Nneka Emenyonu | University of California, San Francisco (original) (raw)

CV by Nneka Emenyonu

Research paper thumbnail of Please visit my LinkedIn profile for my CV

Papers by Nneka Emenyonu

Research paper thumbnail of Diminishing Availability of Publicly Funded Slots for Antiretroviral Initiation among HIV-Infected ART-Eligible Patients in Uganda

Background: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART... more Background: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described.

Research paper thumbnail of Contraceptive use and associated factors among women enrolling into HIV care in southwestern Uganda

Infectious diseases in obstetrics and gynecology, 2012

Research paper thumbnail of Sexual relationship power and malnutrition among HIV-positive women in rural Uganda

AIDS and behavior, 2012

Inequality within partner relationships is associated with HIV acquisition and gender violence, b... more Inequality within partner relationships is associated with HIV acquisition and gender violence, but little is known about more pervasive effects on women's health. We performed a cross-sectional analysis of associations between sexual relationship power and nutritional status among women in Uganda. Participants completed questionnaires and anthropometric measurements. We assessed sexual relationship power using the Sexual Relationship Power Scale (SRPS). We performed logistic regression to test for associations between sexual relationship power and poor nutritional status including body mass index, body fat percentage, and mid-upper arm circumference. Women with higher sexual relationship power scores had decreased odds of low body mass index (OR 0.29, p = 0.01), low body fat percentage (OR 0.54, p = 0.04), and low mid-upper arm circumference (OR 0.22, p = 0.01). These relationships persisted in multivariable models adjusted for potential confounders. Targeted interventions to improve intimate partner relationship equality should be explored to improve health status among women living with HIV in rural Africa.

Research paper thumbnail of The WHOMEN’s Scale (Women’s HAART Optimism Monitoring and EvaluatioN Scale v.1) and the Association with Fertility Intentions and Sexual Behaviours Among HIV-Positive Women in Uganda

Aids and Behavior, 2009

The objective of this study was to develop a reliable HAART optimism scale among HIV-positive wom... more The objective of this study was to develop a reliable HAART optimism scale among HIV-positive women in Uganda and to test the scale’s validity against measures of fertility intentions, sexual activity, and unprotected sexual intercourse. We used cross-sectional survey data of 540 women (18–50 years) attending Mbarara University’s HIV clinic in Uganda. Women were asked how much they agreed or disagreed with 23 statements about HAART. Data were subjected to a principal components and factor analyses. Subsequently, we tested the association between the scale and fertility intentions and sexual behaviour using Wilcoxon rank sum test. Factor analysis yielded three factors, one of which was an eight-item HAART optimism scale with moderately high internal consistency (α = 0.70). Women who reported that they intended to have (more) children had significantly higher HAART optimism scores (median = 13.5 [IQR: 12–16]) than women who did not intend to have (more) children (median = 10.5 [IQR: 8–12]; P < 0.0001). Similarly, women who were sexually active and who reported practicing unprotected sexual intercourse had significantly higher HAART optimism scores than women who were sexually abstinent or who practiced protected sexual intercourse. Our reliable and valid scale, termed the Women’s HAART Optimism Monitoring and EvaluatioN scale (WHOMEN’s scale), may be valuable to broader studies investigating the role of HAART optimism on reproductive intentions and sexual behaviours of HIV-positive women in high HIV prevalence settings.

Research paper thumbnail of Antiretroviral Therapy is Associated with Increased Fertility Desire, but not Pregnancy or Live Birth, among HIV+ Women in an Early HIV Treatment Program in Rural Uganda

Aids and Behavior, 2009

To assess the association between antiretroviral therapy (ART) and fertility history and desire a... more To assess the association between antiretroviral therapy (ART) and fertility history and desire among HIV-positive Ugandan women, we conducted a cross-sectional study among HIV-positive Ugandan women aged 18-50 years who attended an HIV clinic at Mbarara University in western Uganda between November 1, 2005 and June 6, 2006. Of 538 women approached, 501 were enrolled. ART use was associated with increased odds of fertility desire (AOR 2.99, 95% CI 1.38-6.28), and decreased odds of pregnancy (AOR 0.56, 95% CI 0.33-0.95) and live birth (AOR 0.30, 95% CI 0.13-0.66). ART was associated with an increase in fertility desire, but was not associated

Research paper thumbnail of Creation and evaluation of EMR-based paper clinical summaries to support HIV-care in Uganda, Africa

International Journal of Medical Informatics, 2010

Purpose-Getting the right information to providers can improve quality of care. We set out to pro... more Purpose-Getting the right information to providers can improve quality of care. We set out to provide patient-specific Electronic Medical Record (EMR)-based clinical summaries for providers taking care of HIV-positive adult patients in the resource-limited setting of Mbarara, Uganda.

