Diane V Havlir

University of California, San Francisco, San Francisco, California, United States

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Publications (219)2216.77 Total impact

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    ABSTRACT: Objectives Targeting high TB transmission sites may offer a novel approach to TB prevention in sub-Saharan Africa. We sought to characterize TB transmission sites in a rural Ugandan township.Methods We recruited adults starting TB treatment in Tororo, Uganda over one year. 54 TB cases provided names of frequent contacts, sites of residence, health care, work and social activities, and two sputum samples. Mycobacterium tuberculosis (MTB) culture-positive specimens underwent spoligotyping to identify strains with shared genotypes. We visualized TB case social networks, and obtained, mapped and geo-coded global positioning system measures for every location that cases reported frequenting one month before treatment. Locations of spatial overlap among genotype-clustered cases were considered potential transmission sites.ResultsSix distinct genotypic clusters were identified involving 21/33(64%) MTB culture-positive, genotyped cases; none shared a home. Although 18/54(33%) TB cases shared social network ties, none of the genotype-clustered cases shared social ties. Using spatial analysis, we identified potential sites of within-cluster TB transmission for five of six genotypic clusters. All sites but one were health care and social venues, including sites of drinking, worship and marketplaces. Cases reported spending the largest proportion of pre-treatment person-time (22.4%) at drinking venues.Conclusions Using molecular epidemiology, geospatial and social network data from adult TB cases identified at clinics, we quantified person-time spent at high-risk locations across a rural Ugandan community, and determined the most likely sites of recent TB transmission to be health care and social venues. These sites may not have been identified using contact investigation alone.This article is protected by copyright. All rights reserved.
    Tropical Medicine & International Health 01/2015; · 2.30 Impact Factor
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    ABSTRACT: Combination antiretroviral therapy (ART) is now the global standard for HIV-infected pregnant and breastfeeding women at all CD4 cell counts. We compared the efficacy and safety of an efavirenz versus lopinavir/ritonavir regimen for HIV-infected pregnant women initiating ART in rural Uganda. Randomized clinical trial. We performed a planned secondary analysis comparing viral load suppression (HIV-1 RNA ≤400 copies/ml), safety, and HIV transmission to infants in a trial designed to test the hypothesis that lopinavir/ritonavir versus efavirenz-based ART would reduces placental malaria (PROMOTE, ClinicalTrials.gov, NCT00993031). HIV-infected, ART-naïve pregnant women at 12-28 weeks gestation and any CD4 cell count were randomized. ART was provided and participants were counseled to breastfeed for 1 year postpartum. The median age of the 389 study participants was 29 years; median CD4 cell count was 370 cells/μl. At delivery, virologic suppression was 97.6% in the efavirenz arm and 86.0% in the lopinavir/ritonavir arm (P < 0.001). At 48 weeks postpartum, 91.0% of women on efavirenz and 88.4% on lopinavir/ritonavir had viral suppression (P = 0.49). Grade 1 or 2 gastrointestinal adverse events were higher among women on lopinavir/ritonavir versus efavirenz. Only two infants acquired HIV (both in the lopinavir/ritonavir arm), and HIV-free infant survival was similar between study arms: 92.9% (lopinavir/ritonavir) versus 97.2% (efavirenz) (P = 0.10). Virologic suppression at delivery was higher with an efavirenz versus lopinavir/ritonavir-based regimen. However, women in both arms achieved high levels of virologic suppression through 1 year postpartum and the risk of transmission to infants was low.
