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Introduction: Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation., Materials and Methods: Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated., Results: A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need., Conclusions: This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Artemisinin-resistant Plasmodium falciparum is spreading in Southeast Asia and Africa. In vivo susceptibility to artemisinin is studied by looking at the rate of decline of peripheral parasitemia (parasite clearance half-life). However, parasites that are adhered/sequestered to the endothelium and undetectable in the peripheral blood are not considered in the estimation of parasite clearance. Here, we evaluated the influence of sequestration on in vivo artemisinin efficacy in Uganda, where artemisinin resistance is spreading., Methods: We analyzed 133 patients with P. falciparum malaria included in an in vivo study on artemisinin efficacy in northern Uganda in 2018 and 2019. The parasite clearance half-life was estimated from peripheral parasitemia after artemisinin monotherapy. P. falciparum histidine-rich protein 2 (PfHRP2) was measured in pretreatment plasma. The number of sequestered parasites was estimated from PfHRP2 concentration and peripheral parasitemia., Results: The estimated number of sequestered parasites per plasma volume ranged from 0 to 2 564 000/μL. Inflammation, thrombocytopenia, and dyslipidemia were significantly associated with sequestration independent of peripheral parasitemia. The median parasite clearance half-lives were 1.65 hours in patients infected with Pfkelch13 wild-type parasites (n = 104) and 3.95 hours in those with A675V artemisinin-resistant mutant (n = 18). In the multivariable model for the wild-type population, 1 000 000/μL of sequestered parasites were estimated to delay parasite clearance by 16.8% (95% confidence interval, 5.1%-28.5%), although it was not clear in the A675V population., Conclusions: In patients with P. falciparum malaria without artemisinin-resistant mutations, intensive sequestration delays parasite clearance after treatment, which may contribute to reduced artemisinin efficacy., Competing Interests: Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Emerging from a 20-year armed conflict, Uganda adopted several laws and policies to protect the rights of people with disabilities, including their sexual and reproductive health (SRH) rights. However, the SRH rights of people with disabilities continue to be infringed in Uganda. We explored policy actors' perceptions of existing pro-disability legislation and policy implementation, their perceptions of potential barriers experienced by people with disabilities in accessing and using SRH services in post-conflict Northern Uganda, and their recommendations on how to redress these inequities., Methods: Through an intersectionality-informed approach, we conducted and thematically analysed 13 in-depth semi-structured interviews with macro level policy actors (national policy-makers and international and national organisations); seven focus groups (FGs) at meso level with 68 health service providers and representatives of disabled people's organisations (DPOs); and a two-day participatory workshop on disability-sensitive health service provision for 34 healthcare providers., Results: We identified four main themes: (1) legislation and policy implementation was fraught with numerous technical and financial challenges, coupled with lack of prioritisation of disability issues; (2) people with disabilities experienced multiple physical, attitudinal, communication, and structural barriers to access and use SRH services; (3) the conflict was perceived to have persisting impacts on the access to services; and (4) policy actors recommended concrete solutions to reduce health inequities faced by people with disabilities., Conclusion: This study provides substantial evidence of the multilayered disadvantages people with disabilities face when using SRH services and the difficulty of implementing disability-focused policy in Uganda. Informed by an intersectionality approach, policy actors were able to identify concrete solutions and recommendations beyond the identification of problems. These recommendations can be acted upon in a practical road map to remove different types of barriers in the access to SRH services by people with disabilities, irrespective of their geographic location in Uganda., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity., Methods: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered., Results: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society., Conclusion: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: In the six Southeast Asian countries that make up the Greater Mekong Subregion, Plasmodium falciparum has developed resistance to derivatives of artemisinin, the main component of first-line treatments for malaria. Clinical resistance to artemisinin monotherapy in other global regions, including Africa, would be problematic., Methods: In this longitudinal study conducted in Northern Uganda, we treated patients who had P. falciparum infection with intravenous artesunate (a water-soluble artemisinin derivative) and estimated the parasite clearance half-life. We evaluated ex vivo susceptibility of the parasite using a ring-stage survival assay and genotyped resistance-related genes., Results: From 2017 through 2019, a total of 14 of 240 patients who received intravenous artesunate had evidence of in vivo artemisinin resistance (parasite clearance half-life, >5 hours). Of these 14 patients, 13 were infected with P. falciparum parasites with mutations in the A675V or C469Y allele in the kelch13 gene. Such mutations were associated with prolonged parasite clearance half-lives (geometric mean, 3.95 hours for A675V and 3.30 hours for C469Y, vs. 1.78 hours for wild-type allele; P<0.001 and P = 0.05, respectively). The ring-stage survival assay showed a higher frequency of parasite survival among organisms with the A675V allele than among those with the wild-type allele. The prevalence of parasites with kelch13 mutations increased significantly, from 3.9% in 2015 to 19.8% in 2019, due primarily to the increased frequency of the A675V and C469Y alleles (P<0.001 and P = 0.004, respectively). Single-nucleotide polymorphisms flanking the A675V mutation in Uganda were substantially different from those in Southeast Asia., Conclusions: The independent emergence and local spread of clinically artemisinin-resistant P. falciparum has been identified in Africa. The two kelch13 mutations may be markers for detection of these resistant parasites. (Funded by the Japan Society for the Promotion of Science and others.)., (Copyright © 2021 Massachusetts Medical Society.)

