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Maher D.,MRC UVRI Uganda Research Unit on AIDS
Tropical Medicine and International Health | Year: 2010

The global financial crisis poses a threat to global health, and may exacerbate diseases of poverty, e.g. HIV, malaria and tuberculosis. Exploring the implications of the global financial crisis for the health sector response to tuberculosis is useful to illustrate the practical problems and propose possible solutions. The response to tuberculosis is considered in the context of health sector development. Problems and solutions are considered in five key areas: financing, prioritization, government regulation, integration and decentralization. Securing health gains in global tuberculosis control depends on protecting expenditure by governments of countries badly affected by tuberculosis and by donors, taking measures to increase efficiencies, prioritizing health expenditures and strengthening government regulation. Lessons learned will be valuable for stakeholders involved in the health sector response to tuberculosis and other diseases of poverty. © 2009 Blackwell Publishing Ltd.


A safe and effective vaginal microbicide could substantially reduce HIV acquisition for women. Consistent gel use is, however, of great importance to ensure continued protection against HIV infection, even with a safe and effective microbicide. We assessed the long-term correlates of consistent gel use in the MDP 301 clinical trial among HIV-negative women in sero-discordant couples in south-west Uganda. HIV-negative women living with an HIV-infected partner were enrolled between 2005 and 2008, in a three-arm phase III microbicide trial and randomized to 2% PRO2000, 0.5% PRO2000 or placebo gel arms. Follow-up visits continued up to September 2009. The 2% arm was stopped early due to futility and the 229 women enrolled in this arm were excluded from this analysis. Data were analyzed on 544 women on the 0.5% and placebo arms who completed at least 52 weeks of follow-up, sero-converted or became pregnant before 52 weeks. Consistent gel use was defined as satisfying all of the following three conditions: (i) reported gel use at the last sex act for at least 92% of the 26 scheduled visits or at least 92% of the visits attended if fewer than 26; (ii) at least one used applicator returned for each visit for which gel use was reported at the last sex act; (iii) attended at least 13 visits (unless the woman sero-converted or became pregnant during follow-up). Logistic regression models were fitted to investigate factors associated with consistent gel use. Of the 544 women, 473 (86.9%) were followed for at least 52 weeks, 29 (5.3%) sero-converted and 42 (7.7%) became pregnant before their week 52 visit. Consistent gel use was reported by 67.8%. Women aged 25 to 34 years and those aged 35 years or older were both more than twice as likely to have reported consistently using gel compared to women aged 17 to 24 years. Living in a household with three or more rooms used for sleeping compared to one room was associated with a twofold increase in consistent gel use. In rural Uganda younger women and women in houses with less space are likely to require additional support to achieve consistent microbicide gel use. Protocol Number ISRCTN64716212.


Mbonye M.,MRC UVRI Uganda Research Unit on AIDS
Journal of the International AIDS Society | Year: 2012

Gender inequity is manifested in the social and economic burden women carry in relation to men. We investigate women's experiences of gender relations from childhood to adult life and how these may have led to and kept women in sex work. Participants were drawn from an ongoing epidemiological cohort study of women working in high HIV/STI risk environments in Kampala. From over 1000 enrolled women, we selected 101 for a qualitative sub-study. This analysis focuses on 58 women who engaged in sex work either as a main job or as a side job. In-depth life history interviews were conducted to capture points of vulnerability that enhance gender inequity throughout their lives. Most participants were young, single parents, poorly educated, who occupied low skilled and poorly paying jobs. All women knew their HIV status and they disclosed this in the interview; 31 were uninfected while 27 said they were infected. Parental neglect in childhood was reported by many. Participants described experiences of violence while growing up sometimes perpetuated by relatives and teachers. Early unwanted pregnancies were common and for many led to leaving school. Some women stated a preference for multiple and short-term money-driven sexual relationships. Needing to earn money for child care was often the main reason for starting and persisting with sex work. Violence perpetrated by clients and the police was commonly reported. Alcohol and drug use was described as a necessary "evil" for courage and warmth, but sometimes this affected clear decision making. Many felt powerless to bargain for and maintain condom use. Leaving sex work was considered but rarely implemented. Inequities in gender and power relations reduce economic and social opportunities for better lives among women and increase risky sexual behaviour. Interventions focused on these inequities that also target men are crucial in improving safer practices and reducing risk.


Grant
Agency: GTR | Branch: MRC | Program: | Phase: Intramural | Award Amount: 211.97K | Year: 2012

In Uganda (and other countries in Africa), HIV positive persons are advised to take cotrimoxazole (commonly known as Septrin), every day, since studies have shown that this leads to a reduction in the frequency of common illnesses that affect persons with HIV and improves their health. The mechanism underlying this benefit of cotrimoxazole is not clear. Cotrimoxazole kills certain bacteria and has some effect on malaria parasites. However this benefit has also been found in people who have bacteria resistant to cotrimoxazole. One possible mechanism could be that cotrimoxazole reduces the number of bacteria in the intestines or limits the damage to the intestinal mucosa. In HIV infected persons the intestinal barrier is damaged and there is passage of bacterial products from the intestine into the body. This “microbial translocation” is thought to cause general activation of the immune system, which worsens the outcome of HIV infection. So in this study we are comparing patients who keep taking cotrimoxazole or stop, for evidence of bacterial products crossing from the intestines into the blood, damage to the intestinal wall and immune activation. Understanding how cotrimoxazole exerts its effect will help us to improve the care of HIV infected persons.


Grant
Agency: GTR | Branch: MRC | Program: | Phase: Intramural | Award Amount: 754.14K | Year: 2011

There is an increasing demand on primary health care services in Africa for the provision of chronic disease care, due to the dual burden of chronic non-communicable diseases (such as diabetes, hypertension and asthma) and HIV infection that today requires lifelong treatment. From a health services delivery point of view, the management of chronic HIV infection and the management of other chronic disease have many features in common. In this research project we aim to contribute to the health systems’ response to chronic diseases, by providing data on the burden of treatable chronic diseases including HIV infection in 2 selected study populations in Uganda and Tanzania, and then then to design and evaluate a health system intervention to improve the management of chronic diseases in primary health care services. The first phase of this study will consist of: (i) a baseline review of policy and practices in regard to the long term HIV care and care of treatable chronic disease. (ii) a population survey to be conducted in 2 communities in Uganda and Tanzania in order to document the burden of treatable chronic diseases and chronic HIV infection (iii) a health facility survey from the same communities to assess the capacity of sampled health facilities to manage these conditions. These surveys will be supplemented by social sciences and health economic studies and conducted in close collaboration with the national health services, with the overall aim being to find and institute simple service interventions that will improve the management of chronic diseases in primary health care centres such as dispensaries, peripheral health centres and outpatient departments of district hospitals. In the 2nd phase of the study we will use the findings from the 1st phase to design and implement a simple and affordable package of health service interventions aimed at improving the management of chronic diseases in primary health care centres such as dispensaries, peripheral health centres and outpatient departments of district hospitals. Through a follow on study, the impact of this health service intervention on access to care for chronic diseases and the quality of care delivery will be evaluated.

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