    AIDS (London, England) 11/2014; · 6.56 Impact Factor
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    ABSTRACT: We evaluated the acceptability and use of macronutrient supplementation among HIV-infected pregnant Ugandan women receiving antiretroviral therapy in a clinical study (NCT 00993031). We first conducted formative research among 56 pregnant and lactating women to select a supplement regimen. Acceptability and use of the supplementation regimen (35 sachets of lipid-based nutrient supplements (LNS) and 4 or 6 kg of instant soy porridge for the household provided monthly) were evaluated among 87 pregnant women. Organoleptic assessments of LNS were favorable. Participants reported consuming LNS a mean of 6.1 days per week, and adherence to recommended consumption behaviors (e.g. frequency, quantity, not sharing) was >80 %. Few women reported negative social consequences of supplementation. The majority of participants also consumed most of the porridge intended for the household. In sum, LNS was acceptable and used regularly. Larger studies to evaluate physical and psychosocial consequences of LNS during pregnancy among HIV-infected women are warranted.
    AIDS and Behavior 11/2014; · 3.49 Impact Factor
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    ABSTRACT: BackgroundImproving childhood tuberculosis (TB) evaluation and care is a global priority, but data on performance at community health centers in TB endemic regions are sparse.ObjectiveTo describe the current practices and quality of TB evaluation for children with cough ≥2 weeks' duration presenting to community health centers in Uganda.MethodsCross-sectional analysis of children (<15 years) receiving care at five Level IV community health centers in rural Uganda for any reason between 2009–2012. Quality of TB care was assessed using indicators derived from the International Standards of Tuberculosis Care (ISTC).ResultsFrom 2009–2012, 1713 of 187,601 (0.9%, 95% CI: 0.4–1.4%) children presenting to community health centers had cough ≥ 2 weeks' duration. Of those children, only 299 (17.5%, 95% CI: 15.7–19.3%) were referred for sputum microscopy, but 251 (84%, 95% CI: 79.8–88.1%) completed sputum examination if referred. The yield of sputum microscopy was only 3.6% (95% CI: 1.3–5.9%), and only 55.6% (95% CI: 21.2–86.3%) of children with acid-fast bacilli positive sputum were started on treatment. Children under age 5 were less likely to be referred for sputum examination and to receive care in accordance with ISTC. The proportion of children evaluated in accordance with ISTC increased over time (4.6% in 2009 to 27.9% in 2012, p = 0.03), though this did not result in increased case-detection.ConclusionThe quality of TB evaluation was poor for children with cough ≥2 weeks' duration presenting for health care. Referrals for sputum smear microscopy and linkage to TB treatment were key gaps in the TB evaluation process, especially for children under the age of five.
    PLoS ONE 08/2014; 9(8):e105935. · 3.53 Impact Factor
    This article is viewable in ResearchGate's enriched format
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    ABSTRACT: The emergence of resistance to artemisinin derivatives in Southeast Asia, manifested as delayed clearance of Plasmodium falciparum following treatment with artemisinins, is a major concern. Recently, the artemisinin resistance phenotype was attributed to mutations in portions of a P. falciparum gene (PF3D7_1343700) encoding kelch (K13) propeller domains, providing a molecular marker to monitor the spread of resistance. The P. falciparum cysteine protease falcipain-2 (FP2; PF3D7_1115700) has been shown to contribute to artemisinin action, as hemoglobin degradation is required for potent drug activity, and a stop mutation in the FP2 gene was identified in parasites selected for artemisinin resistance. Although delayed parasite clearance after artemisinin-based combination therapy (ACT) has not yet been noted in Uganda and ACTs remain highly efficacious, characterizing the diversity of these genes is important to assess the potential for resistance selection and to provide a baseline for future surveillance. We therefore sequenced the K13-propeller domain and FP2 gene in P. falciparum isolates from children previously treated with ACT in Uganda, including samples from 2006-7 (n = 49) and from 2010-12 (n = 175). Using 3D7 as the reference genome, we identified 5 non-synonymous polymorphisms in the K13-propeller domain (133 isolates) and 35 in FP2 (160 isolates); these did not include the polymorphisms recently associated with resistance after in vitro selection or identified in isolates from Asia. The prevalence of K13-propeller and FP2 polymorphisms did not increase over time, and was not associated with either time since prior receipt of an ACT or the persistence of parasites ≥2 days following treatment with an ACT. Thus, the K13-propeller and FP2 polymorphisms associated with artemisinin resistance are not prevalent in Uganda, and we did not see evidence for selection of polymorphisms in these genes.
