Directorate of Graduate Training, Research, and Innovations

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Advanced HIV disease at diagnosis among newly diagnosed people with HIV in rural eastern Uganda: a retrospective cohort study
(Elsevier, 2025-10-22) Ssentongo, Saadick Mugerwa; Appeli, Saidi; Izudi, Jonathan
Objectives Advanced HIV disease (AHD) at diagnosis substantially contributes to HIV-related morbidity and mortality but has been understudied. We determined the prevalence and factors associated with AHD at diagnosis among newly diagnosed people with HIV (PWH) in rural eastern Uganda. Methods We conducted a retrospective cohort study of newly diagnosed PWH between May 2020 and July 2023 across 23 public health facilities in 14 districts in rural eastern Uganda. AHD at diagnosis was defined by a cluster of differentiation 4 count <200 cells/µL or World Health Organization clinical stage 3-4 disease. A generalized linear mixed model was used to identify factors associated with AHD at diagnosis. Results Among 1233 participants, we found that 24/1233 (1.9%) had AHD at diagnosis. In adjusted analysis, AHD at diagnosis was independently associated with being male rather than female (adjusted odds ratio, 3.84; 95% confidence interval, 1.53-9.61). Conclusions The low prevalence of AHD at diagnosis among newly diagnosed PWH suggests progress toward earlier diagnosis in rural eastern Uganda. Men tended to present with AHD at diagnosis more than women, although the finding is imprecise. Our findings highlight the need for targeted, gender-sensitive interventions to promote early diagnosis and care linkage.
Advanced HIV disease at diagnosis among newly diagnosed people with HIV in rural eastern Uganda: a retrospective cohort study
(Elsevier, 2025-10-04) Ssentongo, Saadick Mugerwa; Appeli, Saidi; Izudi, Jonathan
Objectives Advanced HIV disease (AHD) at diagnosis substantially contributes to HIV-related morbidity and mortality but has been understudied. We determined the prevalence and factors associated with AHD at diagnosis among newly diagnosed people with HIV (PWH) in rural eastern Uganda. Methods We conducted a retrospective cohort study of newly diagnosed PWH between May 2020 and July 2023 across 23 public health facilities in 14 districts in rural eastern Uganda. AHD at diagnosis was defined by a cluster of differentiation 4 count <200 cells/µL or World Health Organization clinical stage 3-4 disease. A generalized linear mixed model was used to identify factors associated with AHD at diagnosis. Results Among 1233 participants, we found that 24/1233 (1.9%) had AHD at diagnosis. In adjusted analysis, AHD at diagnosis was independently associated with being male rather than female (adjusted odds ratio, 3.84; 95% confidence interval, 1.53-9.61). Conclusions The low prevalence of AHD at diagnosis among newly diagnosed PWH suggests progress toward earlier diagnosis in rural eastern Uganda. Men tended to present with AHD at diagnosis more than women, although the finding is imprecise. Our findings highlight the need for targeted, gender-sensitive interventions to promote early diagnosis and care linkage.
Determinants of underweight and overweight/ obesity among people with tuberculosis in Kampala, Uganda: A cross-sectional study
(PLOS, 2026-02-13) Kyazze, Simon; Appeli, Saidi; Baluku, Joseph Baruch; Izudi, Jonathan
Background Malnutrition significantly contributes to mortality among people with tuberculosis (TB). However, evidence on factors associated with the specific forms of malnutrition, specifically underweight and overweight/obesity, beyond clinical determinants, remains limited in many settings. We investigated the prevalence and determinants of underweight and overweight/obesity among people with pulmonary TB across five health facilities in Kampala, Uganda. Methods This analytic cross-sectional study involved people with pulmonary TB, either clinically diagnosed or bacteriologically confirmed, aged ≥18 years sampled across five health facilities in Kampala, Uganda. Nutritional status was assessed using body mass index (BMI, kg/m²) and categorized as underweight (<18.5), normal weight (18.5–24.9), and overweight/obese (≥25.0). To identify factors independently associated with nutritional status, normal weight was considered as the reference category in a multinomial logistic regression analysis, adjusting for multiple covariates and clustering at the health facility level. The measure of association was the adjusted relative risk ratios (aRRR) and the corresponding 95% confidence intervals (CI). Results Of the 818 participants studied, 417 (51.0%) had normal weight, 302 (36.9%) were underweight, and 99 (12.1%) were overweight or obese. Adjusted analysis showed that being underweight was associated with household food insecurity (aRRR 2.04, 95% CI: 1.48–2.80) while being overweight or obese was associated with self-employment (aRRR 2.26, 95% CI: 1.35–3.79) and being newly diagnosed with TB (aRRR 2.10, 95% CI: 1.30–3.41). Conclusion This study, conducted among people with pulmonary TB in an urban setting in Uganda, showed that underweight and overweight/obesity are prevalent. Furthermore, the study showed that food insecurity is associated with being underweight, while being overweight or obese is associated with being self-employed or newly diagnosed with TB. Therefore, TB control programs need to regularly assess the nutritional status of people with TB to mitigate the effect of being underweight or overweight on treatment outcomes.
