Mbarara University Grants Office

Mbarara University of Science and Technology
Grants Office

PAIR Study Description

PAIR is a pilot study designed to examine the relationship between event-level alcohol use and unprotected sex among sexually active, alcohol-consuming, HIV+ Ugandan adults.

Background

Objectives of the study
Primary Aim: Carry out qualitative interviews with 20 HIV-positive, sexually active, alcohol-consuming men and women
Secondary Aim: pilot testing of prostate specific antigen (PSA) as a biomarker of self-reported recent unprotected sex among sexually active HIV-positive women.
Long term goal is to provide pilot data for a larger prospective cohort study designed to examine event-level alcohol use and unprotected sex and to ultimately develop targeted interventions.

Study Progress Report

The study was launched on 13th July 2012 in the ISS clinic however the study activities did not take off until the above approvals were received (refer to the dates above). On Monday 24th September study activities kicked off and we started recruiting participants.

Achievements

The study was successfully approved by the IRB and UNCST successfully
We have so far been able to enroll and recruit 2 female participants from the BREATH study successfully.

Challenges

The challenge we are facing is that the funds are delayed due to some reasons however we anticipate successful operation of the study activities. We have so far received the first part of the sub contract which was successfully spent on the study activities and we are awaiting the second part of which invoice was submitted to the funders.

Way forward

PAIR study is a pilot study which upon successful completion at the end of the year will provide pilot data for a larger prospective cohort study designed to examine event-level alcohol use and unprotected sex and to ultimately develop targeted interventions.

Sustainable Household Income Project (SHIP)

Historical Background

The Sustainable Household Income project (SHIP), began as an extension of the existing Family Treatment Fund program. Family Treatment Fund (FTF) was launched in 2002 as the first free HIV antiretroviral treatment (ART) program in rural southwestern Uganda.  Low cost generic ART was provided through private individual donations to the neediest patients for less than a dollar a day. Medical care was provided free through the Mbarara University HIV clinic. A new patient was started on ART when FTF received sufficient funds to secure 5 years of treatment ($2000). Since 2002, FTF has provided ART to over 1000 individuals. 

Rational behind the proposed research and Potential benefits to patients and/or society:
Now that ART is more widely available, the ancillary costs of HIV care have emerged as a major barrier to ART treatment success. Securing transportation to pick up monthly ART refills and routine medical evaluations is the most frequent and long-term ancillary cost of care. For many patients in Mbarara, Uganda, the cost of transportation ($2-10 USD) exceeds 30-50% of a family’s total monthly income. This financial demand is added to other ancillary costs of care, such as loss of income and food production during the full day required to attend a medical clinic visit and pick up ART refills.  Increased food demands, as people become healthier, also create financial burdens.  Like metastatic cancer, advanced AIDS is an appetite suppressant.  When malnourished people with advanced AIDS recover on ART, they often develop a severe hunger response due to reversal of the appetite suppressant effects of HIV/AIDS.  This hunger response strains household financial resources such that some patients have discontinued ART because they cannot meet the financial demands to provide sufficient food for recovery.
Interrupting ART treatment irreversibly threatens treatment success. Treatment interruptions of several days predictably lead to HIV viral rebound. When the HIV virus rebounds after treatment discontinuation, it becomes rapidly resistant to treatment. Because the cost of “second-line” medications is prohibitive in many resource-poor settings, most patients only have one opportunity for treatment. Failure to meet the ancillary costs of care, which can be $2-5 USD per month, can lead to HIV drug resistance, clinical treatment failure and death. These tragic events are compounded by loss of income production due to care of the ill and dying person living this HIV/AIDS and orphaned dependents.
While FTF has been successful in helping clients regain their strength through providing free ART, it has done little to address broader causes of poverty. FTF clients return to their homes with no means of generating income to support their families despite the return of their physical health and capacity for income generation.  Ongoing poverty threatens the very success of the program. FTF hopes to end this cycle of poverty and physical decline by promoting sustainable income generation and financial management strategies through the SHIP Program. 