    PLoS ONE 08/2014; 9(8):e105690. · 3.53 Impact Factor
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    ABSTRACT: Human immunodeficiency virus (HIV)-exposed uninfected children (HEU) have an increased risk of morbidity and mortality compared with HIV-unexposed uninfected children (HUU); however, prior studies have not fully accounted for the role of both breastfeeding and age on this association. In this cohort of HEU and HUU in Uganda, non-breastfeeding HEU, from 6-11 months compared with non-breastfeeding HUU had a higher risk of hospitalizations [relative risk (RR): 10.1, 95% confidence interval (CI): 3.70-27.6], severe febrile illness (RR: 3.84, 95% CI: 2.06-7.17), severe diarrhea (RR: 6.37, 95% CI: 2.32-17.4) and severe malnutrition (RR: 18.4, 95% CI: 4.68-72.0). There were no differences between morbidity outcomes between breastfeeding HEU and HUU children, aged 6-11 months. In the 12-24 month age group, the only difference in morbidity outcomes among non-breast feeding children was an increased risk of severe malnutrition for HEU. These data suggest that the increased risk of morbidity among HEU aged 6-11 years is partially explained by early cessation of breastfeeding.
    Journal of Tropical Pediatrics 08/2014; · 0.86 Impact Factor
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    ABSTRACT: Chemoprevention offers a promising strategy for prevention of malaria in African children. However, the optimal chemoprevention drug and dosing strategy is unclear in areas of year-round transmission and resistance to many antimalarial drugs. To compare three available regimens, we conducted an open-label randomized controlled trial of chemoprevention in Ugandan children.
    PLoS Medicine 08/2014; 11(8):e1001689. · 15.25 Impact Factor
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    ABSTRACT: Protease inhibitor-based antiretroviral therapy (ART) has been associated with preterm birth in some studies. We examined risk factors for preterm birth among women randomized to lopinavir/ritonavir- or efavirenz-based ART.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 07/2014; · 4.39 Impact Factor
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    ABSTRACT: HIV antiretroviral therapy (ART) is being rapidly scaled up in sub-Saharan Africa, including recently patients with CD4 T-cell counts above 350 cells/μl. However, concerns persist about adherence and virologic suppression among these asymptomatic, high CD4 cell count individuals.
    AIDS (London, England) 07/2014; · 6.56 Impact Factor
  • The Journal of Infectious Diseases 06/2014; · 5.78 Impact Factor
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    ABSTRACT: Studies with direct-acting antivirals (DAAs) for hepatitis C virus (HCV) monoinfection and HIV coinfection were highlighted at the 2013 Conference on Retroviruses and Opportunistic Infections (CROI). In HCV monoinfected patients, several interferon alfa-sparing, all-oral regimens demonstrated cure rates of greater than 90% with 12 weeks of treatment, including for hard-to-treat patients. Cure rates of 75% were attained in HIV/HCV coinfected patients with the addition of the investigational HCV protease inhibitor (PI) simeprevir to peginterferon alfa and ribavirin. Drug-drug interaction data to inform safe coadminstration of antiretroviral therapy with DAA-based HCV treatment were presented. There was continued emphasis on pathogenesis, management, and prevention of the long-term complications of HIV disease and its therapies, including cardiovascular disease, renal disease, alterations in bone metabolism, and vitamin D deficiency, along with a growing focus on biomarkers to predict development of end-organ disease. Understanding the elevated risk for non-AIDS-defining malignancies in the HIV-infected population and optimal management was a focal point of this year's data. Finally, the conference provided important information on tuberculosis coinfection and cryptococcal meningitis.
    Topics in antiviral medicine. 05/2014; 21(2):62-74.