Background: Short birth interval is associated with adverse perinatal, maternal, and infant outcomes, although evidence on actionable factors underlying short birth interval remains limited. We explored women and community views on short birth intervals to inform potential solutions to promote a culturally safe child spacing in Northern Uganda., Methods: Gendered fuzzy cognitive mapping sessions (n = 21), focus group discussions (n = 12), and an administered survey questionnaire (n = 255) generated evidence on short birth intervals. Deliberative dialogues with women, their communities, and service providers suggested locally relevant actions promote culturally safe child spacing., Results: Women, men, and youth have clear understandings of the benefits of adequate child spacing. This knowledge is difficult to translate into practice as women are disempowered to exercise child spacing. Women who use contraceptives without their husbands' consent risk losing financial and social assets and are likely to be subject to intra-partner violence. Women were not comfortable with available contraceptive methods and reported experiencing well-recognized side effects. They reported anxiety about the impact of contraception on the health of their future children. This fear was fed by rumors in their communities about the effects of contraceptives on congenital diseases. The women and their communities suggested a home-based sensitization program focused on improving marital relationships (spousal communication, mutual understanding, male support, intra-partner violence) and knowledge and side-effects management of contraceptives., Conclusions: The economic context, gender power dynamics, inequality, gender bias in land tenure and ownership regulations, and the limited contraceptive supply reduce women's capacity to practice child spacing.

