Background Subacute uterine inversion is a very rare complication of mid-trimester termination of... more Background Subacute uterine inversion is a very rare complication of mid-trimester termination of pregnancy that should be considered in a situation where unsafe abortion occurs. Case presentation We present a case of subacute uterine inversion complicated by hypovolemic shock following an unsafe abortion in a 17-year-old nulliparous unmarried girl. She presented with a history of collapse, mass protruding per vagina that followed Valsalva, and persistent lower abdominal pain but not vaginal bleeding. This followed her second attempt to secretly induce an abortion at 18 weeks amenorrhea. On examination, she was agitated, severely pale, cold on palpation, with an axillary temperature of 35.8 °C, a tachycardia of 143 beats per minute and unrecordable low blood pressure. The abdomen was soft and non-tender with no palpable masses; the uterine fundus was absent at its expected periumbilical position and cupping was felt instead. A fleshy mass with gangrenous patches protruding in the in...
Background Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but data ... more Background Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but data are limited on HIV incidence among PrEP users in generalized epidemic settings, particularly outside of selected risk groups. We performed a population-based PrEP study in rural Kenya and Uganda and sought to evaluate both changes in HIV incidence and clinical and virologic outcomes following seroconversion on PrEP. Methods and findings During population-level HIV testing of individuals ≥15 years in 16 communities in the Sustainable East Africa Research in Community Health (SEARCH) study (NCT01864603), we offered universal access to PrEP with enhanced counseling for persons at elevated HIV risk (based on serodifferent partnership, machine learning–based risk score, or self-identified HIV risk). We offered rapid or same-day PrEP initiation and flexible service delivery with follow-up visits at facilities or community-based sites at 4, 12, and every 12 weeks up to week 144. Among participa...
As antiretroviral therapy (ART) rapidly expands in sub-Saharan Africa using new efficient care mo... more As antiretroviral therapy (ART) rapidly expands in sub-Saharan Africa using new efficient care models, data on costs of these approaches are lacking. We examined costs of a streamlined HIV care delivery model within a large HIV test-and-treat study in Uganda and Kenya. We calculated observed per-person-per-year (ppy) costs of streamlined care in 17 health facilities in SEARCH Study intervention communities (NCT: 01864603) via micro-costing techniques, time-and-motion studies, staff interviews, and administrative records. Cost categories included salaries, ART, viral load testing, recurring goods/services, and fixed capital/facility costs. We then modeled costs under three increasingly efficient scale-up scenarios: lowest-cost ART, centralized viral load testing, and governmental healthcare worker salaries. We assessed the relationship between community-specific ART delivery costs, retention in care, and viral suppression. Estimated streamlined HIV care delivery costs were $291/ppy. ...
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 5, 2018
Global guidelines recommend preexposure prophylaxis (PrEP) for individuals with substantial HIV r... more Global guidelines recommend preexposure prophylaxis (PrEP) for individuals with substantial HIV risk. Data on PrEP uptake in sub-Saharan Africa outside of clinical trials are limited. We report on "early adopters" of PrEP in SEARCH, an ongoing population-based study in rural Uganda and Kenya. Following community mobilization and education on PrEP, population-based HIV testing was conducted. HIV-uninfected adults were offered PrEP based on an empirically-derived HIV risk score or an individual's self-identified HIV risk (if not identified by score). We analyzed predictors of early PrEP adoption (starting PrEP within 30 days versus delayed/no start) among adults identified for PrEP using logistic regression. Of 21,212 HIV-uninfected adults in five communities, 4,064 were identified for PrEP (2,991 [74%] by empiric risk score; 1,073 [26%] by self-identified risk). Of these, 739 started PrEP within 30 days (11% of those identified by risk score; 39% of self-identified); 77...