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    ABSTRACT: Background. Artemisinin-based combination therapies (ACTs) are highly efficacious and safe but data from HIV-infected children concurrently receiving antiretroviral therapy (ART) and ACTs are limited. Methods. We evaluated 28-day outcomes following malaria treatment with artemether-lumefantrine (AL) or dihydroartemisinin-piperaquine (DP) in two cohorts of HIV-infected Ugandan children taking various ART regimens. In one cohort, children under six years of age were randomized to lopinavir/ritonavir (LPV/r) or non-nucleoside reverse transcriptase inhibitors (NNRTI) based ART and treated with AL for uncomplicated malaria. In another cohort, children under 12 months of age were started on nevirapine-based ART if they were eligible, and randomized to AL or DP for the treatment of their first and all subsequent uncomplicated malaria episodes. Results. There were 773 and 165 treatments for malaria with AL and DP, respectively. Initial response to therapy was excellent, with 99% clearance of parasites and<1% risk of repeat therapy within 3 days. Recurrent parasitemia within 28 days was common following AL treatment. The risk of recurrent parasitemia was significantly lower among children taking LPV/r-based ART compared to children taking nevirapine-based ART following AL treatment (15.3% vs. 35.5%, P=0.009), and those treated with DP compared to AL (8.6% vs. 36.2%, P<0.001). Both ACT regimens were safe and well tolerated. Conclusion. Treatment of uncomplicated malaria with AL or DP was efficacious and safe in HIV-infected children taking ART. However there was a high risk of recurrent parasitemia following AL treatment which was significantly lower in children taking LPV/r-based ART compared to nevirapine-based ART.
    Clinical Infectious Diseases 04/2014; · 9.42 Impact Factor
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    ABSTRACT: Human Immunodeficiency Virus-infected patients are disproportionately affected by cardiovascular disease and sudden cardiac death (SCD). Whether left ventricular (LV) dysfunction predicts SCD in those with human immunodeficiency virus (HIV) is unknown. We sought to determine the impact of LV on SCD in patients with HIV. We previously characterized all SCDs and AIDS deaths in2860 consecutive patients in a public HIV clinic between 2000 and 2009. Transthoracic echocardiograms (TTEs) performed during the study period were identified. The effect of ejection fraction (EF), diastolic dysfunction, pulmonary artery pressure, and LV masson SCD and acquired immune deficiency syndrome (AIDS) deathwere evaluated:423patients had at least one TTE; 13 SCDs and 55 AIDS deaths had at least one TTE. In the propensity-adjusted analysis, EF 30-39% and EF <30% predicted SCD (HR 9.5, 95% CI 1.7-53.3, p=0.01 and HR 38.5, 95% CI 7.6-195.0, p<0.001, respectively) but not AIDS death. Diastolic dysfunction also predicted SCD (HR 14.8, 95% CI 4.0-55.4, p<0.001) but not AIDS death, even after adjustingfor EF. The association between EF<40% and SCD was greater in subjects with detectable vs. undetectable HIV-RNA (adjusted HR 11.7, 95%CI 2.9-47.2, p=0.001 vs. HR 2.7, 95%CI 0.3-27.6, p=0.41; p=0.07 for interaction).In conclusion, LV systolic and diastolic dysfunction predict SCD but not AIDS death in a large HIV cohort, with greater effect in those with detectable HIV RNA. Further investigation is needed to thoroughly evaluate the effect of low EF and HIV factors on SCD incidence and the potential benefit of implantable cardioverter-defibrillator therapy in this high-risk population.
