Kenneth Roger Katumba

Introduction: Daily oral pre‐exposure prophylaxis (PrEP) use remains low among adolescent girls and young women (AGYW). We evaluated whether a peer support intervention improved daily oral PrEP uptake and adherence among AGYW at high risk of HIV acquisition in Kampala, Uganda. Methods: We conducted an open‐label randomized controlled trial (January 2023−June 2024) among 14‐ to 24‐year‐olds engaged in sex work. Eligible participants were randomized 1:1 to receive either health worker counselling only (control) or supplemented with peer support (intervention). Peer leaders delivered co‐created peer education sessions starting 1 month after enrolment. Participants were followed for 12 months. Co‐primary outcomes were PrEP uptake (yes/no) and adherence, evaluated using two separate measures; optimal if: ≥85% pill‐counts (primary measure); positive point‐of‐care urine tenofovir test. Both arms received adherence counselling based on urine results. Secondary outcomes: PrEP persistence (time to discontinuation) and cost‐effectiveness (cost per disability adjusted life year/DALY averted). Analysis used logistic regression (uptake); generalized estimating equations (adherence), Cox regression (persistence) and incremental cost‐effectiveness ratio (ICER) below US$537 per DALY averted was considered cost‐effective. Results: We enrolled 394 participants (197 per arm) with a mean age of 19.4 (SD ±2.3) years. The intervention did not impact PrEP uptake (OR 1.15; 95% CI 0.77−1.71) but improved adherence, pill count (OR 2.20; 95% CI 1.23−3.95) and urine assay (OR 2.18; 95% CI 1.22−3.91). Optimal adherence was low but significantly higher in the intervention by both measures: pill count (intervention = 54.8%, control = 39.6%, p = 0.008), urine assay (intervention = 54.8%, control = 40.8%, p = 0.001). Median duration before PrEP discontinuation was 38 days (IQR 0–319 days); intervention (56 days), control (29 days). The intervention had no effect on persistence (HR 0.86; 95% CI 0.64−1.14). It was cost‐effective with the urine tenofovir assay (ICER = $459) but not with pill counts (ICER = $581). Conclusions: This peer‐led intervention improved PrEP adherence among AGYW in Kampala and is recommended in high‐incidence settings. Urine tenofovir testing can be used to assess adherence if affordable. Enhanced peer support strategies are needed until long‐acting PrEP becomes accessible and acceptable. Future research should optimize timing, intensity and delivery models of peer support interventions and integrate them with long‐acting PrEP to improve sustainability.

Between 8%–39% of people living with HIV (PLWH) in sub-Saharan Africa have a depressive disorder (DD). Despite considerable gains in the treatment of PLWH, DD is increasingly recognised as a threat to successful treatment and prevention. PLWH incur higher health-related costs than the general population due to chronic care management needs. We aimed to estimate the combined economic burden of DD and HIV amongst PLWH and explore their mechanisms of coping with high-of-pocket health expenditure. This was a cost of illness study nested in a cluster-randomized trial that assessed the effectiveness of integrating treatment of DD into routine HIV care in Uganda (HIV+D trial). The study used cross-sectional data collected from 1115 PLWH across both trial arms at baseline, using the 9-item Patient Health Questionnaire (PHQ-9) to measure DD and a structured cost questionnaire. The mean monthly economic cost of HIV and DD amongst n = 486 participants reporting at least one non-zero cost item was United States Dollars (USD) 11.72 (2022 prices), while the mean across the whole sample (including zeroes) was USD 5.05. Mean monthly out-of-pocket expenditure amongst participants reporting at least one non-zero item was USD 7.22, which is 4% of average monthly household income. It was USD 3.11 in the sample as a whole. Moderate DD symptoms (PHQ-9 between 15–19) and severe symptoms (PHQ-9 ≥ 20) were reported by 30% and 5% of respondents respectively, with the remainder experiencing mild symptoms. Social protection mechanisms combined with the integration of the management of DD into routine HIV care could help alleviate this burden.