In Uganda, artemether-lumefantrine was introduced as an artemisinin-based combination therapy (ACT) for malaria in 2006. We have previously reported a moderate decrease in ex vivo efficacy of lumefantrine in Northern Uganda, where we also detected ex vivo artemisinin-resistant Plasmodium falciparum. Therefore, it is necessary to search for candidate partner alternatives for ACT. Here, we investigated ex vivo susceptibility to four ACT partner drugs as well as quinine and chloroquine, in 321 cases between 2013 and 2018. Drug-resistant mutations in pfcrt and pfmdr1 were also determined. Ex vivo susceptibility to amodiaquine, quinine, and chloroquine was well preserved, whereas resistance to mefloquine was found in 45.8%. There were few cases of multi-drug resistance. Reduced sensitivity to mefloquine and lumefantrine was significantly associated with the pfcrt K76 wild-type allele, in contrast to the association between chloroquine resistance and the K76T allele. Pfmdr1 duplication was not detected in any of the cases. Amodiaquine, a widely used partner drug for ACT in African countries, may be the first promising alternative in case lumefantrine resistance emerges. Therapeutic use of mefloquine may not be recommended in this area. This study also emphasizes the need for sustained monitoring of antimalarial susceptibility in Northern Uganda to develop proper treatment strategies., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: Describe participatory codesign of interventions to improve access to perinatal care services in Northern Uganda., Study Design: Mixed-methods participatory research to codesign increased access to perinatal care. Fuzzy cognitive mapping, focus groups and a household survey identified and documented the extent of obstructions to access. Deliberative dialogue focused stakeholder discussions of this evidence to address the obstacles to access. Most significant change stories explored the participant experience of this process., Setting: Three parishes in Nwoya district in the Gulu region, Northern Uganda., Participants: Purposively sampled groups of women, men, female youth, male youth, community health workers, traditional midwives and service providers. Each of seven stakeholder categories included 5-8 participants in each of three parishes., Results: Stakeholders identified several obstructions to accessing perinatal care: lack of savings in preparation for childbirth in facility costs, lack of male support and poor service provider attitudes. They suggested joining saving groups, practising saving money and income generation to address the short-term financial shortfall.They recommended increasing spousal awareness of perinatal care and they proposed improving service provider attitudes. Participants described their own improved care-seeking behaviour and patient-provider relationships as short-term gains of the codesign., Conclusion: Participatory service improvement is feasible and acceptable in postconflict settings like Northern Uganda. Engaging communities in identifying perinatal service delivery issues and reflecting on local evidence about these issues generate workable community-led solutions and increases trust between community members and service providers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Community participatory interventions mobilizing women of childbearing age are an effective strategy to promote maternal and child health. In 2017, we implemented this strategy in Gulu Northern Uganda. This study explored the perceived impact of this approach on women's capability., Methods: We conducted a qualitative study based on three data collection methods: 14 in-depth individual interviews with participating women of childbearing age, five focus group discussions with female facilitators, and document analysis. We used the Sen capability approach as a conceptual framework and undertook a thematic analysis., Results: Women adopted safe and healthy behaviors for themselves and their children. They were also able to respond to some of their family's financial needs. They reported a reduction in domestic violence and in mistreatment towards their children. The facilitators perceived improved communication skills, networking, self-confidence, and an increase in their social status. Nevertheless, the women still faced unfreedoms that deprived them of living the life they wanted to lead. These unfreedoms are related to their lack of access to economic opportunities and socio-cultural norms underlying gender inequalities., Conclusion: To expand women's freedoms, we need more collective political actions to tackle gender inequalities and need to question the values underlying women's social status.

Background: Usage of chloroquine was discontinued from the treatment of Plasmodium falciparum infection in almost all endemic regions because of global spread of resistant parasites. Since the first report in Malawi, numerous epidemiological studies have demonstrated that the discontinuance led to re-emergence of chloroquine-susceptible P. falciparum, suggesting a possible role in future malaria control. However, most studies were cross-sectional, with few studies looking at the persistence of chloroquine recovery in long term. This study fills the gap by providing, for a period of at least 6 years, proof of persistent re-emergence/stable recovery of susceptible parasite populations using both molecular and phenotypic methods., Methods: Ex vivo drug-susceptibility assays to chloroquine (n = 319) and lumefantrine (n = 335) were performed from 2013 to 2018 in Gulu, Northern Uganda, where chloroquine had been removed from the official malaria treatment regimen since 2006. Genotyping of pfcrt and pfmdr1 was also performed., Results: Chloroquine resistance (≥ 100 nM) was observed in only 3 (1.3%) samples. Average IC 50 values for chloroquine were persistently low throughout the study period (17.4-24.9 nM). Parasites harbouring pfcrt K76 alleles showed significantly lower IC 50 s to chloroquine than the parasites harbouring K76T alleles (21.4 nM vs. 43.1 nM, p-value = 3.9 × 10 -8 ). Prevalence of K76 alleles gradually increased from 71% in 2013 to 100% in 2018., Conclusion: This study found evidence of stable persistence of chloroquine susceptibility with the fixation of pfcrt K76 in Northern Uganda after discontinuation of chloroquine in the region. Accumulation of similar evidence in other endemic areas in Uganda could open channels for possible future re-use of chloroquine as an option for malaria treatment or prevention.