    The American journal of cardiology 04/2014; · 3.58 Impact Factor
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    ABSTRACT: Use of antiretroviral treatment for HIV-1 infection has decreased AIDS-related morbidity and mortality and prevents sexual transmission of HIV-1. However, the best time to initiate antiretroviral treatment to reduce progression of HIV-1 infection or non-AIDS clinical events is unknown. We reported previously that early antiretroviral treatment reduced HIV-1 transmission by 96%. We aimed to compare the effects of early and delayed initiation of antiretroviral treatment on clinical outcomes. The HPTN 052 trial is a randomised controlled trial done at 13 sites in nine countries. We enrolled HIV-1-serodiscordant couples to the study and randomly allocated them to either early or delayed antiretroviral treatment by use of permuted block randomisation, stratified by site. Random assignment was unblinded. The HIV-1-infected member of every couple initiated antiretroviral treatment either on entry into the study (early treatment group) or after a decline in CD4 count or with onset of an AIDS-related illness (delayed treatment group). Primary events were AIDS clinical events (WHO stage 4 HIV-1 disease, tuberculosis, and severe bacterial infections) and the following serious medical conditions unrelated to AIDS: serious cardiovascular or vascular disease, serious liver disease, end-stage renal disease, new-onset diabetes mellitus, and non-AIDS malignant disease. Analysis was by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT00074581. 1763 people with HIV-1 infection and a serodiscordant partner were enrolled in the study; 886 were assigned early antiretroviral treatment and 877 to the delayed treatment group (two individuals were excluded from this group after randomisation). Median CD4 counts at randomisation were 442 (IQR 373-522) cells per μL in patients assigned to the early treatment group and 428 (357-522) cells per μL in those allocated delayed antiretroviral treatment. In the delayed group, antiretroviral treatment was initiated at a median CD4 count of 230 (IQR 197-249) cells per μL. Primary clinical events were reported in 57 individuals assigned to early treatment initiation versus 77 people allocated to delayed antiretroviral treatment (hazard ratio 0·73, 95% CI 0·52-1·03; p=0·074). New-onset AIDS events were recorded in 40 participants assigned to early antiretroviral treatment versus 61 allocated delayed initiation (0·64, 0·43-0·96; p=0·031), tuberculosis developed in 17 versus 34 patients, respectively (0·49, 0·28-0·89, p=0·018), and primary non-AIDS events were rare (12 in the early group vs nine with delayed treatment). In total, 498 primary and secondary outcomes occurred in the early treatment group (incidence 24·9 per 100 person-years, 95% CI 22·5-27·5) versus 585 in the delayed treatment group (29·2 per 100 person-years, 26·5-32·1; p=0·025). 26 people died, 11 who were allocated to early antiretroviral treatment and 15 who were assigned to the delayed treatment group. Early initiation of antiretroviral treatment delayed the time to AIDS events and decreased the incidence of primary and secondary outcomes. The clinical benefits recorded, combined with the striking reduction in HIV-1 transmission risk previously reported, provides strong support for earlier initiation of antiretroviral treatment. US National Institute of Allergy and Infectious Diseases.
    The Lancet Infectious Diseases 03/2014; · 19.45 Impact Factor
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    ABSTRACT: Household food insecurity (HHFI) may be a barrier to both optimal maternal nutritional status and infant feeding practices, but few studies have tested this relationship quantitatively, and never among HIV-infected individuals. We therefore described the prevalence of HHFI and explored if it was associated with poorer maternal nutritional status, shorter duration of exclusive breastfeeding (EBF) and fewer animal-source complementary foods. We assessed these outcomes using bivariate and multivariate analyses among 178 HIV-infected pregnant and breastfeeding (BF) women receiving combination antiretroviral therapy in the PROMOTE trial (NCT00993031), a prospective, longitudinal cohort study in Tororo, Uganda. HHFI was common; the prevalence of severe, moderate, and little to no household hunger was 7.3, 39.9, and 52.8 %, respectively. Poor maternal nutritional status was common and women in households experiencing moderate to severe household hunger (MSHH) had statistically significantly lower body mass index (BMIs) at enrollment (21.3 vs. 22.5, p < 0.01) and prior to delivery (22.6 vs. 23.8, p < 0.01). BMI across time during pregnancy, but not gestational weight gain, was significantly lower for MSHH [adjusted beta (95 % CI) -0.79 (-1.56, -0.02), p = 0.04; -2.06 (-4.31, 0.19), p = 0.07], respectively. The prevalence (95 % CI) of EBF at 6 months was 67.2 % (59.7-73.5 %), and the proportion of women BF at 12 months was 80.4 % (73.3-85.7 %). MSHH was not associated with prevalence of EBF at 6 months or BF at 12 months. However, among those women still EBF at 4 months (81.4 % of population), those experiencing MSHH were significantly more likely to cease EBF between 4 and 6 months (aHR 2.38, 95 % CI 1.02-5.58). The prevalence of HHFI, maternal malnutrition, and suboptimal infant feeding practices are high and the causal relationships among these phenomena must be further explored.