Research paper thumbnail of Transportation Costs Impede Sustained Adherence and Access to HAART in a Clinic Population in Southwestern Uganda: A Qualitative Study

Aids and Behavior, 2010

The cost of transportation for monthly clinic visits has been identified as a potential barrier t... more The cost of transportation for monthly clinic visits has been identified as a potential barrier to antiretroviral (ARV) adherence in sub-Saharan Africa and elsewhere, although there is limited data on this issue. We conducted open-ended interviews with 41 individuals living with HIV/AIDS and attending a clinic in Mbarara, Uganda, to understand structural barriers to ARV adherence and clinical care. Almost all respondents cited the need to locate funds for the monthly clinic visit as a constant source of stress and anxiety, and lack of money for transportation was a key factor in cases of missed doses and missed medical appointments. Participants struggled with competing demands between transport costs and other necessities such as food, housing and school fees. Our findings suggest that transportation costs can compromise both ARV adherence and access to care. Interventions that address this barrier will be important to ensure the success of ARV programs in sub-Saharan Africa.

Research paper thumbnail of Real-Time Adherence Monitoring for HIV Antiretroviral Therapy

Aids and Behavior, 2010

Current adherence assessments typically detect missed doses long after they occur. Real-time, wir... more Current adherence assessments typically detect missed doses long after they occur. Real-time, wireless monitoring strategies for antiretroviral therapy may provide novel opportunities to proactively prevent virologic rebound and treatment failure. Wisepill, a wireless pill container that transmits a cellular signal when opened, was pilot tested in ten Ugandan individuals for 6 months. Adherence levels measured by Wisepill, unannounced pill counts, and self-report were compared with each other, prior standard electronic monitoring, and HIV RNA. Wisepill data was initially limited by battery life and signal transmission interruptions. Following device improvements, continuous data was achieved with median (interquartile range) adherence levels of 93% (87–97%) by Wisepill, 100% (99–100%) by unannounced pill count, 100% (100–100%) by self-report, and 92% (79–98%) by prior standard electronic monitoring. Four individuals developed transient, low-level viremia. After overcoming technical challenges, real-time adherence monitoring is feasible for resource-limited settings and may detect suboptimal adherence prior to viral rebound.

Research paper thumbnail of Retention in care and connection to care among HIV-infected patients on antiretroviral therapy in Africa: estimation via a sampling-based approach

PloS one, 2011

Introduction: Current estimates of retention among HIV-infected patients on antiretroviral therap... more Introduction: Current estimates of retention among HIV-infected patients on antiretroviral therapy (ART) in Africa consider patients who are lost to follow-up (LTF) as well as those who die shortly after their last clinic visit to be no longer in care and to represent limitations in access to care. Yet many lost patients may have ''silently'' transferred and deaths shortly after the last clinic visit more likely represent limitations in clinical care rather than access to care after initial linkage.

Research paper thumbnail of Food insecurity is associated with morbidity and patterns of healthcare utilization among HIV-infected individuals in a resource-poor setting

AIDS (London, England), 2012

We undertook a longitudinal study in rural Uganda to understand the association of food insecurit... more We undertook a longitudinal study in rural Uganda to understand the association of food insecurity with morbidity and patterns of healthcare utilization among HIV-infected individuals enrolled in an antiretroviral therapy program. Longitudinal cohort study. Participants were enrolled from the Uganda AIDS Rural Treatment Outcomes cohort, and underwent quarterly structured interviews and blood draws. The primary predictor was food insecurity measured by the validated Household Food Insecurity Access Scale. Primary outcomes included health-related quality of life measured by the validated Medical Outcomes Study-HIV Physical Health Summary (PHS), incident self-reported opportunistic infections, number of hospitalizations, and missed clinic visits. To estimate model parameters, we used the method of generalized estimating equations, adjusting for sociodemographic and clinical variables. Explanatory variables were lagged by 3 months to strengthen causal interpretations. Beginning in May 2007, 458 persons were followed for a median of 2.07 years, and 40% were severely food insecure at baseline. Severe food insecurity was associated with worse PHS, opportunistic infections, and increased hospitalizations (results were similar in concurrent and lagged models). Mild/moderate food insecurity was associated with missed clinic visits in concurrent models, whereas in lagged models, severe food insecurity was associated with reduced odds of missed clinic visits. Based on the negative impact of food insecurity on morbidity and patterns of healthcare utilization among HIV-infected individuals, policies and programs that address food insecurity should be a critical component of HIV treatment programs worldwide.