Journal of clinical tuberculosis and other mycobacterial diseases, 2017
Reducing tuberculosis (TB) deaths among children requires a better understanding of the gaps in t... more Reducing tuberculosis (TB) deaths among children requires a better understanding of the gaps in the care cascade from TB diagnosis to treatment completion. We sought to assess the child TB care cascade in 32 rural communities in Uganda and Kenya using programmatic data. This is a retrospective cohort study of 160,851 children (ages <15 years) living in 12 rural communities in Kenya and 22 in Uganda. We reviewed national TB registries from health centers in and adjacent to the 32 communities, and we included all child TB cases recorded from January 1, 2013 to June 30, 2016. To calculate the first step of the child TB care cascade, the number of children with active TB, we divided the number of reported child TB diagnoses by the 2015 World Health Organization (WHO) child TB case detection ratio for Africa of 27%. The remaining components of the Child TB Care Cascade were ascertained directly from the TB registries and included: diagnosed with TB, started on TB treatment, and comple...
Journal of the International AIDS Society, Jul 21, 2017
The 2015 WHO recommendation of antiretroviral therapy (ART) for all HIV-positive persons calls fo... more The 2015 WHO recommendation of antiretroviral therapy (ART) for all HIV-positive persons calls for treatment initiation in millions of persons newly eligible with high CD4+ counts. Efficient and effective care models are urgently needed for this population. We evaluated clinical outcomes of asymptomatic HIV-positive adults and children starting ART with high CD4+ counts using a novel streamlined care model in rural Uganda and Kenya. In the 16 intervention communities of the HIV test-and-treat Sustainable East Africa Research for Community Health Study (NCT01864603), all HIV-positive individuals irrespective of CD4 were offered ART (efavirenz [EFV]/tenofovir disoproxil fumarate + emtricitabine (FTC) or lamivudine (3TC). We studied adults (≥fifteen years) with CD4 ≥ 350/μL and children (two to fourteen years) with CD4 > 500/μL otherwise ineligible for ART by country guidelines. Clinics implemented a patient-centred streamlined care model designed to reduce patient-level barriers an...
Antiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set gl... more Antiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set global targets to diagnose 90% of HIV-positive individuals, treat 90% of diagnosed individuals with ART, and suppress viral replication among 90% of treated individuals, for a population-level target of 73% of all HIV-positive persons with HIV viral suppression. To describe changes in the proportions of HIV-positive individuals with HIV viral suppression, HIV-positive individuals who had received a diagnosis, diagnosed individuals treated with ART, and treated individuals with HIV viral suppression, following implementation of a community-based testing and treatment program in rural East Africa. Observational analysis based on interim data from 16 rural Kenyan (n = 6) and Ugandan (n = 10) intervention communities in the SEARCH Study, an ongoing cluster randomized trial. Community residents who were 15 years or older (N = 77 774) were followed up for 2 years (2013-2014 to 2015-2016). HIV se...
Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown... more Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up. Within a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly ef...
We sought to measure retention in care and identify predictors of non-retention among patients re... more We sought to measure retention in care and identify predictors of non-retention among patients receiving ART with streamlined delivery during the first year of the ongoing SEARCH "test-and-treat" trial (NCT 01864603) in rural Uganda and Kenya. Prospective cohort of patients in the intervention arm of the SEARCH Study. We measured retention in care at 12 months among HIV-infected adults who linked to care and were offered ART regardless of CD4 cell count, following community-wide HIV-testing. Kaplan-Meier estimates and Cox proportional hazards modeling were used to calculate the probability of retention at one year and identify predictors of non-retention. Among 5,683 adults (age ≥ 15) who linked to care, 95.5% (95% CI: 92.9 - 98.1%) were retained in care at 12 months. The overall probability of retention at one year was 89.3% (95% CI: 87.6 - 90.7%) among patients newly linking to care and 96.4% (95% CI: 95.8 - 97.0%) among patients previously in care. Younger age and pre-A...