    Maternal and Child Health Journal 03/2014; · 2.24 Impact Factor
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    ABSTRACT: To determine the frequency and predictors of hypertension linkage to care after implementation of a linkage intervention in rural Uganda. During a multidisease screening campaign for HIV, diabetes and hypertension in rural Uganda, hypertensive adults received education, appointment to a local health facility and travel voucher. We measured frequency and predictors of linkage to care, defined as visiting any health facility for hypertension management within 6 months. Predictors of linkage to care were calculated using collaborative-targeted maximum likelihood estimation (C-TMLE). Participants not linking were interviewed using a standardised instrument to determine barriers to care. Over 5 days, 2252 adults were screened for hypertension and 214 hypertensive adults received a linkage intervention for further management. Of these, 178 (83%) linked to care within 6 months (median = 22 days). Independent predictors of successful linkage included older age, female gender, higher education, manual employment, tobacco use, alcohol consumption, hypertension family history and referral to local vs. regional health centre. Barriers for patients who did not see care included expensive transport (59%) and feeling well (59%). A community health campaign that offered hypertension screening, education, referral appointment and travel voucher achieved excellent linkage to care (83%). Young adults, men and persons with low levels of formal education were among those least likely to seek care.
    Tropical Medicine & International Health 02/2014; · 2.30 Impact Factor
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    ABSTRACT: Line probe assays(LPA), nucleic acid tests used for the rapid diagnosis of tuberculosis(MTB), non-tuberculosis mycobacteria(NTM) and MTB drug resistance, have limited performance data in HIV-infected individuals, in whom paucibacillary tuberculosis(TB) is common. In this study, the strategy of testing sputum with GenoType MTBDRplus(MTBDR-Plus) and GenoType Direct(Direct) was compared to a gold standard of 1 mycobacterial growth indicator(MGIT) liquid culture. HIV+ TB suspects from Southern Africa and South America with <7 days of TB treatment had 1 sputum tested with Direct LPA, MTBDR-Plus LPA, smear microscopy, MGIT, biochemical mycobacterial speciation, and culture-based drug susceptibility testing (DST). Of 639 participants, 59.3% were MGIT MTB culture positive, of which 276 (72.8%) were AFB smear positive. MTBDR-Plus had sensitivity of 81.0% and specificity of 100%, with sensitivity of 44.1% in AFB smear negative vs. 94.6% in AFB smear positive. For specimens that were positive for MTB by MTBDR-Plus, sensitivity and specificity for rifampin resistance were 91.7% and 96.6%, respectively, and for isoniazid (INH) 70.6% and 99.1%. The Direct LPA had sensitivity of 88.4% and specificity of 94.6% for MTB detection, with a sensitivity of 72.5% in smear negative specimens. 10/639 MGIT cultures grew M.avium complex or M.kansasii, half of which were detected by Direct LPA. Both LPA assays performed well in HIV infection, including in AFB smear negative specimens, with 72.5% sensitivity for MTB identification with Direct LPA and 44.1% with MTBDR-Plus. LPAs have a continued role for use in settings where rapid identification of INH resistance and clinically relevant NTM are priorities.