Research paper thumbnail of No association found between traditional healer use and delayed antiretroviral initiation in rural Uganda

AIDS and behavior, 2013

Traditional healer and/or spiritual counselor (TH/SC) use has been associated with delays in HIV ... more Traditional healer and/or spiritual counselor (TH/SC) use has been associated with delays in HIV testing. We examined HIV-infected individuals in southwestern Uganda to test the hypothesis that TH/SC use was also associated with lower CD4 counts at antiretroviral therapy (ART) initiation. Approximately 450 individuals initiating ART through an HIV/AIDS clinic at the Mbarara University of Science and Technology (MUST) were recruited to participate. Patients were predominantly female, ranged in age from 18 to 75, and had a median CD4 count of 130. TH/SC use was not associated with lower CD4 cell count, but age and quality-of-life physical health summary score were associated with CD4 cell count at initiation while asset index was negatively associated with CD4 count at ART initiation. These findings suggest that TH/SC use does not delay initiation of ART. La consulta con un curandero tradicional y/o consejero espiritual (TH/SC) ha sido asociada a retrasos para someterse a la prueba de VIH. Evaluamos personas con VIH en el sudoeste de Uganda para poner a prueba la hipótesis de que consultar con un TH/SC también está asociado a un conteo bajo de células CD4 al inicio de una terapia antirretroviral (ART). Se reclutó aproximadamente 450 personas iniciando ART en una clínica de VIH/SIDA en la Universidad de Mbarara de Ciencia y Tecnología (MUST). Los pacientes fueron predominantemente mujeres, entre las edades de 18 y 75, cuyo recuento mediano de CD4 estaba en 130. Se encontró que la consulta con un TH/SC no está asociada a un recuento menor de células CD4. Sin embargo, la edad y la calidad de vida física sí se encontraron asociados al recuento de células CD4 al inicio. En contraste, el índice-de-recurso se encontró asociado negativamente con el recuento de CD4 al inicio del ART. Estos hallazgos sugieren que la consulta con un TH/SC no resulta en un atraso para iniciar la ART.

Research paper thumbnail of Phosphatidylethanol (PEth) as a biomarker of alcohol consumption in HIV-positive patients in sub-Saharan Africa

Alcoholism, clinical and experimental research, 2012

Background-Alcohol is heavily consumed in sub-Saharan Africa and affects HIV transmission and tre... more Background-Alcohol is heavily consumed in sub-Saharan Africa and affects HIV transmission and treatment but is difficult to measure. Our goal was to examine the test characteristics of a direct metabolite of alcohol consumption, phosphatidylethanol (PEth).

Research paper thumbnail of Impact of CD8+ T-cell activation on CD4+ T-cell recovery and mortality in HIV-infected Ugandans initiating antiretroviral therapy

AIDS (London, England), 2011

Methods-HIV-infected adults starting ART and achieving a plasma HIV RNA level (VL) <400 copies/ml... more Methods-HIV-infected adults starting ART and achieving a plasma HIV RNA level (VL) <400 copies/ml by month 6 were sampled from the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort in Mbarara, Uganda. CD4 count, VL, and the % activated (CD38+HLA-DR+) T cells were measured every 3 months.

Research paper thumbnail of Self-Report of Alcohol Use Increases When Specimens for Alcohol Biomarkers Are Collected in Persons With HIV in Uganda

Journal of acquired immune deficiency syndromes (1999), 2012

Research paper thumbnail of Self-reported alcohol abstinence associated with ART initiation among HIV-infected persons in rural Uganda

Drug and alcohol dependence, 2014

There is limited data on the impact of anti-retroviral treatment (ART) initiation on alcohol cons... more There is limited data on the impact of anti-retroviral treatment (ART) initiation on alcohol consumption. We characterized predictors of abstaining from alcohol among HIV-infected individuals following ART initiation. We analyzed data from a prospective cohort of HIV-infected adults in Mbarara, Uganda with quarterly measures of self-reported alcohol consumption, socio-demographics, health status, and blood draws. We used pooled logistic regression to evaluate predictors of becoming abstinent from alcohol for at least 90 days after baseline. Among the 502 participants, 108 (21.5%) were current drinkers who consumed alcohol within 90 days of baseline, 206 (41.0%) were former drinkers, and 188 (37.5%) were lifetime abstainers at baseline. Among current drinkers, 67 (62.0%) drank at hazardous levels. 90 of current drinkers (83.3%) abstained from alcohol at least for 90 days over 3.6 median years of follow-up [IQR 2-4.8]; of those 69 (76.7%) remained abstinent for a median duration of follow-up of 3.25 years [1.6-4.5]. Becoming abstinent was independently associated with lower baseline AUDIT score (adjusted odds ratio [AOR] 0.95 [95%CI 0.91-0.99]), baseline physical health score (AOR 0.92 [0.87-0.97]), and decreases in physical health score at follow-up visits (AOR 0.92 [0.88-0.97)). Alcohol abstinence was most likely to start immediately after ART initiation (AORs for 6 month versus 3 month visit: 0.25 [0.10-0.61]; 9 month visit or later versus 3 month visit: 0.04 [0.02-0.09]). We found that a large majority of drinkers starting ART reported that they became and remained abstinent from alcohol. ART initiation may be an opportune time to implement interventions for alcohol consumption and other health behaviors.