Background Subacute uterine inversion is a very rare complication of mid-trimester termination of... more Background Subacute uterine inversion is a very rare complication of mid-trimester termination of pregnancy that should be considered in a situation where unsafe abortion occurs. Case presentation We present a case of subacute uterine inversion complicated by hypovolemic shock following an unsafe abortion in a 17-year-old nulliparous unmarried girl. She presented with a history of collapse, mass protruding per vagina that followed Valsalva, and persistent lower abdominal pain but not vaginal bleeding. This followed her second attempt to secretly induce an abortion at 18 weeks amenorrhea. On examination, she was agitated, severely pale, cold on palpation, with an axillary temperature of 35.8 °C, a tachycardia of 143 beats per minute and unrecordable low blood pressure. The abdomen was soft and non-tender with no palpable masses; the uterine fundus was absent at its expected periumbilical position and cupping was felt instead. A fleshy mass with gangrenous patches protruding in the in...
Background Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but data ... more Background Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, but data are limited on HIV incidence among PrEP users in generalized epidemic settings, particularly outside of selected risk groups. We performed a population-based PrEP study in rural Kenya and Uganda and sought to evaluate both changes in HIV incidence and clinical and virologic outcomes following seroconversion on PrEP. Methods and findings During population-level HIV testing of individuals ≥15 years in 16 communities in the Sustainable East Africa Research in Community Health (SEARCH) study (NCT01864603), we offered universal access to PrEP with enhanced counseling for persons at elevated HIV risk (based on serodifferent partnership, machine learning–based risk score, or self-identified HIV risk). We offered rapid or same-day PrEP initiation and flexible service delivery with follow-up visits at facilities or community-based sites at 4, 12, and every 12 weeks up to week 144. Among participa...
As antiretroviral therapy (ART) rapidly expands in sub-Saharan Africa using new efficient care mo... more As antiretroviral therapy (ART) rapidly expands in sub-Saharan Africa using new efficient care models, data on costs of these approaches are lacking. We examined costs of a streamlined HIV care delivery model within a large HIV test-and-treat study in Uganda and Kenya. We calculated observed per-person-per-year (ppy) costs of streamlined care in 17 health facilities in SEARCH Study intervention communities (NCT: 01864603) via micro-costing techniques, time-and-motion studies, staff interviews, and administrative records. Cost categories included salaries, ART, viral load testing, recurring goods/services, and fixed capital/facility costs. We then modeled costs under three increasingly efficient scale-up scenarios: lowest-cost ART, centralized viral load testing, and governmental healthcare worker salaries. We assessed the relationship between community-specific ART delivery costs, retention in care, and viral suppression. Estimated streamlined HIV care delivery costs were $291/ppy. ...
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 5, 2018
Global guidelines recommend preexposure prophylaxis (PrEP) for individuals with substantial HIV r... more Global guidelines recommend preexposure prophylaxis (PrEP) for individuals with substantial HIV risk. Data on PrEP uptake in sub-Saharan Africa outside of clinical trials are limited. We report on "early adopters" of PrEP in SEARCH, an ongoing population-based study in rural Uganda and Kenya. Following community mobilization and education on PrEP, population-based HIV testing was conducted. HIV-uninfected adults were offered PrEP based on an empirically-derived HIV risk score or an individual's self-identified HIV risk (if not identified by score). We analyzed predictors of early PrEP adoption (starting PrEP within 30 days versus delayed/no start) among adults identified for PrEP using logistic regression. Of 21,212 HIV-uninfected adults in five communities, 4,064 were identified for PrEP (2,991 [74%] by empiric risk score; 1,073 [26%] by self-identified risk). Of these, 739 started PrEP within 30 days (11% of those identified by risk score; 39% of self-identified); 77...
