BACKGROUND: Despite global efforts to improve HIV care, late diagnosis and delayed antiretroviral therapy (ART) initiation continue to pose mortality risks among people living with HIV (PLHIV) with advanced HIV disease (AHD). This study investigated factors associated with mortality among PLHIV with AHD in rural North-Central Uganda from January 2018 to December 2021. METHODS: We retrospectively reviewed electronic medical records from 18 health facilities, collecting data on demographics and clinical characteristics, including baseline CD4 count, ART regimen, BMI, TB status, TPT use, WHO clinical stage, and viral load. AHD was defined as a baseline CD4 < 200 cells/mm³. Cox proportional hazards modeling identified mortality-associated factors, reported as adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs), using a 5% significance level. RESULTS: We analyzed 1161 PLHIV with AHD, contributing 1565.6 person-years. There were 84 deaths (7.2%), yielding a mortality rate of 5.4 per 100 person-years (95% CI: 4.33-6.64). Mortality was significantly associated with age ≥ 50 years (aHR 4.16 [1.77-9.77]), no viral load test (aHR 16.23 [7.44-35.39]), viral load non-suppression (aHR 9.05 [3.37-24.29]), CD4 ≤ 50 (aHR 1.91 [1.08-3.39]), no TB prophylaxis (aHR 3.51 [1.83-6.74]), and WHO stage 3 or 4 (aHR 1.91 [1.12-3.27]). CONCLUSION: Despite advances in HIV programs, the mortality rate among patients with AHD highlights ongoing challenges. Early identification of AHD patients, regular viral load testing, optimizing ART and ensuring adherence, along with promoting tuberculosis preventive therapy, could help reduce mortality, improve patient outcomes, and achieve HIV epidemic control by 2030.

INTRODUCTION: The antiretroviral therapy (ART) initiation policy in Uganda recommends that ART is initiated on the same day of HIV diagnosis to those who do not have contraindications. We assessed determinants of retention in ART care at the first follow-up (FFU) after same-day ART initiation and retention in long-term care beyond the FFU visit. METHODS: We conducted a retrospective longitudinal analysis among persons living with HIV aged ≥18 years who initiated ART during April 2016-February 2021 after the inception of Uganda's Test-and-Treat ART policy, which states that 'all individuals diagnosed with HIV should initiate ART regardless of clinical stage CD4 count'. Missing the FFU after ART initiation (missing FFU) was defined as not returning for FFU within 1 month of ART initiation; loss to follow-up long-term (LTFU-LT) was defined as delaying more than 3 months to return for a scheduled ART drug refill after the FFU appointment. LTFU-LT time was defined as the time from the FFU visit date to the last follow-up visit date during the study period. We used log-binomial distributions to estimate unadjusted and adjusted relative risks (adjRRs) of missing FFU, and we used Cox proportional hazard models to estimate unadjusted and adjusted hazard ratios (adjHRs) for LTFU-LT. RESULTS: Overall, 8332 clients initiated ART on the same day of HIV diagnosis. Most were female (55%), aged 25-34 years (44%), resided in the semi-urban or rural district (41% and 41%, respectively) and had a median age of 25 years (IQR = 24-35). Overall, missing FFU was 15.1%. Increased likelihood/risk of missing FFU was seen in clients who initiated ART at outreach health service centres versus health facilities (adjRRs = 1.79, 95% CI = 1.6-2.0), in younger clients aged 18-24 years and 25-34 years versus ≥45 years [(adjRRs = 1.65, 95% CI = 1.3-2.0) and (adjRRs = 1.31, 95% CI = 1.1-1.6), respectively], and clients residing in agrarian districts versus fishing districts (adjRRs = 1.24, 95% CI = 1.1-1.4). Overall, the LTFU-LT rate was 25 clients/100 pys (95% CI = 23.9-25.9) and was associated with younger age (18-34 years versus ≥45 years, adjHRs = 1.77, 95% CI = 1.5-2.1), residence in semi-urban (adjHRs = 1.33, 95% CI = 1.2-1.5) or agrarian district (adjHRs = 1.30, 95% CI = 1.2-1.5) versus fishing-community district. CONCLUSION: Retention-strengthening strategies in tandem with same-day ART initiation efforts for younger clients and clients initiated on ART from mobile and outreach health service settings might improve HIV treatment retention. Best practices for retaining fishing-community clients might improve health outcomes if applied to agrarian and semi-urban communities.