Background: Limited health service resources must be used in a manner which does "the most for the most". This is partly achieved through the use of a triage system. Whereas efforts have been made to introduce paediatric triage in Uganda such as Emergency Triage Assessment and Treatment Plus (ETAT+), it is not clear if hospitals have local protocols for adult triage being used in each setting., Objectives: To determine the presence of existing hospital triage systems, the cadre of staff undertaking triage and barriers to development/improvement of formal triage systems., Methodology: This was a descriptive cross-sectional study. Acholi sub-region was randomly selected for the study among the three sub-regions in Northern Uganda. The study was conducted in 6 of the 7 hospitals in the region. It was a written self-administered questionnaire., Results: Thirty-three participants from 6 hospitals consented and participated in the study. Only one hospital (16.7%) of the 6 hospitals surveyed had a formal hospital-based adult triage protocol in place. Only 2 (33.3%) hospitals had an allocated emergency department, the rest receive emergency patients/perform triage from OPD and wards. Lack of training, variation of triage protocols from hospital to another, shortage of staff on duty, absence of national guidelines on triage and poor administrative support were the major barriers to improvement/development of formal triage in all these hospitals., Conclusion: Formal adult hospital-based triage is widely lacking in Northern Uganda and staff do perform subjective "eyeball" judgments to make triage decisions.

Background: The objectives of this study are (1) to estimate the cost of operating the Kampala Cancer Registry (KCR) and (2) to use cost data from the KCR to project the resource needs and cost of expanding and sustaining cancer registration in Uganda, focusing on the recently established Gulu Cancer Registry (GCR) in rural Northern Uganda., Methods: We used Centers for Disease Control and Prevention's (CDC's) International Registry Costing Tool (IntRegCosting Tool) to estimate the KCR's activity-based cost for 2014. We grouped the registry activities into fixed cost, variable core cost, and variable other cost activities. After a comparison KCR and GCR characteristics, we used the cost of the KCR to project the likely ongoing costs for the new GCR., Results: The KCR incurred 42% of its expenditures in fixed cost activities, 40% for variable core cost activities, and the remaining 18% for variable other cost activities. The total cost per case registered was 28,201 Ugandan shillings (approximately US $10 in 2014) to collect and report cases using a combination of passive and active cancer data collection approaches. The GCR performs only active data collection, and covers a much larger area, but serves a smaller population compared to the KCR., Conclusion: After identifying many differences between KCR and GCR that could potentially affect the cost of registration, our best estimate is that the GCR, though newer and in a rural area, should require fewer resources than the KCR to sustain operations as a stand-alone entity. The optimal structure of the GCR needs to be determined in the future., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: Recent studies using next-generation sequencing (NGS) analysis disclosed the importance of the intrinsic activation of the B-cell receptor (BCR) pathway in the pathogenesis of sporadic Burkitt lymphoma (sBL) due to mutations of TCF3/ID3 genes. Since no definitive data are available on the genetic landscape of endemic Burkitt (eBL), we first assessed the mutation frequency of TCF3/ID3 in eBL compared with sBL and subsequently the somatic hypermutation status of the BCR to answer whether an extrinsic activation of BCR signaling could also be demonstrated in Burkitt lymphoma., Methods: We assessed the mutations of TCF3/ID3 by RNAseq and the BCR status by NGS analysis of the immunoglobulin genes (IGs)., Results: We detected mutations of TCF3/ID3 in about 30% of the eBL cases. This rate is significantly lower than that detected in sBL (64%). The NGS analysis of IGs revealed intraclonal diversity, suggesting an active targeted somatic hypermutation process in eBL compared with sBL., Conclusions: These findings support the view that the antigenic pressure plays a key role in the pathogenetic pathways of eBL, which may be partially distinct from those driving sBL development., (© American Society for Clinical Pathology, 2016.)