Background: Structural, interpersonal and individual level factors can present barriers for HIV prevention behaviour among people at high risk of HIV acquisition, including women who sell sex. In this paper we document the contexts in which women selling sex in Kampala meet and provide services to their clients. Methods: We collected qualitative data using semi-structured interviews. Women were eligible to participate if they were 18 years or older, self-identified as sex workers or offered sex for money and spoke Luganda or English. Ten women who met clients in venues and outdoor locations were selected randomly from a clinic for women at high risk of HIV acquisition. Ten other women who met clients online were recruited using snowball sampling. Interviews included demographic data, and themes included reasons for joining and leaving sex work, work locations, nature of relationships with clients and peers, interaction with authorities, regulations on sex work, and reported stigma. We conducted interviews over three months. Data were analysed thematically using a framework analysis approach. The coding framework was based on structural factors identified from literature, but also modified inductively with themes arising from the interviews. Results: Women met clients in physical and virtual spaces. Physical spaces included venues and outdoor locations, and virtual spaces were online platforms like social media applications and websites. Of the 20 women included, 12 used online platforms to meet clients. Generally, women from the clinic sample were less educated and predominantly unmarried, while those from the snowball sample had more education, had professional jobs, or were university students. Women from both samples reported experiences of stigma, violence from clients and authorities, and challenges accessing health care services due to the illegality of sex work. Even though all participants worked in settings where sex work was illegal and consequently endured harsh treatment, those from the snowball sample faced additional threats of cybersecurity attacks, extortion from clients, and high levels of violence from clients. Conclusions: To reduce risk of HIV acquisition among women who sell sex, researchers and implementers should consider these differences in contexts, challenges, and risks to design innovative interventions and programs that reach and include all women.

Background UPTAKE is a programme to accelerate access and facilitate adherence to effective and innovative long-acting technologies to prevent HIV and unintended pregnancy among Adolescent Girls and Young Women (AGYW) and Female Sex Workers (FSW) through behavioural science in Kenya and Uganda. We identified characteristics which predict the use of HIV and pregnancy prevention products and measured the strength of preferences. Methods A quantitative survey was administered to 326 AGYW and 334 FSW in both countries. Descriptive, inferential, and segmentation analysis was applied to reveal user-preferences, behavioural patterns and the predicting factors of product uptake. Results Product usage, particularly for HIV prevention, was lower among AGYW than FSW. Although awareness of long-acting prevention products including implants and intra-uterine devices (IUDs) was high among both groups, uptake remained low, primarily due to perceived side effects. For pregnancy prevention, the male condom was most used among both AGYW and FSW, followed by injectables. For HIV prevention, male condoms were most used, followed by oral pre-exposure prophylaxis (PrEP). Effectiveness and easy accessibility were the most highly valued product features. The influential factors driving and predicting uptake varied by product. At the 0.05 significance level, risk preference, stigma, Intimate Partner Violence (IPV), locus of control, peer influence, subjective risk, country, and age appeared significant in influencing uptake of various products. Segmentation was only found influential for the uptake of implants and male condoms among AGYW. Conclusion More than half of participants are aware of long-acting contraceptive products, though only 17% of AGYW and 22% of FSW used implants, and less than 2% used IUDs. Furthermore, very few recognised the ring as a HIV prevention method, and none used it. Behavioural interventions should be tailored by product and respond to the key influential factors to increase awareness and bridge the gap between awareness and uptake.

Each year, nearly 30 million children globally are at risk of developmental difficulties and disability as a result of newborn health conditions, with the majority living in resource-constrained countries. This study estimates the annual cost to families related to caring for a young child with developmental disability in Uganda. Nested within a feasibility trial of early care and support for young children with developmental disabilities, this sub-study estimated the cost of illness, the cost of paternal abandonment of the caregiver and the affordability of care by household. Seventy-three caregivers took part in this sub-study. The average annual cost of illness to families was USD 949. The main cost drivers were the cost of seeking care and income lost due to loss of employment. Households caring for a child with a disability spent more than the national average household expenditure, and the annual cost of illness for all households was more than 100% of the national GDP per capita. In addition, 84% of caregivers faced economic consequences and resorted to wealth-reducing coping strategies. Families caring for a child with severe impairment incurred USD 358 more on average than those with mild or moderate impairment. Paternal abandonment was common (31%) with affected mothers losing an average of USD 430 in financial support. Caring for a young child with developmental disability was unaffordable to all the study households. Programmes of early care and support have the potential to reduce these financial impacts. National efforts to curb this catastrophic health expenditure are necessary.

Background: It is rare to find HIV/AIDS care providers in sub-Saharan Africa routinely providing mental health services, yet 8–30% of the people living with HIV have depression. In an ongoing trial to assess integration of collaborative care of depression into routine HIV services in Uganda, we will assess quality of life using the standard EQ-5D-5L, and the capability-based OxCAP-MH which has never been adapted nor used in a low-income setting. We present the results of the translation and validation process for cultural and linguistic appropriateness of the OxCAP-MH tool for people living with HIV/AIDS and depression in Uganda. Methods: The translation process used the Concept Elaboration document, the source English version of OxCAP-MH, and the Back-Translation Review template as provided during the user registration process of the OxCAP-MH, and adhered to the Translation and Linguistic Validation process of the OxCAP-MH, which was developed following the international principles of good practice for translation as per the International Society for Pharmacoeconomics and Outcomes Research’s standards. Results: The final official Luganda version of the OxCAP-MH was obtained following a systematic iterative process, and is equivalent to the English version in content, but key concepts were translated to ensure cultural acceptability, feasibility and comprehension by Luganda-speaking people. Conclusion: The newly developed Luganda version of the OxCAP-MH can be used both as an alternative or as an addition to health-related quality of life patient-reported outcome measures in research about people living with HIV with comorbid depression, as well as more broadly for mental health research.