BACKGROUND: Tuberculosis (TB) is the leading cause of death among people living with HIV (PLHIV). Antiretroviral therapy (ART) initiation lowers the risk of HIV-associated TB. Earlier studies have shown TB incidence to be high in the first year of ART. We undertook a study to (1) assess the incidence of TB and (2) associated factors among persons initiating ART in a rural cohort. METHODS: We conducted a retrospective cohort analysis study among PLHIV aged ≥ 18 years, initiated on ART from January 1, 2012, to December 31, 2019, and TB disease-free at the time of ART initiation, at Kalisizo ART clinic. TB disease incidence was calculated by dividing the number of new TB cases by the total follow-up time expressed per 100 person-years among persons followed up until the date of incident TB disease, loss to follow-up, transfer out, death or censored at the end of the study; whichever occurred first. Factors associated with TB disease incidence were assessed in the multivariable analysis by Poisson regression analysis at 5% significance level. RESULTS: For the period 2012 to 2019, 2,589 PLHIV were initiated on ART; 57% (1,470/2,589) were female. Females were more likely to be aged below 35 years while males were more likely to be aged 25-44 years (p < 0.001). Eighty-seven per cent (1,269/1,470) of females compared to 78% (866/1,119) of males were in WHO clinical stage 1 (p < 0.001). Sixty-one TB disease events were observed in 7,363 person-years. The overall TB disease incidence was 0.83 (95% CI: 0.63-1.06) per 100 person-years. Males were more likely than females to develop TB disease, adjusted incidence rate ratio (adj IRR) 2.13 (95% CI: 1.27-3.57) per 100 person-years, p = 0.004. Compared to using ART for 0-5 months, time on ART was associated with a lower TB incidence rate at 6-12 months, 13-24 months, > 24 months (adj IRR 0.20 (95% CI: 0.09-0.46), 0.14 (95% CI: 0.06-0.33), 0.16 (95% CI: 0.08-0.31) p < 0.001 respectively). CONCLUSIONS AND RECOMMENDATIONS: Incidence of TB among PLHIV on ART was low in this rural population. Clinicians offering care to people with HIV in the rural setting should have a heightened index of suspicion for TB disease.

Key populations (KP), such as female sex workers (FSW) and men who have sex with men (MSM) can engage in multiple behaviors associated with HIV risk, but they are typically categorized by a single defining behavior, i.e., selling sex and sex with a man, respectively. We estimated the prevalence of engaging in multiple KP defining behaviors such as buying/selling sex, receptive anal sex, and injection drug use (IDU) among KP in Uganda. Data were collected at survey offices in four sites (Kampala, Jinja, Mbarara, and Masaka) through respondent-driven sampling. Data across multiple sites were combined and reweighted based on the combined sample size for each population. We fitted weighted multinomial logistic models for additional KP defining behaviors using demographics as predictors, and the simplest plausible model was identified for each KP using the Bayesian Information Criterion. Among FSW and sexually exploited minors under 18 years of age, 21.8% (CI: 20.1-23.5%) ever engaged in anal sex and 12.0% (CI: 10.6-13.3%) ever engaged in IDU in our model. Among MSM, 54.8% (CI: 52.0-57.7%) ever engaged in buying/selling sex and 11.0% (CI: 9.3-12.8%) ever engaged in IDU in the model. While KP are generally viewed as independent groups, our findings demonstrate that KP defining behaviors such as buying/selling sex, anal sex with a man, and IDU are shared across populations, with buying/selling sex particularly common among MSM. Consideration of comprehensive behaviors by outreach and service providers may better inform HIV risk reduction and prevention services for key populations.

BACKGROUND: Widespread COVID-19 vaccine uptake can facilitate epidemic control. A February 2021 study in Uganda suggested that public vaccine uptake would follow uptake among leaders. In May 2021, Baylor Uganda led community dialogue meetings with district leaders from Western Uganda to promote vaccine uptake. We assessed the effect of these meetings on the leaders' COVID-19 risk perception, vaccine concerns, perception of vaccine benefits and access, and willingness to receive COVID-19 vaccine. METHODS: All departmental district leaders in the 17 districts in Western Uganda, were invited to the meetings, which lasted approximately four hours. Printed reference materials about COVID-19 and COVID-19 vaccines were provided to attendees at the start of the meetings. The same topics were discussed in all meetings. Before and after the meetings, leaders completed self-administered questionnaires with questions on a five-point Likert Scale about risk perception, vaccine concerns, perceived vaccine benefits, vaccine access, and willingness to receive the vaccine. We analyzed the findings using Wilcoxon's signed-rank test. RESULTS: Among 268 attendees, 164 (61%) completed the pre- and post-meeting questionnaires, 56 (21%) declined to complete the questionnaires due to time constraints and 48 (18%) were already vaccinated. Among the 164, the median COVID-19 risk perception scores changed from 3 (neutral) pre-meeting to 5 (strong agreement with being at high risk) post-meeting (p < 0.001). Vaccine concern scores reduced, with medians changing from 4 (worried about vaccine side effects) pre-meeting to 2 (not worried) post-meeting (p < 0.001). Median scores regarding perceived COVID-19 vaccine benefits changed from 3 (neutral) pre-meeting to 5 (very beneficial) post-meeting (p < 0.001). The median scores for perceived vaccine access increased from 3 (neutral) pre-meeting to 5 (very accessible) post-meeting (p < 0.001). The median scores for willingness to receive the vaccine changed from 3 (neutral) pre-meeting to 5 (strong willingness) post-meeting (p < 0.001). CONCLUSION: COVID-19 dialogue meetings led to district leaders' increased risk perception, reduced concerns, and improvement in perceived vaccine benefits, vaccine access, and willingness to receive the COVID-19 vaccine. These could potentially influence public vaccine uptake if leaders are vaccinated publicly as a result. Broader use of such meetings with leaders could increase vaccine uptake among themselves and the community.