    Journal of clinical microbiology 01/2014; · 4.23 Impact Factor
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    ABSTRACT: The high burden of undiagnosed HIV in sub-Saharan Africa is a major obstacle for HIV prevention and treatment. Multi-disease, community health campaigns (CHCs) offering HIV testing are a successful approach to rapidly increase HIV testing rates and identify undiagnosed HIV. However, a greater understanding of population-level uptake is needed to maximize effectiveness of this approach. After community sensitization and a census, a five-day campaign was performed in May 2012 in a rural Ugandan community. The census enumerated all residents, capturing demographics, household location, and fingerprint biometrics. The CHC included point-of-care screening for HIV, malaria, TB, hypertension and diabetes. Residents who attended vs. did not attend the CHC were compared to determine predictors of participation. Over 12 days, 18 census workers enumerated 6,343 residents. 501 additional residents were identified at the campaign, for a total community population of 6,844. 4,323 (63%) residents and 556 non-residents attended the campaign. HIV tests were performed in 4,795/4,879 (98.3%) participants; 1,836 (38%) reported no prior HIV testing. Of 2674 adults tested, 257 (10%) were HIV-infected; 125/257 (49%) reported newly diagnosed HIV. In unadjusted analyses, adult resident campaign non-participation was associated with male sex (62% male vs. 67% female participation, p = 0.003), younger median age (27 years in non-participants vs. 32 in participants; p<0.001), and marital status (48% single vs. 71% married/widowed/divorced participation; p<0.001). In multivariate analysis, single adults were significantly less likely to attend the campaign than non-single adults (relative risk [RR]: 0.63 [95% CI: 0.53-0.74]; p<0.001), and adults at home vs. not home during census activities were significantly more likely to attend the campaign (RR: 1.20 [95% CI: 1.13-1.28]; p<0.001). CHCs provide a rapid approach to testing a majority of residents for HIV in rural African settings. However, complementary strategies are still needed to engage young, single adults and achieve universal testing.
    PLoS ONE 01/2014; 9(1):e84317. · 3.53 Impact Factor
    This article is viewable in ResearchGate's enriched format
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    ABSTRACT: Hypertension is one of the largest causes of preventable morbidity and mortality worldwide. There are few population-based studies on hypertension epidemiology to guide public health strategies in sub-Saharan Africa. Using a community-based strategy that integrated screening for HIV and non-communicable diseases, we determined the prevalence, awareness, treatment rates, and sociodemographic factors associated with hypertension in rural Uganda. A household census was performed to enumerate the population in Kakyerere parish in Mbarara district, Uganda. A multi-disease community-based screening campaign for hypertension, diabetes, and HIV was then conducted. During the campaign, all adults received a blood pressure (BP) measurement and completed a survey examining sociodemographic factors. Hypertension was defined as elevated BP (>=140/>=90 mmHg) on the lowest of three BP measurements or current use of antihypertensives. Prevalence was calculated and standardized to age distribution. Sociodemographic factors associated with hypertension were evaluated using a log-link Poisson regression model with robust standard errors. Community participation in the screening campaign was 65%, including 1245 women and 1007 men. The prevalence of hypertension was 14.6%; awareness of diagnosis (38.1%) and current receipt of treatment (20.6%) were both low. Age-standardized to the WHO world standard population, hypertension prevalence was 19.8%, which is comparable to 21.6% in the US and 18.4% in the UK. Sociodemographic factors associated with hypertension included increasing age, male gender, overweight, obesity, diabetes, alcohol consumption, and family history. Prevalence of modifiable factors was high: 28.3% women were overweight/obese and 24.1% men consumed >=10 alcoholic drinks per month. We found a substantial burden of hypertension in rural Uganda. Awareness and treatment of hypertension is low in this region. Enhanced community-based education and prevention efforts tailored to addressing modifiable factors are needed.
