Nelson Kaulukusi Sewankambo

Rheumatic heart disease (RHD) requires long-term secondary antibiotic prophylaxis to prevent disease progression, yet sustained patient engagement remains challenging in many low- and middle-income countries. Within Uganda’s first integrated decentralized RHD control program, Accelerating Delivery of Rheumatic Heart Disease Preventive Services in Uganda (ADUNU), we applied a human-centered design (HCD) approach to co-develop strategies for improving engagement in care. Using two Group Level Assessment sessions (with n = 43 stakeholders) and three design focus group discussions (n = 23 stakeholders), participants identified and prioritized feasible implementation strategies. Strategies were synthesized into four domains: community integrated follow-up, structured patient health education and counselling, provider capacity and service delivery improvement, and strengthening stock planning for medicine availability. These co-developed strategies directly address barriers related to missed appointments, limited understanding of RHD, provider-patient interactions, and medicine stockouts within decentralized primary care settings. This participatory approach generated contextually grounded strategies, ready for prospective testing within decentralized RHD programs.

BACKGROUND: The World Health Organization recommends echocardiographic screening and secondary prophylaxis for rheumatic heart disease (RHD), but evidence on how to implement these interventions within healthcare systems is limited. We report early implementation and clinical outcomes of an RHD program in northern Uganda. METHODS: From May 2023, the District Health Office in Kitgum trained primary healthcare workers in RHD screening and implemented registry-based secondary antibiotic prophylaxis in public facilities. We analyzed program and registry data through December 31, 2024. Data were obtained from aggregated program reports and individual-level records from the national RHD registry. We developed an RHD care cascade to examine screening uptake and outcomes, including adherence to secondary antibiotic prophylaxis. Adherence was categorized as perfect (100%), near perfect (90%–99%), acceptable (80%–89%), suboptimal (60% to 79%), or poor (2 tests. Time-to-event analysis was conducted to assess the probability of receiving an injection over time since enrollment. RESULTS: Health workers screened about 1% of the district’s target population each month. Over 18 months, 25 358 people were screened, including 1213 (4.8%) positive screens and 333 (1.3%) confirmed RHD cases. Among those screened, 16 406 (64%) were female, and 10 746 (42%) and 7333 (28%) were children (aged 5 years–14 years) and adolescents (aged 15 years–24 years), respectively. Of those with positive screens, 972 (80%) received confirmatory echocardiograms. Confirmed cases were relatively young (mean age 28 years), and 224 (67%) were female. Overall, 220 (75%) individuals achieved at least acceptable adherence. Among those who defaulted, 79% did so within 6 months of enrollment. CONCLUSIONS: An integrated RHD program in Uganda achieved successful delivery of echocardiographic screening within primary healthcare and acceptable early outcomes. The care cascade framework can be used to monitor similar RHD programs and identify opportunities for improvement.

The overall goal of intensive care treatment is to ensure patients return to an acceptable functional state, and, the decision-making in administering life

In a cluster-randomised trial in Uganda and Tanzania, we showed that integrated management, compared with standard vertical care, could achieve a high standard of care for diabetes and hypertension without adversely affecting outcomes for HIV. However, evidence on the value for money of integrated care is needed to inform policy. Our economic evaluation aimed to establish the value for money of integrated care compared with vertical care for HIV, diabetes and hypertension. A societal perspective was adopted, considering provider and patient costs for integrated and standard care in Uganda and Tanzania over one year. Provider costs were estimated for 6714 participants based on five representative health facilities per country. Patient costs were captured via questionnaire from a sub-sample of 2708 participants. Provider costs at scale were estimated using national prevalence and utilisation data. Key inputs were varied in two-way sensitivity analyses. Among participants with single conditions, mean provider and patient costs per patient-visit did not differ significantly between integrated and standard care. Among participants with multiple conditions, mean provider and patient costs per patient-visit were, respectively, Int$18.67 (95%CI 10.89-26.45, p < 0.0001) and Int$5.86 (95%CI 2.57-9.16, p = 0.0005) lower in integrated clinics. If scaled up, integrated care could save providers Int$229 million in Uganda and Int$72 million in Tanzania. From a societal perspective, integrated care for participants with multiple conditions generated mean cost-savings of Int$41.54 (95%CI 29.42-53.67, p < 0.0001) per patient-visit. Integrated care is cost-saving from a societal perspective and should be considered for scale-up in Tanzania, Uganda and similar settings. ISRCTN43896688.

Advancing doctoral and postdoctoral international bioethics training in low-and-middle income countries (LMICs) is essential to address the emerging and reemerging healthcare needs of local populations. The COVID-19 pandemic underscored the need for sustenance of global collaboration and rapid adaptability in the future to further prioritize research frameworks to benefit LMICs. Thus, the purpose of the manuscript is to share the successes, challenges, and future considerations of building bioethics research capacity in seven federally funded training programs supported by the Fogarty International Center of the National Institutes of Health D43 mechanism. We advocate for continued investment in training programs recognizing that it requires committed time and effort, specialized funding opportunities, cultural sensitivity, and interdisciplinary faculty support both domestically and internationally. This investment supports cross-disciplinary collaboration, enhances the ethical conduct of research and recognizes the importance of context-sensitive research that generates evidence-based data for global solutions.

Background: Preventing HIV infections among adolescents and young adults (AYAs) is crucial for curtailing the epidemic. Oral pre-exposure prophylaxis (PrEP) is a highly effective prevention method increasingly available to this age group in sub-Saharan Africa but population-based data on awareness and use of PrEP among AYAs remains limited. Methods: Analyzing survey data from 2 rounds of the Rakai Community Cohort Study, an open, population-based cohort, we estimated prevalence ratios associating various sociodemographic characteristics with PrEP awareness and ever-use among 15- to 24-year-olds in south-central Uganda between 2018 and 2023. Results: Most (62.4%, N = 3308/5301) participants were aware of PrEP as an HIV prevention method but only 1.7% (N = 133/7999) of AYAs had ever used it. Among the 35.5% (N = 2838/7999) of participants meeting PrEP eligibility criteria, ever-use was similarly rare (2.6%, N = 75/2838). Compared with 20 to 24-year-olds, 15 to 19-year-olds were less likely to report awareness [fullyadjPR (prevalence ratio) = 0.82, 95%CI (confidence interval): 0.78, 0.86] or ever-use (fullyadjPR = 0.35, 95%CI: 0.21, 0.58). Participants from fishing communities were more likely to be PrEP-aware (fullyadjPR = 1.22, 95%CI: 1.16, 1.29) or have ever used the prevention method (fullyadjPR = 6.07, 95%CI: 4.10, 8.98) than those from non-fishing communities. Conclusions: In this cross-sectional study of AYAs in Uganda, awareness of PrEP was common but ever-use was rare, even among the third of respondents who were likely PrEP-eligible. This suggests that prevention policies and barriers besides unawareness of the method impede PrEP initiation. Efforts that target those barriers, particularly for adolescents, are critical for reducing HIV incidence among this priority population.