Research paper thumbnail of Evaluating a scalable model for implementing electronic health records in resource-limited settings

Journal of The American Medical Informatics Association, 2010

Current models for implementing electronic health records (EHRs) in resource-limited settings may... more Current models for implementing electronic health records (EHRs) in resource-limited settings may not be scalable because they fail to address human-resource and cost constraints. This paper describes an implementation model which relies on shared responsibility between local sites and an external threepronged support infrastructure consisting of: (1) a national technical expertise center, (2) an implementer's community, and (3) a developer's community. This model was used to implement an opensource EHR in three Ugandan HIV-clinics. Preepost timeemotion study at one site revealed that Primary Care Providers spent a third less time in direct and indirect care of patients (p<0.001) and 40% more time on personal activities (p¼0.09) after EHRs implementation. Time spent by previously enrolled patients with non-clinician staff fell by half (p¼0.004) and with pharmacy by 63% (p<0.001). Surveyed providers were highly satisfied with the EHRs and its support infrastructure. This model offers a viable approach for broadly implementing EHRs in resourcelimited settings.

Research paper thumbnail of Regional anthropometry changes in antiretroviral-naïve persons initiating a Zidovudine-containing regimen in Mbarara, Uganda

AIDS research and human retroviruses, 2011

Lipodystrophy is commonly reported in Africa after antiretroviral therapy (ART) is initiated, but... more Lipodystrophy is commonly reported in Africa after antiretroviral therapy (ART) is initiated, but few studies have objectively measured changes in body composition. Body composition was determined in 76 HIV-infected participants from Mbarara, Uganda after starting a thymidine-analog regimen, and annual change was determined using repeated measures analysis. We measured skinfolds (tricep, thigh, subscapular, and abdomen), circumferences (arm, hip, thigh, waist), and total lean and fat mass (using bioelectric impedance analysis). A cross-sectional sample of 49 HIV-uninfected participants was studied for comparison. At baseline, most body composition measures were lower in HIV-infected than uninfected participants, but waist circumference was similar. After 12 months on ART, there was little difference in body composition measures between HIV-infected and uninfected participants; median waist circumference appeared higher in HIV-infected participants (79 vs. 75 cm; p ¼ 0.090). Among HIV-infected participants, increases were observed in total lean and fat mass, circumference, and skinfold measures; only the increase in tricep skinfold did not reach statistical significance (þ1.05 mm; 95% confidence interval: À0.24, 2.34; p ¼ 0.11). Regional anthropometry in peripheral and central body sites increased over 12 months after ART initiation in HIV-infected persons from southwestern Uganda, suggesting a restoration to health. Gains in the tricep skinfold, a reliable marker of subcutaneous fat, appeared blunted, which could indicate an inhibitory effect of zidovudine on peripheral subcutaneous fat recovery.

Research paper thumbnail of Rethinking the "pre" in pre-therapy counseling: no benefit of additional visits prior to therapy on adherence or viremia in Ugandans initiating ARVs

PloS one, 2012

Background: Many guidelines recommend adherence counseling prior to initiating antiretrovirals (A... more Background: Many guidelines recommend adherence counseling prior to initiating antiretrovirals (ARVs), however the additional benefit of pre-therapy counseling visits on early adherence is not known. We sought to assess for a benefit of adherence counseling visits prior to ARV initiation versus adherence counseling during the early treatment period.

Research paper thumbnail of Diminishing Availability of Publicly Funded Slots for Antiretroviral Initiation among HIV-Infected ART-Eligible Patients in Uganda

PLOS One, 2010

Background: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART... more Background: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described.

Research paper thumbnail of Please visit my LinkedIn profile for my CV

Research paper thumbnail of Diminishing Availability of Publicly Funded Slots for Antiretroviral Initiation among HIV-Infected ART-Eligible Patients in Uganda

Background: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART... more Background: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described.