Endemic Burkitt lymphoma (eBL) is primarily found in children in equatorial regions and represents the first historical example of a virus-associated human malignancy. Although Epstein-Barr virus (EBV) infection and MYC translocations are hallmarks of the disease, it is unclear whether other factors may contribute to its development. We performed RNA-Seq on 20 eBL cases from Uganda and showed that the mutational and viral landscape of eBL is more complex than previously reported. First, we found the presence of other herpesviridae family members in 8 cases (40%), in particular human herpesvirus 5 and human herpesvirus 8 and confirmed their presence by immunohistochemistry in the adjacent non-neoplastic tissue. Second, we identified a distinct latency program in EBV involving lytic genes in association with TCF3 activity. Third, by comparing the eBL mutational landscape with published data on sporadic Burkitt lymphoma (sBL), we detected lower frequencies of mutations in MYC, ID3, TCF3 and TP53, and a higher frequency of mutation in ARID1A in eBL samples. Recurrent mutations in two genes not previously associated with eBL were identified in 20% of tumors: RHOA and cyclin F (CCNF). We also observed that polyviral samples showed lower numbers of somatic mutations in common altered genes in comparison to sBL specimens, suggesting dual mechanisms of transformation, mutation versus virus driven in sBL and eBL respectively.

Introduction: Gonorrhea is one of the most common sexually transmitted infections (STls) in developing countries, and the emergence of resistance to antimicrobial agents in Neisseria gonorrhoeae is a major obstacle in the control of gonorrhoea. Periodical determination of the prevalence and monitoring of antimicrobial susceptibility of N. gonorrhoeae is essential for the early detection of emergence of drug resistance., Methods: A total of 640 consecutive patients who attended the Outpatient Department (OPD) Clinics at St. Mary's Hospital Lacor between Jan 2007-Dec 2011, with gonococcal urethriris symptoms and whose urethral swabs and high vagina swabs (HVS) were cultured, were involved in the study. Two hundred and fifty six (256) patients had positive pus swab culture, of which 151 (23.6%) showed growth of Neisseria gonorrhoeae. All the isolates were tested for antimicrobial susceptibility using the Kirby Bauer-disc diffusion techniques., Results: Gonococcal isolates showed rapid decrease in susceptibility to the antimicrobials especially to ampicillin, tetracycline and erythomycin, ciprofloxacin, and intermediate to chloramphenicol, however, gentamicin and cefotaxime have remained as a single dose sensitive treatment for Neisseria gonorrhoeae. Sensitization on drug use and adopting preventive measures and continuous education on safer sexual behavior through health care authorities would lead to reduction in the prevalence of Neisseria gonorrhoeae and resistance to antimicrobial., Discussion: Gonorrhea is one of the most common sexually transmitted infections (STIs) in developing countries, and the emergence of resistance to antimicrobial agents in Neisseria gonorrhoeae is a major obstacle in the control of gonorrhea. Periodical monitoring of antimicrobial susceptibility of N. gonorrhea is essential for the early detection of emergence of drug resistance.

Background: Recent evidence suggests that lipid pathway is altered in many human tumours. In Burkitt lymphoma this is reflected by the presence of lipid droplets which are visible in the cytoplasm of neoplastic cells in cytological preparations. These vacuoles are not identifiable in biopsy section as lipids are "lost" during tissue processing., Methods and Results: In this study we investigated the expression of genes involved in lipid metabolism, at both RNA and protein level in Burkitt lymphoma and in other B-cell aggressive lymphoma cases. Gene expression profile indicated a significant over-expression of the adipophilin gene and marked up-regulation of other genes involved in lipid metabolism in Burkitt lymphoma. These findings were confirmed by immunohistochemistry on a series od additional histological samples: 45 out of 47 BL cases showed strong adipophilin expression, while only 3 cases of the 33 of the not-Burkitt lymphoma category showed weak adipophilin expression (p<0.05)., Conclusions: Our preliminary results suggest that lipid metabolism is altered in BL, and this leads to the accumulation of lipid vacuoles. These vacuoles may be specifically recognized by a monoclonal antibody against adipophilin, which may therefore be a useful marker for Burkitt lymphoma because of its peculiar expression pattern. Moreover this peptide might represent an interesting candidate for interventional strategies.

