Mulago Hospital

About: Mulago Hospital is a healthcare organization based out in Kampala, Uganda. It is known for research contribution in the topics: Population & Health care. The organization has 542 authors who have published 545 publications receiving 34804 citations.

Environmental exposure to metal mixtures and linear growth in healthy Ugandan children

Abstract: Background Stunting is an indicator of poor linear growth in children and is an important public health problem in many countries. Both nutritional deficits and toxic exposures can contribute to lower height-for-age Z-score (HAZ) and stunting (HAZ < -2). Objectives In a community-based cross-sectional sample of 97 healthy children ages 6–59 months in Kampala, Uganda, we examined whether exposure to Pb, As, Cd, Se, or Zn were associated with HAZ individually or as a mixture. Methods Blood samples were analyzed for a mixture of metals, which represent both toxins and essential nutrients. The association between HAZ and metal exposure was tested using multivariable linear regression and Weighted Quantile Sum (WQS) regression, which uses mixtures of correlated exposures as a predictor. Results There were 22 stunted children in the sample, mean HAZ was -0.74 (SD = 1.84). Linear regression showed that Pb (β = -0.80, p = 0.021) and Se (β = 1.92, p = 0.005) were significantly associated with HAZ. The WQS models separated toxic elements with a presumed negative effect on HAZ (Pb, As, Cd) from essential nutrients with presumed positive effect on HAZ (Se and Zn). The toxic mixture was significantly associated with lower HAZ (β = -0.47, p = 0.03), with 62% of the effect from Pb. The nutrient WQS index did not reach statistical significance (β = -0.47, p = 0.16). Discussion Higher blood lead and lower blood selenium level were both associated with lower HAZ. The significant associations by linear regression were reinforced by the WQS models, although not all associations reached statistical significance. These findings suggest that healthy children in this neighborhood of Kampala, Uganda, who have a high burden of toxic exposures, may experience detrimental health effects associated with these exposures in an environment where exposure sources are not well characterized.

Virologic Response to First-line Efavirenz- or Nevirapine-based Antiretroviral Therapy in HIV-infected African Children.

Abstract: BACKGROUND: Poorer virologic response to nevirapine vs efavirenz-based antiretroviral therapy (ART) has been reported in adult systematic reviews and pediatric studies. METHODS: We compared drug discontinuation and viral load (VL) response in ART-naive Ugandan/Zimbabwean children ≥3 years of age initiating ART with clinician-chosen nevirapine vs efavirenz in the ARROW trial. Predictors of suppression <80, <400 and <1000 copies/ml at 36, 48 and 144 weeks were identified using multivariable logistic regression with backwards elimination (p=0.1). RESULTS: 445(53%) children received efavirenz and 391(47%) nevirapine. Children receiving efavirenz were older (median 8.6 years vs 7.5 nevirapine, p<0.001) and had higher CD4% (12% vs 10%, p=0.05) but similar pre-ART VL (p=0.17). The initial non-nucleoside-reverse-transcriptase-inhibitor (NNRTI) was permanently discontinued for adverse events in 7/445 (2%) children initiating efavirenz vs 9/391 (2%) initiating nevirapine (p=0.46); at switch to second-line in 17 vs 23, for tuberculosis in 0 vs 26, for pregnancy in 6 vs 0, and for other reasons in 15 vs 5. Early (36-48 week) virologic suppression <80 copies/ml was superior with efavirenz, particularly in children with higher pre-ART VL (p=0.0004); longer-term suppression was superior with nevirapine in older children (p=0.05). Early suppression was poorer in the youngest and oldest children, regardless of NNRTI (p=0.02); longer-term suppression was poorer in those with higher pre-ART VL regardless of NNRTI (p=0.05). Results were broadly similar for <400 and <1000 copies/ml. CONCLUSION: Short-term VL suppression favored efavirenz, but long-term relative performance was age-dependent, with better suppression in older children with nevirapine, supporting WHO's recommendation that nevirapine remain an alternative NNRTI.

Hypertension care cascade at a large urban HIV clinic in Uganda: a mixed methods study using the Capability, Opportunity, Motivation for Behavior change (COM-B) model.

