rapid HIV testing algorithm 
BMC Research Notes  2012;5:154.
Background
Rapid HIV tests provide same-day results and are widely used in HIV testing programs in areas with limited personnel and laboratory infrastructure. The Uganda Ministry of Health currently recommends the serial rapid testing algorithm with Determine, STAT-PAK, and Uni-Gold for diagnosis of HIV infection. Using this algorithm, individuals who test positive on Determine, negative to STAT-PAK and positive to Uni-Gold are reported as HIV positive. We conducted further testing on this subgroup of samples using qualitative DNA PCR to assess the potential for false positive tests in this situation.
Results
Of the 3388 individuals who were tested, 984 were HIV positive on two consecutive tests, and 29 were considered positive by a tiebreaker (positive on Determine, negative on STAT-PAK, and positive on Uni-Gold). However, when the 29 samples were further tested using qualitative DNA PCR, 14 (48.2%) were HIV negative.
Conclusion
Although this study was not primarily designed to assess the validity of rapid HIV tests and thus only a subset of the samples were retested, the findings show a potential for false positive HIV results in the subset of individuals who test positive when a tiebreaker test is used in serial testing. These findings highlight a need for confirmatory testing for this category of individuals.
doi:10.1186/1756-0500-5-154
PMCID: PMC3392728  PMID: 22429706
False positive; HIV testing algorithm; Rapid diagnostic tests; Qualitative PCR testing
8.  Missed Opportunities for HIV Testing and Late-Stage Diagnosis among HIV-Infected Patients in Uganda 
PLoS ONE  2011;6(7):e21794.
Background
Late diagnosis of HIV infection is a major challenge to the scale-up of HIV prevention and treatment. In 2005 Uganda adopted provider-initiated HIV testing in the health care setting to ensure earlier HIV diagnosis and linkage to care. We provided HIV testing to patients at Mulago hospital in Uganda, and performed CD4 tests to assess disease stage at diagnosis.
Methods
Patients who had never tested for HIV or tested negative over one year prior to recruitment were enrolled between May 2008 and March 2010. Participants who tested HIV positive had a blood draw for CD4. Late HIV diagnosis was defined as CD4≤250 cells/mm. Predictors of late HIV diagnosis were analyzed using multi-variable logistic regression.
Results
Of 1966 participants, 616 (31.3%) were HIV infected; 47.6% of these (291) had CD4 counts ≤250. Overall, 66.7% (408) of the HIV infected participants had never received care in a medical clinic. Receiving care in a non-medical setting (home, traditional healer and drug stores) had a threefold increase in the odds of late diagnosis (OR = 3.2; 95%CI: 2.1–4.9) compared to receiving no health care.
Conclusions
Late HIV diagnosis remains prevalent five years after introducing provider-initiated HIV testing in Uganda. Many individuals diagnosed with advanced HIV did not have prior exposure to medical clinics and could not have benefitted from the expansion of provider initiated HIV testing within health facilities. In addition to provider-initiated testing, approaches that reach individuals using non-hospital based encounters should be expanded to ensure early HIV diagnosis.
doi:10.1371/journal.pone.0021794
PMCID: PMC3130049  PMID: 21750732

Results 1-8 (8)