Burkitt lymphoma (BL) is classified into 3 clinical subsets: endemic, sporadic, and immunodeficiency-associated BL. So far, possible differences in their gene expression profiles (GEPs) have not been investigated. We studied GEPs of BL subtypes, other B-cell lymphomas, and B lymphocytes; first, we found that BL is a unique molecular entity, distinct from other B-cell malignancies. Indeed, by unsupervised analysis all BLs clearly clustered apart of other lymphomas. Second, we found that BL subtypes presented slight differences in GEPs. Particularly, they differed for genes involved in cell cycle control, B-cell receptor signaling, and tumor necrosis factor/nuclear factor κB pathways. Notably, by reverse engineering, we found that endemic and sporadic BLs diverged for genes dependent on RBL2 activity. Furthermore, we found that all BLs were intimately related to germinal center cells, differing from them for molecules involved in cell proliferation, immune response, and signal transduction. Finally, to validate GEP, we applied immunohistochemistry to a large panel of cases and showed that RBL2 can cooperate with MYC in inducing a neoplastic phenotype in vitro and in vivo. In conclusion, our study provided substantial insights on the pathobiology of BLs, by offering novel evidences that may be relevant for its classification and possibly future treatment.

A comprehensive, representative malaria survey has been carried out in a population of internally displaced persons (IDP) in the district of Gulu, Northern Uganda. It included 74 households and 390 persons, and covered socio-economic and environmental information, individual physical data, malaria and the drug sensitivity of Plasmodium falciparum. The prevalence of infections with Plasmodium falciparum was 54.4% at a geometric mean asexual parasitaemia of 229/microl blood, typical for hyperendemic conditions. P. falciparum turned out to be highly resistant to chloroquine and amodiaquine. It showed also reduced sensitivity against lumefantrine and artemisinin, obviously the result of the liberal use of the lumefantrine-artemether combination without evidence-based indication.

To inform our understanding of male and female health care use, we assessed sex differences in hospital admissions by diagnosis and for in-patient mortality using discharge records for 210319 patients admitted to the Lacor Hospital in northern Uganda in the period 1992-2004. These differences were interpreted using a gender framework. The overall number of admissions was similar by sex, yet differences emerged among age groups. In children (0-14 years), malaria was the leading cause of admission, and the distribution of diseases was similar between sexes. Among 15-44 year olds, females had more admissions, overall, and for malaria, cancer and anaemia, in addition to delivery and gynaeco-obstetrical conditions (25.7% of female admissions). Males had more admissions for injuries, liver disease and tuberculosis in the same age group. In older persons (>or=45 years), women had more admissions for cancer, hypertension, malaria and diarrhoea, while, as for the previous age group, males had more admissions for injuries, liver disease and tuberculosis. This study provides insight into sex- and gender-related differences in health. The analysis and documentation of these differences are crucial for improving service delivery and for assessing the achievement of the dual goals of improving health status and reducing health inequalities.