    BMC Public Health 12/2013; 13(1):1151. · 2.32 Impact Factor
    This article is viewable in ResearchGate's enriched format
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    ABSTRACT: In the PROMOTE-pediatrics trial, HIV-infected Ugandan children randomized to receive lopinavir-ritonavir (LPV/r)-based antiretroviral therapy (ART) experienced a lower incidence of malaria compared to children receiving non-nucleoside-reverse-transcriptase-inhibitor (NNRTI)-based-ART. Here we present the results of the non-inferiority (NI) analysis of virologic efficacy and comparison of immunologic outcomes. ART-naïve or -experienced (HIV RNA < 400 copies/ml) children ages 2 months to 6 years received either LPV/r or NNRTI-based-ART. The proportion of children with virologic suppression (HIV RNA <400copies/ml) at 48 weeks was compared using a pre-specified NI margin of -11% in per-protocol analysis. Time to virologic failure by 96 weeks, change in CD4 counts and percentages, and incidence of adverse event rates were also compared. Of 185 children enrolled, 91 initiated LPV/r and 92 initiated NNRTI-based ART. At baseline, the median age was 3.1 years (range: 0.4 to 5.9) and 131 (71%) were ART-naïve. The proportion of children with virologic suppression at 48 weeks was 80% (67/84) in the LPV/r-arm vs. 76% (59/78) in the NNRTI-arm, a difference of 4% (95%CI: -9% to +17%). Time to virologic failure, CD4 changes, and the incidence of DAIDS grade III/IV adverse events were similar between arms. LPV/r-based ART was not associated with worse virologic efficacy, immunologic efficacy, or adverse event rates compared to NNRTI-based ART. Considering these results and the reduction in malaria incidence associated with LPV/r previously reported for this trial, wider use of LPV/r to treat HIV-infected African children in similar malaria endemic settings could be considered.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2013; · 4.39 Impact Factor

Publication Stats

14k Citations
2,216.77 Total Impact Points


  • 2003–2015
    • University of California, San Francisco
      • • Division of Hospital Medicine
      • • Division of HIV/AIDS
      San Francisco, California, United States
  • 2003–2014
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2009–2013
    • CSU Mentor
      Long Beach, California, United States
  • 2008–2013
    • Makerere University
      • • School of Medicine
      • • Department of Internal Medicine
      Kampala, Central Region, Uganda
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 2012
    • International Union Against Tuberculosis and Lung Disease (The Union)
      Lutetia Parisorum, Île-de-France, France
  • 1998–2012
    • Cornell University
      • Department of Medicine
      Ithaca, New York, United States
  • 1994–2011
    • University of California, San Diego
      • • Department of Physics
      • • Department of Medicine
      San Diego, California, United States
  • 2010
    • Michigan State University
      East Lansing, Michigan, United States
  • 2008–2010
    • CUNY Graduate Center
      New York City, New York, United States
  • 2006–2008
    • Makerere University Business School
      Kampala, Central Region, Uganda
    • National Institute for Research in Tuberculosis
      Chennai, Tamil Nādu, India
  • 2005
    • Centers for Disease Control and Prevention
      • Division of HIV/AIDS Prevention, Intervention and Support
      Druid Hills, GA, United States
  • 2000–2003
    • Weill Cornell Medical College
      New York City, New York, United States
    • University Hospital of Ioannina
      Yannina, Epirus, Greece
  • 2002
    • University of Alabama at Birmingham
      Birmingham, Alabama, United States
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2001
    • University of Zurich
      Zürich, Zurich, Switzerland
    • Case Western Reserve University School of Medicine
      • Department of Medicine
      Cleveland, Ohio, United States
  • 1999–2001
    • University of Minnesota Twin Cities
      • • Division of Pediatric Infectious Diseases
      • • Department of Microbiology
      Minneapolis, MN, United States
    • Pfizer Inc.
      New York City, New York, United States
  • 1991
    • Case Western Reserve University
      • School of Medicine
      Cleveland, Ohio, United States