Research paper thumbnail of Contraceptive use and associated factors among women enrolling into HIV care in southwestern Uganda

Infectious diseases in obstetrics and gynecology, 2012

Research paper thumbnail of Sexual relationship power and malnutrition among HIV-positive women in rural Uganda

AIDS and behavior, 2012

Inequality within partner relationships is associated with HIV acquisition and gender violence, b... more Inequality within partner relationships is associated with HIV acquisition and gender violence, but little is known about more pervasive effects on women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s health. We performed a cross-sectional analysis of associations between sexual relationship power and nutritional status among women in Uganda. Participants completed questionnaires and anthropometric measurements. We assessed sexual relationship power using the Sexual Relationship Power Scale (SRPS). We performed logistic regression to test for associations between sexual relationship power and poor nutritional status including body mass index, body fat percentage, and mid-upper arm circumference. Women with higher sexual relationship power scores had decreased odds of low body mass index (OR 0.29, p = 0.01), low body fat percentage (OR 0.54, p = 0.04), and low mid-upper arm circumference (OR 0.22, p = 0.01). These relationships persisted in multivariable models adjusted for potential confounders. Targeted interventions to improve intimate partner relationship equality should be explored to improve health status among women living with HIV in rural Africa.

Research paper thumbnail of The WHOMEN’s Scale (Women’s HAART Optimism Monitoring and EvaluatioN Scale v.1) and the Association with Fertility Intentions and Sexual Behaviours Among HIV-Positive Women in Uganda

Aids and Behavior, 2009

The objective of this study was to develop a reliable HAART optimism scale among HIV-positive wom... more The objective of this study was to develop a reliable HAART optimism scale among HIV-positive women in Uganda and to test the scale’s validity against measures of fertility intentions, sexual activity, and unprotected sexual intercourse. We used cross-sectional survey data of 540 women (18–50 years) attending Mbarara University’s HIV clinic in Uganda. Women were asked how much they agreed or disagreed with 23 statements about HAART. Data were subjected to a principal components and factor analyses. Subsequently, we tested the association between the scale and fertility intentions and sexual behaviour using Wilcoxon rank sum test. Factor analysis yielded three factors, one of which was an eight-item HAART optimism scale with moderately high internal consistency (α = 0.70). Women who reported that they intended to have (more) children had significantly higher HAART optimism scores (median = 13.5 [IQR: 12–16]) than women who did not intend to have (more) children (median = 10.5 [IQR: 8–12]; P < 0.0001). Similarly, women who were sexually active and who reported practicing unprotected sexual intercourse had significantly higher HAART optimism scores than women who were sexually abstinent or who practiced protected sexual intercourse. Our reliable and valid scale, termed the Women’s HAART Optimism Monitoring and EvaluatioN scale (WHOMEN’s scale), may be valuable to broader studies investigating the role of HAART optimism on reproductive intentions and sexual behaviours of HIV-positive women in high HIV prevalence settings.

Research paper thumbnail of Antiretroviral Therapy is Associated with Increased Fertility Desire, but not Pregnancy or Live Birth, among HIV+ Women in an Early HIV Treatment Program in Rural Uganda

Aids and Behavior, 2009

To assess the association between antiretroviral therapy (ART) and fertility history and desire a... more To assess the association between antiretroviral therapy (ART) and fertility history and desire among HIV-positive Ugandan women, we conducted a cross-sectional study among HIV-positive Ugandan women aged 18-50 years who attended an HIV clinic at Mbarara University in western Uganda between November 1, 2005 and June 6, 2006. Of 538 women approached, 501 were enrolled. ART use was associated with increased odds of fertility desire (AOR 2.99, 95% CI 1.38-6.28), and decreased odds of pregnancy (AOR 0.56, 95% CI 0.33-0.95) and live birth (AOR 0.30, 95% CI 0.13-0.66). ART was associated with an increase in fertility desire, but was not associated

Research paper thumbnail of Creation and evaluation of EMR-based paper clinical summaries to support HIV-care in Uganda, Africa

International Journal of Medical Informatics, 2010

Purpose-Getting the right information to providers can improve quality of care. We set out to pro... more Purpose-Getting the right information to providers can improve quality of care. We set out to provide patient-specific Electronic Medical Record (EMR)-based clinical summaries for providers taking care of HIV-positive adult patients in the resource-limited setting of Mbarara, Uganda.

Research paper thumbnail of Transportation Costs Impede Sustained Adherence and Access to HAART in a Clinic Population in Southwestern Uganda: A Qualitative Study

Aids and Behavior, 2010

The cost of transportation for monthly clinic visits has been identified as a potential barrier t... more The cost of transportation for monthly clinic visits has been identified as a potential barrier to antiretroviral (ARV) adherence in sub-Saharan Africa and elsewhere, although there is limited data on this issue. We conducted open-ended interviews with 41 individuals living with HIV/AIDS and attending a clinic in Mbarara, Uganda, to understand structural barriers to ARV adherence and clinical care. Almost all respondents cited the need to locate funds for the monthly clinic visit as a constant source of stress and anxiety, and lack of money for transportation was a key factor in cases of missed doses and missed medical appointments. Participants struggled with competing demands between transport costs and other necessities such as food, housing and school fees. Our findings suggest that transportation costs can compromise both ARV adherence and access to care. Interventions that address this barrier will be important to ensure the success of ARV programs in sub-Saharan Africa.