This study aims at estimating the recent trends in HIV-1 prevalence and the factors associated with infection among pregnant women in the Gulu District of north Uganda, a rural area severely affected by civil strife. In 2000-2003, a total of 4459 antenatal clinic attendees of Lacor Hospital were anonymously tested for HIV-1 infection. The overall and age-specific prevalence did not show any significant trend over time. The age-standardized prevalence slightly declined, from 12.1% in 2000 to 11.3% in 2003. Increased age [20-24 years: adjusted odds ratio (AOR) 1.63; 95% CI 1.18-2.25; >or=25 years: AOR 2.56; 95% CI 1.91-3.44], residence in urban areas (AOR 1.76; 95% CI 1.41-2.18), being unmarried (AOR 1.60; 95% CI 1.27-2.01), increased age of partner (25-34 years: AOR 1.87; 95% CI 1.29-2.73; >or=35 years: AOR 2.68; 95% CI 1.72-4.16), modern occupation of partner (AOR 1.98; 95% CI 1.53-2.58), and short time of residence at the current address (AOR 1.36; 95% CI 1.05-1.76) were associated with infection. The HIV-1 prevalence in this rural district is high and similar to that observed in urban antenatal clinics, probably reflecting the effect of the last 18 years of civil strife.

Objectives: To estimate differences in fertility by HIV serostatus and to validate an adjustment method for estimating the HIV prevalence in the general female population using data from an antenatal clinic., Methods: We used Cox regression models to retrospectively estimate the age-specific relative fertility (RF) of HIV-positive compared to HIV-negative women among 3314 antenatal clinic attenders in northern Uganda. RF and the age distribution of women in the general female population were used to extrapolate the antenatal clinic-based HIV prevalence. This procedure was indirectly validated by comparing the adjusted estimate with those based on standard adjustment factors derived from general female populations in Uganda and Tanzania., Results: HIV-positive women reported a lower fertility than HIV-negative women [age-adjusted RF=0.83, 95% confidence interval (CI): 0.75-0.93]. Except for girls aged 15-19 (RF=0.96, 95% CI: 0.74-1.24) HIV-positive women in all age groups were less fertile (20-24 year: RF=0.83, 95% CI: 0.67-1.01; 25-29 years: RF=0.79, 95% CI: 0.62-1.00; 30-49 year: RF=0.79, 95% CI: 0.65-0.96]. Adjusting the antenatal clinic-based HIV prevalence (11.6%) for these differences yields a higher estimate (13.8%) that is lower than those based on standard adjustment factors derived from general female populations (from 14.6% to 17.7%)., Conclusions: The age-specific pattern of differential fertility by HIV serostatus derived from antenatal clinic data is consistent with findings from population-based studies conducted in Africa. However, differences in fertility between HIV positive and HIV-negative clients underestimate those in the general female population yielding inaccurate estimates when used to extrapolate the HIV prevalence.

Objectives: To validate the use of data from a programme for the prevention of mother-to-child transmission (PMTCT) in estimating HIV-1 prevalence in North Uganda., Methods: The study was conducted at St. Mary's Hospital Lacor. We compared the estimated prevalence for 3580 attendees at the antenatal clinic who were selected for anonymous surveillance to that for 6785 pregnant women who agreed to undergo voluntary counselling and testing (VCT) for enrolment in the PMTCT programme. Log-binomial regression models were used to identify the factors associated with both VCT uptake and HIV-1 infection, which could bias the prevalence estimates based on PMTCT data., Results: In 2001-2003, the age-standardized prevalence was similar (11.1% in the anonymous surveillance group and 10.9% in the VCT group). The estimates were also similar when compared for each year tested. Analogously, no important differences were observed in age-specific prevalence. Of the factors associated with HIV-1 infection, only time of residence at current address [prevalence proportion ratio (PPR) = 1.05; 95% confidence interval (CI), 1.00-1.10], marital status (PPR = 1.05; 95% CI, 1.01-1.10) and partner's occupation (PPR = 1.05; 95% CI, 1.01-1.10) were associated with VCT uptake, yet the associations were weak., Conclusions: The prevalence estimated based on the VCT data collected as part of the PMTCT programme could be used for HIV-1 surveillance in North Uganda. At the national level, however, it needs to be evaluated whether PMTCT data could replace, or instead be combined with, the data from sentinel surveillance.