Ebola virus disease (EVD) is a rare and often deadly viral hemorrhagic fever (VHF); four species of Ebola virus (Zaire ebolavirus, Sudan ebolavirus, Taï Forest ebolavirus, and Bundibugyo ebolavirus) cause occasional outbreaks among humans and nonhuman primates* (1). Infection is transmitted through direct contact with infectious blood, body fluids, and animal tissues. Symptoms include fever, abdominal pain, diarrhea, vomiting, generalized body weakness, and hemorrhage. Since 2000, four outbreaks of EVD caused by Sudan ebolavirus have been identified in Uganda; the largest outbreak (in 2000) resulted in 425 cases and 224 (53%) deaths (2,3). No vaccine is available to prevent Sudan ebolavirus infection, and treatment is supportive. The estimated case fatality rate is 55% (4).

BACKGROUND: Safeguarding the psychological well-being of healthcare workers (HCWs) is crucial to ensuring sustainability and quality of healthcare services. During the COVID-19 pandemic, HCWs may be subject to excessive mental stress. We assessed the risk perception and immediate psychological state of HCWs early in the pandemic in referral hospitals involved in the management of COVID-19 patients in Uganda. METHODS: We conducted a cross-sectional survey in five referral hospitals from April 20-May 22, 2020. During this time, we distributed paper-based, self-administered questionnaires to all consenting HCWs on day shifts. The questionnaire included questions on socio-demographics, occupational behaviors, potential perceived risks, and psychological distress. We assessed risk perception towards COVID-19 using 27 concern statements with a four-point Likert scale. We defined psychological distress as a total score > 12 from the 12-item Goldberg's General Health Questionnaire (GHQ-12). We used modified Poisson regression to identify factors associated with psychological distress. RESULTS: Among 335 HCWs who received questionnaires, 328 (98%) responded. Respondents' mean age was 36 (range 18-59) years; 172 (52%) were male. The median duration of professional experience was eight (range 1-35) years; 208 (63%) worked more than 40 h per week; 116 (35%) were nurses, 52 (14%) doctors, 30 (9%) clinical officers, and 86 (26%) support staff. One hundred and forty-four (44%) had a GHQ-12 score > 12. The most common concerns reported included fear of infection at the workplace (81%), stigma from colleagues (79%), lack of workplace support (63%), and inadequate availability of personal protective equipment (PPE) (56%). In multivariable analysis, moderate (adjusted prevalence ratio, [aPR] = 2.2, 95% confidence interval [CI] 1.2-4.0) and high (aPR = 3.8, 95% CI 2.0-7.0) risk perception towards COVID-19 (compared with low-risk perception) were associated with psychological distress. CONCLUSIONS: Forty-four percent of HCWs surveyed in hospitals treating COVID-19 patients during the early COVID-19 epidemic in Uganda reported psychological distress related to fear of infection, stigma, and inadequate PPE. Higher perceived personal risk towards COVID-19 was associated with increased psychological distress. To optimize patient care during the pandemic and future outbreaks, workplace management may consider identifying and addressing HCW concerns, ensuring sufficient PPE and training, and reducing infection-associated stigma.

Rapid detection of increases in HIV transmission enables targeted outbreak response efforts to reduce the number of new infections. We analyzed US HIV surveillance data and identified spatiotemporal clusters of diagnoses. This systematic method can help target timely investigations and preventive interventions for maximum public health benefit.

The Global Health Security Agenda (GHSA), a partnership of nations, international organizations, and civil society, was launched in 2014 with a mission to build countries' capacities to respond to infectious disease threats and to foster global compliance with the International Health Regulations (IHR 2005). The US Centers for Disease Control and Prevention (CDC) assists partner nations to improve IHR 2005 capacities and achieve GHSA targets. To assess progress through these CDC-supported efforts, we analyzed country activity reports dating from April 2015 through March 2017. Our analysis shows that CDC helped 17 Phase I countries achieve 675 major GHSA accomplishments, particularly in the cross-cutting areas of public health surveillance, laboratory systems, workforce development, and emergency response management. CDC's engagement has been critical to these accomplishments, but sustained support is needed until countries attain IHR 2005 capacities, thereby fostering national and regional health protection and ensuring a world safer and more secure from global health threats.