Research paper thumbnail of Real-Time Adherence Monitoring for HIV Antiretroviral Therapy

Aids and Behavior, 2010

Current adherence assessments typically detect missed doses long after they occur. Real-time, wir... more Current adherence assessments typically detect missed doses long after they occur. Real-time, wireless monitoring strategies for antiretroviral therapy may provide novel opportunities to proactively prevent virologic rebound and treatment failure. Wisepill, a wireless pill container that transmits a cellular signal when opened, was pilot tested in ten Ugandan individuals for 6 months. Adherence levels measured by Wisepill, unannounced pill counts, and self-report were compared with each other, prior standard electronic monitoring, and HIV RNA. Wisepill data was initially limited by battery life and signal transmission interruptions. Following device improvements, continuous data was achieved with median (interquartile range) adherence levels of 93% (87–97%) by Wisepill, 100% (99–100%) by unannounced pill count, 100% (100–100%) by self-report, and 92% (79–98%) by prior standard electronic monitoring. Four individuals developed transient, low-level viremia. After overcoming technical challenges, real-time adherence monitoring is feasible for resource-limited settings and may detect suboptimal adherence prior to viral rebound.

Research paper thumbnail of Retention in care and connection to care among HIV-infected patients on antiretroviral therapy in Africa: estimation via a sampling-based approach

PloS one, 2011

Introduction: Current estimates of retention among HIV-infected patients on antiretroviral therap... more Introduction: Current estimates of retention among HIV-infected patients on antiretroviral therapy (ART) in Africa consider patients who are lost to follow-up (LTF) as well as those who die shortly after their last clinic visit to be no longer in care and to represent limitations in access to care. Yet many lost patients may have ''silently'' transferred and deaths shortly after the last clinic visit more likely represent limitations in clinical care rather than access to care after initial linkage.

Research paper thumbnail of Food insecurity is associated with morbidity and patterns of healthcare utilization among HIV-infected individuals in a resource-poor setting

AIDS (London, England), 2012

We undertook a longitudinal study in rural Uganda to understand the association of food insecurit... more We undertook a longitudinal study in rural Uganda to understand the association of food insecurity with morbidity and patterns of healthcare utilization among HIV-infected individuals enrolled in an antiretroviral therapy program. Longitudinal cohort study. Participants were enrolled from the Uganda AIDS Rural Treatment Outcomes cohort, and underwent quarterly structured interviews and blood draws. The primary predictor was food insecurity measured by the validated Household Food Insecurity Access Scale. Primary outcomes included health-related quality of life measured by the validated Medical Outcomes Study-HIV Physical Health Summary (PHS), incident self-reported opportunistic infections, number of hospitalizations, and missed clinic visits. To estimate model parameters, we used the method of generalized estimating equations, adjusting for sociodemographic and clinical variables. Explanatory variables were lagged by 3 months to strengthen causal interpretations. Beginning in May 2007, 458 persons were followed for a median of 2.07 years, and 40% were severely food insecure at baseline. Severe food insecurity was associated with worse PHS, opportunistic infections, and increased hospitalizations (results were similar in concurrent and lagged models). Mild/moderate food insecurity was associated with missed clinic visits in concurrent models, whereas in lagged models, severe food insecurity was associated with reduced odds of missed clinic visits. Based on the negative impact of food insecurity on morbidity and patterns of healthcare utilization among HIV-infected individuals, policies and programs that address food insecurity should be a critical component of HIV treatment programs worldwide.

Research paper thumbnail of No association found between traditional healer use and delayed antiretroviral initiation in rural Uganda