Journal of clinical tuberculosis and other mycobacterial diseases, 2017
Reducing tuberculosis (TB) deaths among children requires a better understanding of the gaps in t... more Reducing tuberculosis (TB) deaths among children requires a better understanding of the gaps in the care cascade from TB diagnosis to treatment completion. We sought to assess the child TB care cascade in 32 rural communities in Uganda and Kenya using programmatic data. This is a retrospective cohort study of 160,851 children (ages <15 years) living in 12 rural communities in Kenya and 22 in Uganda. We reviewed national TB registries from health centers in and adjacent to the 32 communities, and we included all child TB cases recorded from January 1, 2013 to June 30, 2016. To calculate the first step of the child TB care cascade, the number of children with active TB, we divided the number of reported child TB diagnoses by the 2015 World Health Organization (WHO) child TB case detection ratio for Africa of 27%. The remaining components of the Child TB Care Cascade were ascertained directly from the TB registries and included: diagnosed with TB, started on TB treatment, and comple...
Journal of the International AIDS Society, Jul 21, 2017
The 2015 WHO recommendation of antiretroviral therapy (ART) for all HIV-positive persons calls fo... more The 2015 WHO recommendation of antiretroviral therapy (ART) for all HIV-positive persons calls for treatment initiation in millions of persons newly eligible with high CD4+ counts. Efficient and effective care models are urgently needed for this population. We evaluated clinical outcomes of asymptomatic HIV-positive adults and children starting ART with high CD4+ counts using a novel streamlined care model in rural Uganda and Kenya. In the 16 intervention communities of the HIV test-and-treat Sustainable East Africa Research for Community Health Study (NCT01864603), all HIV-positive individuals irrespective of CD4 were offered ART (efavirenz [EFV]/tenofovir disoproxil fumarate + emtricitabine (FTC) or lamivudine (3TC). We studied adults (≥fifteen years) with CD4 ≥ 350/μL and children (two to fourteen years) with CD4 > 500/μL otherwise ineligible for ART by country guidelines. Clinics implemented a patient-centred streamlined care model designed to reduce patient-level barriers an...
Antiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set gl... more Antiretroviral treatment (ART) is now recommended for all HIV-positive persons. UNAIDS has set global targets to diagnose 90% of HIV-positive individuals, treat 90% of diagnosed individuals with ART, and suppress viral replication among 90% of treated individuals, for a population-level target of 73% of all HIV-positive persons with HIV viral suppression. To describe changes in the proportions of HIV-positive individuals with HIV viral suppression, HIV-positive individuals who had received a diagnosis, diagnosed individuals treated with ART, and treated individuals with HIV viral suppression, following implementation of a community-based testing and treatment program in rural East Africa. Observational analysis based on interim data from 16 rural Kenyan (n = 6) and Ugandan (n = 10) intervention communities in the SEARCH Study, an ongoing cluster randomized trial. Community residents who were 15 years or older (N = 77 774) were followed up for 2 years (2013-2014 to 2015-2016). HIV se...
Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown... more Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up. Within a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly ef...
We sought to measure retention in care and identify predictors of non-retention among patients re... more We sought to measure retention in care and identify predictors of non-retention among patients receiving ART with streamlined delivery during the first year of the ongoing SEARCH "test-and-treat" trial (NCT 01864603) in rural Uganda and Kenya. Prospective cohort of patients in the intervention arm of the SEARCH Study. We measured retention in care at 12 months among HIV-infected adults who linked to care and were offered ART regardless of CD4 cell count, following community-wide HIV-testing. Kaplan-Meier estimates and Cox proportional hazards modeling were used to calculate the probability of retention at one year and identify predictors of non-retention. Among 5,683 adults (age ≥ 15) who linked to care, 95.5% (95% CI: 92.9 - 98.1%) were retained in care at 12 months. The overall probability of retention at one year was 89.3% (95% CI: 87.6 - 90.7%) among patients newly linking to care and 96.4% (95% CI: 95.8 - 97.0%) among patients previously in care. Younger age and pre-A...
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Papers by Asiphas Owaraganise