SPECIFIC AIMS

a.Specify objectives and hypothesis to be tested in the research project 

SHIP defines its goals in terms of impact on individuals and their households as well as training the next generation of public health leaders in rural Uganda through strengthening the academic mission of MUST.  SHIPs goals for individual and household health promotion are to: 

1) Help PLWHA meet the ancillary costs of HIV care,

2) Increase survival through sustained and uninterrupted lifelong treatment, and
3) Improve quality of life for the entire household through reduced HIV risk behavior, maternal-child mortality, food insecurity, educational attainment, orphan prevention and household economic development

SHIP’s goals for strengthening the MUST academic mission are to:
1) Create a laboratory for small business management
2) Develop evidence-based programs in:
     a. HIV treatment outcomes
     b. HIV prevention
     c .Maternal-child health
     d. Orphan prevention
     e. Food insecurity
     f. Economic development

SHIP will meet the individual and household health promotion goals through a multifaceted income generation training program combined with household financial management services. These income generation activities have been piloted over the last year and include small animal husbandry (chicken and goats), cash crop production (passion fruits), and craft production (baskets). Additional activities will include training in agricultural sustainability, small business management, and personal finance. Through a non-profit social investment in poverty reduction, SHIP will use proceeds from an external revenue source to provide PLWA skills and materials and to start meaningful business ventures that will increase household income generation and positively impact the economic status of our clients.

SHIP will train the next generation of public health leaders in rural Uganda and strengthen the academic mission of MUST through entrepreneurship business clinics. Because SHIP’s mission is to invest in public health at the household level and developing the next generation of public health leaders through strengthening the academic mission of MUST, SHIP is non-profit and will invest all proceeds toward achieving these goals.  

Study updates
Sustainable Household Income Project has been on going since 2009 to date.
20 participants have been consented and recruitment into the SHIP Study, 4 are males and 16 females. 11 participants are HIV positive and 9 are HIV negative. The 11 HIV positive participants have been generating income and recently completed their 6 month follow up visits. The 9 HIV negative participants were recently enrolled into the study and will begin training in March-April 2012.

Recruitment of study participants has been quite slow mainly because the first phase started with pilot preparation of the lemon grass demonstration farm before study participants could be recruited unto the study of which when an economic evaluation was carried out on lemon grass project, it was found not viable so the project has embarked on other income generating activities like Chicken Coop. As of the time of this writing, no data analysis has been performed.

During the course of implementing this study we experienced a minor protocol deviation related to holding a community sensitization meeting where some of the people who attended the community meeting were not eligible for participation in the SHIP study. We reported the issue to the Mbarara University of Science and Technology Institutional Review Committee and Uganda National Council of Science and Technology. As a result we applied for a minor modification to include community meetings as a recruitment method and expanding eligibility to include individuals who are not concurrently enrolled in UARTO. Data analysis has not yet been done.

The “Medical Education for Equitable Services for All Ugandans”, (MESAU) was created as a national platform that unites medical education institutions in Uganda to have a collective social conscience and a sense of purpose to pursue academic excellence, and enhance social accountability to improve Uganda’s health system and the health of her people.

MESAU Vision: Medical education for equitable service delivery to all Ugandans.

MESAU Goal: To develop MESAU institutions as centres of excellence for medical education, research and service that address local and national needs to improve health in Uganda.

MESAU Mission: The MESAU Consortium exists to strengthen country-wide institutional collaboration and to foster transformative, innovative medical education and research founded on strong sustainable institutional systems and social accountability. In doing this, MESAU will contribute to increasing the number and retention of high quality committed health workers capable of addressing Uganda’s health priorities through excellent service in under-served areas in order to improve health outcomes for Uganda and beyond.

Objectives
The main thematic aims of MESAU are:
1.Theme 1: increasing the number of health workers trained. In Year 2 this has involved expanding the infrastructure and processes that will increase the capacity of MESAU institutions to improve the quality and numbers of students graduating in various health professional programs. An anthropological assessment of MESAU is under way will contribute to our understanding of the evolution of a consortium approach and its contribution to medical education across the country.
2.Theme 2: Retaining health workers in areas where they are most needed, through enhancement of Community Based Education Research and Service (COBERS) and Family Medicine interventions.
3.Theme 3: Increasing the capacity of MEPI institutions to conduct locally relevant research

Challenges
The slow bureaucratic procurement process at MUST has led to delays in acquisition of major items like vehicles and skills lab equipment. Another challenge is understaffing and limited capacity at MUST.