Background: Cryptococcal meningitis (CCM) remains one of the leading causes of mortality among HIV infected patients. Due to factors such as the severity of CCM pathology, the quality of life (QOL) of patients post-treatment is likely to be poor. Few studies have reported on QOL of CCM patients post treatment completion. We used data collected among patients in the CryptoDex trial (ISRCTN59144167) to determine QOL and associated factors at week 10 and six months from treatment initiation. Methodology: CryptoDex was a double-blind placebo-controlled trial of adjunctive dexamethasone in HIV infected adults with CCM, conducted between 2013 and 2015 in six countries in Asia and Africa. QOL was determined using the descriptive and Visual Analog Scales (VAS) of the EuroQol Five-Dimension-Three-Level (EQ-5D-3L) tool. We derived index scores, and described these and the VAS scores at 10 weeks and 6 months; and used linear regression to determine the relationship between various characteristics and VAS scores at both time points. VAS scores were interpreted as very good (81–100), good (51–80), normal (31–50) and bad/very bad (0–30). Results: Of 451 patients enrolled in the trial, 238 had QOL evaluations at week 10. At baseline, their mean age (SD) was 35.2(8.5) years. The mean index scores (SD) were 0.785(0.2) and 0.619(0.4) among African and Asian patients respectively at week 10, and 0.879(0.2) and 0.731(0.4) among African and Asian patients respectively at month six. The overall mean VAS score (SD) at 10 weeks was 57.2 (29.7), increasing significantly to 72(27.4) at month six (p<0.001). At week 10, higher VAS score was associated with greater weight (p = 0.007) and being African (p<0.001), while lower VAS score was associated with positive yeast culture at day 14 (p = 0.026). At month six, higher VAS score remained associated with African origin (p = 0.006) while lower VAS score was associated with positive yeast culture (p = 0.006). Lower VAS scores were associated with higher number of inpatient days at 10 weeks and 6 months (p = 0.003 and 0.002 respectively). Conclusion: QOL was good among patients that had completed therapy for CCM, but below perfect. Strategies to improve QOL among CCM survivors are required.

Introduction Early intervention programmes (EIPs) for infants with neurodevelopmental impairment have been poorly studied especially in low-income settings. We aim to evaluate the feasibility and acceptability of a group participatory EIP, the ‘ABAaNA EIP’, for young children with neurodevelopmental impairment in Uganda. Methods and analysis We will conduct a pilot feasibility, single-blinded, randomised controlled trial comparing the EIP with standard care across two study sites (one urban, one rural) in central Uganda. Eligible infants (n=126, age 6–11 completed months) with neurodevelopmental impairment (defined as a developmental quotient Ethics and dissemination The trial protocol has been approved by the relevant Ugandan and UK ethics committees. Recruited families will give written informed consent and we will follow international codes for ethics and good clinical practice. Dissemination will be through peer-reviewed publications, conference presentations and public engagement. Trial registration number ISRCTN44380971; protocol version 3.0, 19th February 2018.

I nternational goals for elimination of hepatitis B virus (HBV) infection set ambitious targets for 2030. In many African populations, HBV prevalence remains high (≥8%) despite the roll-out of infant HBV immunisation from the mid-1990’s onwards. Enhanced efforts are now urgently required to improve an understanding of population epidemiology, in order to determine which interventions are most likely to be effective in advancing populations towards elimination goals. In populations with a high prevalence of infection, catch-up HBV vaccination of adults has sometimes been deployed as a preventive strategy. An alternative approach of ‘test and treat’ could be applied as a tool to interrupt transmission. We used a systematic approach to investigate the relationship between prevalence of HBV infection (HBsAg) and exposure (anti-HBc) in Africa, and then applied a mathematical model to investigate the impact of catch-up vaccination and a ‘test and treat’ strategy in Uganda, representing a high prevalence setting. We demonstrate a strong relationship between the prevalence of HBsAg and anti-HBc (p<0.0001), but with region-specific differences that may reflect different patterns of transmission. In high prevalence settings, catch-up vaccination may have a transient effect but this intervention does not contribute to a sustained decline in prevalence. In contrast, diagnosing and treating infection has a marked impact on reducing prevalence, equivalent to that of infant immunisation. Conclusion: We have developed a high-resolution picture of HBV epidemiology across Africa. Developing insights into regional differences provides an evidence base for the most effective interventions. In combination with robust neonatal immunisation programmes, testing and treating infection is likely to be of most impact in making advances towards elimination targets.