Abstract: Background Persons living with HIV (PLHIV) receiving antiretroviral therapy (ART) have a high prevalence of hypertension (HTN) and increased risk of mortality from cardiovascular diseases. HTN and HIV care integration is recommended in Uganda, though its implementation has lagged. In this study, we sought to analyze the HTN and HIV care cascades and explore barriers and facilitators of HTN/HIV integration within a large HIV clinic in urban Uganda. Methods We conducted an explanatory sequential mixed methods study at Mulago ISS clinic in Kampala, Uganda. We determined proportions of patients in HTN and HIV care cascade steps of screened, diagnosed, initiated on treatment, retained, and controlled. Guided by the Capability, Opportunity, Motivation and Behavior (COM-B) model, we then conducted semi-structured interviews and focus group discussions with healthcare providers (n = 13) and hypertensive PLHIV (n = 32). We coded the qualitative data deductively and analyzed the data thematically categorizing them as themes that influenced HTN care positively or negatively. These denoted barriers and facilitators, respectively. Results Of 15,953 adult PLHIV, 99.1% were initiated on ART, 89.5% were retained in care, and 98.0% achieved control (viral suppression) at 1 year. All 15,953 (100%) participants were screened for HTN, of whom 24.3% had HTN. HTN treatment initiation, 1-year retention, and control were low at 1.0%, 15.4%, and 5.0%, respectively. Barriers and facilitators of HTN/HIV integration appeared in all three COM-B domains. Barriers included low patient knowledge of HTN complications, less priority by patients for HTN treatment compared to ART, sub-optimal provider knowledge of HTN treatment, lack of HTN treatment protocols, inadequate supply of anti-hypertensive medicines, and lack of HTN care performance targets. Facilitators included patients' and providers' interest in HTN/HIV integration, patients' interest in PLHIV peer support, providers' knowledge and skills for HTN screening, optimal ART adherence counseling, and availability of automated BP machines. Conclusion The prevalence of HTN among PLHIV is high, but the HTN care cascade is sub-optimal in this successful HIV clinic. To close these gaps, models of integrated HTN/HIV care are urgently needed. These findings provide a basis for designing contextually appropriate interventions for HTN/HIV integration in Uganda and other low- and middle-income countries.

Chronic Respiratory Symptoms and Lung Abnormalities Among People With a History of Tuberculosis in Uganda: A National Survey.

Abstract: People with pulmonary tuberculosis (TB) are at risk of developing chronic respiratory disorders due to residual lung damage. So far, the scope of the problem in high burden TB countries is relatively unknown. Chronic respiratory symptoms (cough and phlegm lasting >2 weeks) and radiological lung abnormalities were compared between adults with and without a history of TB among the general population of Uganda. Multivariable regression models were used to estimate odds ratios with adjustment for age, gender, smoking, education, setting and region. Random effects models accounted for village clustering effect. Of 45,293 invited people from 70 villages, 41,154 (90.9%) participated in the survey. 798 had a history of TB and among them, 16% had respiratory symptoms and 41% x-ray abnormalities. Adjusted odds ratios showed strong evidence for individuals with a history of TB having increased risk of respiratory symptoms (OR=4·02, 95%CI: 3·25-4·96) and x-ray abnormalities (OR=17·52, 95%CI: 14·76-20·79); attributing 6% and 24% of the respective population risks. In Uganda, a history of TB was a strong predictor of respiratory symptoms and lung abnormalities, before older age and smoking. Eliminating TB disease could reduce the prevalence of chronic respiratory symptoms as much as eliminating smoking.

Low sero-prevalence of hepatitis delta antibodies in HIV/hepatitis B co-infected patients attending an urban HIV clinic in Uganda.

Abstract: Background: Co-infection with hepatitis B (HBV) and hepatitis D (HDV) is common among human immunodeficiency virus (HIV) infected individuals in developing countries and it aggressively accelerates progression of liver disease to cirrhosis and other complications. There is scarcity of data on HDV in sub-Saharan Africa .We investigated the sero-prevalence and factors associated with HDV antibody among HIV/HBV co-infected patients attending a large urban HIV clinic in Uganda. Methods: We screened 189 HIV/HBV co-infected individuals for anti-HDV immunoglobulin G (IgG) and performed logistic regression to determine the associated factors. Socio-demographic, clinical data, immunological status, and liver fibrosis (as determined by the Aspartate transaminase to platelet ratio index and transient elastography) were included. Results: Participants were predominately young and of sound immunologic status (median age 40 years, median CD4 440 cells/μl). 98% were on ART regimens containing anti-HBV active medications (95.2% were on TDF/3TC while 4.8% on 3TC containing regimen). Median duration on ART was 36 months (IQR 22-72). Anti-HDV was detected in 6/198, 3.2% (95% CI 1.14-6.92%), associated with male gender and a duration of more than 5 years since HIV diagnosis. Conclusions: The sero-prevalence of HDV antibodies among the HIV/HBV co-infected patients is low in a Ugandan urban cohort. Keywords: Co-infection in Uganda, hepatitis delta antibodies, hepatitis B virus, HIV