Achievements

MEPI Theme 1
Twenty nine faculty members were trained in the 6 steps approach for curriculum development and the process of developing the curriculum is still going on. Another workshop held from the 9th to 11th March 2012 reviewed the curriculum; a total of 67 participants attended. During this workshop six programs were reviewed, namely, Bachelor of Medicine and Surgery, Medical Laboratory Science, Pharmacy, Nursing, Dentistry and Physiotherapy. New courses were added on to the programs and these included; Family Medicine for MBChB and Entrepreneurship for all the programs.
Space for the establishment of the ERU was identified. Equipment were procured to support teaching and learning at the education resources unit and these included: Five laptops, an LCD projector, two Printers.
Stakeholders meeting was held at MUST. It created awareness and generated support for MESAU-MUST
Competencies for the MBChB, PHarm, BNS/BNC, MLS/MLC were defined and these guided the curriculum review process that has been ongoing at FOM-MUST.
MUST represented in the MEPI Annual Symposium at Johannsburg, South Africa
One Faculty member (Susan Achora, suppotted to complete her medical education in Southern Africa FAIMER Regional Institute (SAFRI)
One faculty member (Wilfred Arubaku) started his Master of Health Professionals Education (MHPE)
The Quality Assurance Committee developed tools for staff, students and infrastructure development assessment.

MEPI Theme 2
The draft CBE COBERS curriculum and the COBERS handbook were produced.
Poster presentations for the Leadership Community Placement reports were made at the MUST Annual scientific conference.
A stakeholder’s workshop held on the 22 March 2012 in Mbarara was attended by 41 participants from MUST, the districts and collaborating institutions. It discussed the COBERS budget, activity plan and how development partners could support MUST to improve COBERS.
MUST procured 10 desktop computers for COBERS sites.
An ICT and distance learning infrastructure needs assessment was carried out.
The staff and students benefited from the MakCHS international grand rounds by means of the recorded sessions.

Way forward
Continued strengthening of the MUST Grants Office and capacity building among the limited staff available.

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REDUCE Study

Study Title: The Role of Undiagnosed Opportunistic Infections in Early Mortality among HIV-infected Patients Starting Antiretroviral Therapy in Africa (REDUCe Study)

Study Personnel: International Principle Investigator (PI): Dr. Geng Elvin
Ugandan Principle Investigator (PI):  Dr. Conrad Muzoora
Coordinator: Emmanuel B. Byaruhanga
Sponsor: NIH
Study Site: Mbarara (ISS Clinic)

Introduction and Aims
Millions of HIV-infected patients are starting life-saving antiretroviral therapy in sub-Saharan Africa. However, the rate of mortality during first 3-6 months of treatment is high and not well explained. We hypothesize that these early deaths are due to opportunistic infections (OI’s) present but undiagnosed at the time of antiretroviral treatment initiation. These opportunistic infections are unlikely to improve on antiretroviral medications alone, which may even hasten mortality through the immune reconstitution inflammatory syndrome (IRIS). This proposal seeks to conduct a pilot study to identify whether early mortality may be due to unrecognized OI’s in a clinic-based cohort in Mbarara, Uganda. Therefore, we propose the following specific aims:

To determine the feasibility of collecting and storing peripheral blood and induced sputum on a consecutive sample of 300 patients starting antiretroviral therapy in Uganda and to later evaluate selected samples for the presence of underlying infections with Mycobacterium tuberculosis, Pneumocystis jirovecii, Cryptococcus neoformans, cytomegalovirus, Bartonella spp., HHV-8 and Histoplasma capsulatum .
To determine all deaths which occur within three months after starting antiretroviral therapy in this sample by adapting an existing patient-tracking protocol.

To estimate preliminary associations between deaths in the first three months on antiretroviral therapy and presence of underlying infections in stored samples.