AIDS and behavior, 2013

Traditional healer and/or spiritual counselor (TH/SC) use has been associated with delays in HIV ... more Traditional healer and/or spiritual counselor (TH/SC) use has been associated with delays in HIV testing. We examined HIV-infected individuals in southwestern Uganda to test the hypothesis that TH/SC use was also associated with lower CD4 counts at antiretroviral therapy (ART) initiation. Approximately 450 individuals initiating ART through an HIV/AIDS clinic at the Mbarara University of Science and Technology (MUST) were recruited to participate. Patients were predominantly female, ranged in age from 18 to 75, and had a median CD4 count of 130. TH/SC use was not associated with lower CD4 cell count, but age and quality-of-life physical health summary score were associated with CD4 cell count at initiation while asset index was negatively associated with CD4 count at ART initiation. These findings suggest that TH/SC use does not delay initiation of ART. La consulta con un curandero tradicional y/o consejero espiritual (TH/SC) ha sido asociada a retrasos para someterse a la prueba de VIH. Evaluamos personas con VIH en el sudoeste de Uganda para poner a prueba la hipótesis de que consultar con un TH/SC también está asociado a un conteo bajo de células CD4 al inicio de una terapia antirretroviral (ART). Se reclutó aproximadamente 450 personas iniciando ART en una clínica de VIH/SIDA en la Universidad de Mbarara de Ciencia y Tecnología (MUST). Los pacientes fueron predominantemente mujeres, entre las edades de 18 y 75, cuyo recuento mediano de CD4 estaba en 130. Se encontró que la consulta con un TH/SC no está asociada a un recuento menor de células CD4. Sin embargo, la edad y la calidad de vida física sí se encontraron asociados al recuento de células CD4 al inicio. En contraste, el índice-de-recurso se encontró asociado negativamente con el recuento de CD4 al inicio del ART. Estos hallazgos sugieren que la consulta con un TH/SC no resulta en un atraso para iniciar la ART.

Research paper thumbnail of Phosphatidylethanol (PEth) as a biomarker of alcohol consumption in HIV-positive patients in sub-Saharan Africa

Alcoholism, clinical and experimental research, 2012

Background-Alcohol is heavily consumed in sub-Saharan Africa and affects HIV transmission and tre... more Background-Alcohol is heavily consumed in sub-Saharan Africa and affects HIV transmission and treatment but is difficult to measure. Our goal was to examine the test characteristics of a direct metabolite of alcohol consumption, phosphatidylethanol (PEth).

Research paper thumbnail of Impact of CD8+ T-cell activation on CD4+ T-cell recovery and mortality in HIV-infected Ugandans initiating antiretroviral therapy

AIDS (London, England), 2011

Methods-HIV-infected adults starting ART and achieving a plasma HIV RNA level (VL) <400 copies/ml... more Methods-HIV-infected adults starting ART and achieving a plasma HIV RNA level (VL) <400 copies/ml by month 6 were sampled from the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort in Mbarara, Uganda. CD4 count, VL, and the % activated (CD38+HLA-DR+) T cells were measured every 3 months.

Research paper thumbnail of Self-Report of Alcohol Use Increases When Specimens for Alcohol Biomarkers Are Collected in Persons With HIV in Uganda

Journal of acquired immune deficiency syndromes (1999), 2012

Research paper thumbnail of Self-reported alcohol abstinence associated with ART initiation among HIV-infected persons in rural Uganda

Drug and alcohol dependence, 2014

There is limited data on the impact of anti-retroviral treatment (ART) initiation on alcohol cons... more There is limited data on the impact of anti-retroviral treatment (ART) initiation on alcohol consumption. We characterized predictors of abstaining from alcohol among HIV-infected individuals following ART initiation. We analyzed data from a prospective cohort of HIV-infected adults in Mbarara, Uganda with quarterly measures of self-reported alcohol consumption, socio-demographics, health status, and blood draws. We used pooled logistic regression to evaluate predictors of becoming abstinent from alcohol for at least 90 days after baseline. Among the 502 participants, 108 (21.5%) were current drinkers who consumed alcohol within 90 days of baseline, 206 (41.0%) were former drinkers, and 188 (37.5%) were lifetime abstainers at baseline. Among current drinkers, 67 (62.0%) drank at hazardous levels. 90 of current drinkers (83.3%) abstained from alcohol at least for 90 days over 3.6 median years of follow-up [IQR 2-4.8]; of those 69 (76.7%) remained abstinent for a median duration of follow-up of 3.25 years [1.6-4.5]. Becoming abstinent was independently associated with lower baseline AUDIT score (adjusted odds ratio [AOR] 0.95 [95%CI 0.91-0.99]), baseline physical health score (AOR 0.92 [0.87-0.97]), and decreases in physical health score at follow-up visits (AOR 0.92 [0.88-0.97)). Alcohol abstinence was most likely to start immediately after ART initiation (AORs for 6 month versus 3 month visit: 0.25 [0.10-0.61]; 9 month visit or later versus 3 month visit: 0.04 [0.02-0.09]). We found that a large majority of drinkers starting ART reported that they became and remained abstinent from alcohol. ART initiation may be an opportune time to implement interventions for alcohol consumption and other health behaviors.