Study design: Nest case-control study
Target enrollment number: 300

Introduction 
HURAPRIM is an international collaborative project on Human Resources for Primary Health Care in Africa. Five African countries are partners in the consortium, to give results representative of different parts of Africa: Mali, Sudan, Uganda, Botswana and South Africa. The first aim of the HURAPRIM project is to arrive at a better understanding of the scope and causes of the deficit in human resources for primary health care in Africa, with a view to then developing interventions to address this problem. Since the start of the project in March 2011, MUST has been working on; the literature review, participatory research and a confidential enquiry into maternal and child deaths.
Confidential enquiry into maternal and child deaths in Uganda, aims at  prioritising how human resources for health could best be used in order to achieve the Millennium Development Goals 4 and 5 (reducing maternal and child mortality). The confidential enquiry is revealing that quality of human resources is as important as quantity, if not more. It has transpired that this process is in itself a promising intervention to improve quality of care and to inform public health policy on allocation of human resources, and is therefore a being proposed that the process be   scaled up in the next phase of HURAPRIM.

In Uganda, we are piloting the confidential enquiry in two sub-counties (Rugando and Nyakayojo) in Kinoni Health sub-district, in Mbarara district which is south-west of the capital. We started in Rugando in October 2011, Nyakayojo was added in February 2012, and Kibuli Parish, Makindye Division, Kampala district, was added in May 2012. These areas were selected because the study team already had good local connections and was confident it would be able to conduct the study to a high standard. Healthy Child Uganda has been working to build up teams of voluntary Village Health Teams (VHTs) in Kinoni health sub-district for the last 10 years, and there is already a system for reporting births and deaths, and a monthly meeting of VHTs in different areas to discuss any child deaths that do occur.

In Kinoni (Uganda) so far 48 deaths have been reported, of which 35 have been analysed. The number of deaths was close to what had been expected except in one parish where the number of deaths was about three times greater than expected. All maternal deaths at Mbarara Regional Referral Hospital since October 2011.Total deaths: 24 Investigated: 23
The information collected from the interviews and medical records is collated and summarised by the fieldworkers and researchers, and presented to a regular monthly panel meeting. In most cases, the maternal deaths are reviewed in a separate meeting from the child deaths. The meetings are mostly held in a hospital. The panel are led by a doctor (paediatrician, obstetrician, or family physician) and also includes other health workers from the hospital and the community plus village health worker representatives. Training for panel members was done with input from experienced case review panel members from the UK. Although it is  not always possible for external members to attend every case review meeting, a system of external supervision was set up, and all cases are reviewed externally as well as by the local panel.

The panel is tasked to determi ne the most likely cause of death, identify avoidable factors, and to make recommendations on how such factors could be avoided in future (with a particular emphasis on how human resources could better be deployed).

HURAPRIM MUST team is comprised of the following;

  1.      Dr Vincent Mubangizi-Local coordinator
  2.      Dr Kumbakumba Elias- PI  for child death investigation
  3.      Dr Joseph Ngonzi-PI –for maternal mortality investigations
  4.      Dr Edgar Mulongo-PI –participatory research
  5.      Dr Sam Maling-advisor on ethical issues
  6.      Ass Prof Jerome Kabakyenga-Provides overall/oversight leadership
  7.      Dr Francis Bajunirwe- Literature review
  8.      Kyokushaba Christine-Research assistant
  9.      Natukunda Slyvia –Research assistant
  10.      Mwesigwa Douglas-Research assistant
  11.      Ayebazibwe Pedson-Research assistant
  12.      Turinawe Ezra-Project Administrator

So far for Child deaths the following recommendations for primary health care have been made

  •    Provide basic in-service training, follow-up and supervision in management of severe childhood illnesses to staff in HCII/III/IV and private clinics and drug shops
  •    There should be funding earmarked for the Medical officer in the HCIV to supervise private clinics / drug shops.
  •    Increase levels of trained health staff at HCII and HCIV
  •    Ensure antimalarials and bednets are always given during antenatal visits
  •    Provide training to TBAs to recognise and refer severely ill babies
  •    HCIV needs to procure or acquire newborn resuscitation equipment and have midwives trained in newborn resuscitation

 And the Recommendations below have  already been implemented

  •    Filing of medical records on the paediatric ward has been improved
  •    Nursing students have been asked to help monitor critically ill children
  •    Artesunate is now recommended by the MoH but not yet available in the government supply chain for the treatment of severe malaria
  •    High-risk antenatal clinic has started at MRRH
  •    Referred patients are now being accompanied more often
  •    2 oxygen heads have been obtained
  •    Triage system has been started at MRRH

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