Research paper thumbnail of Evaluating a scalable model for implementing electronic health records in resource-limited settings

Journal of The American Medical Informatics Association, 2010

Current models for implementing electronic health records (EHRs) in resource-limited settings may... more Current models for implementing electronic health records (EHRs) in resource-limited settings may not be scalable because they fail to address human-resource and cost constraints. This paper describes an implementation model which relies on shared responsibility between local sites and an external threepronged support infrastructure consisting of: (1) a national technical expertise center, (2) an implementer's community, and (3) a developer's community. This model was used to implement an opensource EHR in three Ugandan HIV-clinics. Preepost timeemotion study at one site revealed that Primary Care Providers spent a third less time in direct and indirect care of patients (p<0.001) and 40% more time on personal activities (p¼0.09) after EHRs implementation. Time spent by previously enrolled patients with non-clinician staff fell by half (p¼0.004) and with pharmacy by 63% (p<0.001). Surveyed providers were highly satisfied with the EHRs and its support infrastructure. This model offers a viable approach for broadly implementing EHRs in resourcelimited settings.

Research paper thumbnail of Regional anthropometry changes in antiretroviral-naïve persons initiating a Zidovudine-containing regimen in Mbarara, Uganda

AIDS research and human retroviruses, 2011

Lipodystrophy is commonly reported in Africa after antiretroviral therapy (ART) is initiated, but... more Lipodystrophy is commonly reported in Africa after antiretroviral therapy (ART) is initiated, but few studies have objectively measured changes in body composition. Body composition was determined in 76 HIV-infected participants from Mbarara, Uganda after starting a thymidine-analog regimen, and annual change was determined using repeated measures analysis. We measured skinfolds (tricep, thigh, subscapular, and abdomen), circumferences (arm, hip, thigh, waist), and total lean and fat mass (using bioelectric impedance analysis). A cross-sectional sample of 49 HIV-uninfected participants was studied for comparison. At baseline, most body composition measures were lower in HIV-infected than uninfected participants, but waist circumference was similar. After 12 months on ART, there was little difference in body composition measures between HIV-infected and uninfected participants; median waist circumference appeared higher in HIV-infected participants (79 vs. 75 cm; p ¼ 0.090). Among HIV-infected participants, increases were observed in total lean and fat mass, circumference, and skinfold measures; only the increase in tricep skinfold did not reach statistical significance (þ1.05 mm; 95% confidence interval: À0.24, 2.34; p ¼ 0.11). Regional anthropometry in peripheral and central body sites increased over 12 months after ART initiation in HIV-infected persons from southwestern Uganda, suggesting a restoration to health. Gains in the tricep skinfold, a reliable marker of subcutaneous fat, appeared blunted, which could indicate an inhibitory effect of zidovudine on peripheral subcutaneous fat recovery.

Research paper thumbnail of Rethinking the "pre" in pre-therapy counseling: no benefit of additional visits prior to therapy on adherence or viremia in Ugandans initiating ARVs

PloS one, 2012

Background: Many guidelines recommend adherence counseling prior to initiating antiretrovirals (A... more Background: Many guidelines recommend adherence counseling prior to initiating antiretrovirals (ARVs), however the additional benefit of pre-therapy counseling visits on early adherence is not known. We sought to assess for a benefit of adherence counseling visits prior to ARV initiation versus adherence counseling during the early treatment period.

Research paper thumbnail of Diminishing Availability of Publicly Funded Slots for Antiretroviral Initiation among HIV-Infected ART-Eligible Patients in Uganda

PLOS One, 2010

Background: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART... more Background: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described.

Research paper thumbnail of Health information seeking among Mbararan adolescents: results from the Uganda Media and You survey

To maximize scarce intervention dollars, pediatricians and other adolescent health professionals ... more To maximize scarce intervention dollars, pediatricians and other adolescent health professionals must position health promotion efforts in mediums that most effectively reach youth. This may be especially true in resource-limited settings where access to primary health care and medications is limited. To improve the efficiency and impact of disease prevention and health promotion efforts in resource-limited settings, we examine sources of health information cited by adolescents in Mbarara Uganda. Participants in the Uganda Media and You survey were students aged 12-18 (n 5 500) randomly identified in five secondary schools in Mbarara municipality, Uganda. Ninety-three percent of eligible and invited youth completed the cross-sectional, penciland-paper survey. Four in five adolescents (81%) indicated they turned to parents, teachers, and other adults while around half read a book/went to the library (56%) or turned to siblings and friends (50%) for information about health and disease. More than one in three (38%) indicated that they used the computer and Internet to search for health information. Older versus younger respondents tended to rely upon siblings and friends for all types of health questions. On the other hand, younger versus older youth were significantly more likely to turn to parents, teachers, and other adults for their questions about sexual health. Adults may be an important component of effective disease prevention and health promotion campaigns. Multiple delivery methods may be especially effective for reaching older adolescents. Technology also may be an important health promotion tool in resource-limited settings.