Effect of facility- versus community-based HIV testing services on the diagnosis of advanced HIV disease in Uganda: a quasi-experimental study
(Springer Nature, 2025-12-30) Izudi, Jonathan; Ssentongo, Saadick Mugerwa; Appeli, Saidi; Bajunirwe, Francis
Background Advanced HIV disease (AHD) at first diagnosis remains a significant barrier to HIV epidemic control. We evaluated whether health facility-based or community-based HIV testing services (HTS) better impact the yield of AHD at diagnosis among newly diagnosed people with HIV (PWH) in rural eastern Uganda. Methods We designed a quasi-experimental study and applied instrumental variable analysis, a causal inference methodology, to compare the effect of facility-based HTS versus community-based HTS on the yield of AHD at diagnosis among newly diagnosed PWH. The exposure was HTS comparing community-based versus facility-based, and the outcome was AHD at diagnosis, defined as CD4 < 200 cells/µL or WHO clinical stage 3 or 4 disease at baseline. The instrumental variable was the HTS access radius that reflects the HTS geographical coverage for each health facility. The instrumental variable ensured the categorization of health facilities as offering HTS within a 5 km radius only or both within and beyond 5 km. The relevance of the instrumental variable was assessed using the F-statistic and independence from measured covariates. We used a two-stage residual inclusion approach to estimate the effect of HTS on AHD at diagnosis. Causal effect was reported as an odds ratio (OR) and 95% confidence interval (CI). Results Of 1,233 participants included in the analysis, AHD prevalence was 1.9% (24/1,233). The instrumental variable was strongly correlated with HTS (First-stage F-statistic = 28.05, p < 0.0001) and uncorrelated with AHD and all measured covariates. Facility-based HTS has no significant effect on AHD at diagnosis compared to community-based HTS (OR 1.20, 95% CI 0.49–2.90). Conclusions Persons with AHD at diagnosis are a minority. Facility- and community-based HTS do not differ in identifying AHD among newly diagnosed PWH, but moderate effects cannot be excluded. These findings support efforts to implement both strategies for HIV testing to reach and test persons with advanced HIV.
Effect of food insecurity on hazardous alcohol consumption and psychological well-being among people with tuberculosis in Kampala, Uganda
(Elsevier, 2025-11-27) Izudi, Jonathan; Appeli, Saidi; Bajunirwe, Francis
Rationale: Food insecurity (FI), hazardous alcohol consumption (HAC), and poor mental health are common among people with tuberculosis (TB), yet empirical evidence on their interrelationships remains limited. Objective: We evaluated the effect of FI on HAC and psychological well-being among people with pulmonary TB in Kampala, Uganda. Methods: We collected data across five TB clinics and constructed a quasi-experimental design. FI was the exposure, measured using the FI Experience Scale (FIES). FIES scores range between 0 and 8, and individuals were classified as food insecure if they scored ≥ 4. The primary outcome was HAC, assessed using the Alcohol Use Disorders Identification Test (AUDIT) tool. Participants with AUDIT scores ≥ 16, indicating high-risk drinking or possible alcohol dependence, were categorized as having HAC. The secondary outcome was psychological well-being measured using the World Health Organization’s Five Well-Being Index, with a total score of <15 indicating poor psychological well-being. We used doubly robust estimation to report causal risk ratios (RR) and 95 % confidence intervals (CI). Results: Of 818 participants, 475 (58.1 %) were from food-insecure households, 153 (18.7 %) had HAC, and 316 (38.6 %) had poor psychological well-being. FI was independently associated with HAC (RR 1.43, 95 % CI: 1.21–1.69), but not poor psychological well-being (RR 1.06, 95 % CI: 0.81–1.37). Conclusion: FI is associated with a higher likelihood of HAC but not psychological well-being among people with TB in Kampala, Uganda. Given their high prevalence, there is a need to address food insecurity, HAC, and poor psychological well-being within TB control programs.
Effect of partner support on antenatal care visits among married adolescents in rural northwestern Uganda: A quasi-experimental study
(PLOS, 2026-04-02) Appeli, Saidi; Chandia, Christine; Izudi, Jonathan
Background Adolescent pregnancy is associated with several challenges, and partner support is crucial. However, the causal effect of partner support on the use of maternal health services among pregnant adolescents has not been rigorously examined. We assessed the causal effect of partner support on the frequency of antenatal care (ANC) visits among married adolescents in rural Uganda. Methods We conducted a quasi-experimental study using observational data from a cross-sectional study that involved married adolescents aged 10–19 years in rural northwestern Uganda. The primary exposure was partner support, measured as a binary variable. Adolescents were considered to have received support if their spouse encouraged ANC attendance, accompanied them to visits, or provided financial or emotional support during ANC; otherwise, they were classified as having not received support. The primary outcome was the number of ANC visits, while the secondary outcome was attending four or more ANC visits. Propensity score weighting was used to ensure covariate comparability between the partner support groups (yes vs. no). Poisson regression was used to estimate the causal effect of partner support on the number of antenatal care (ANC) visits (primary outcome), while the modified Poisson regression was used to estimate the causal effect on attending four or more visits (secondary outcome). Results Of 281 participants, 205 (72.9%) received partner support. Among participants with partner support compared to those without partner support, the frequency of ANC visits (Risk Ratio 1.15, 95% CI: 1.00–1.32) and four or more ANC visits (Risk Ratio 1.25, 95% CI: 1.01–1.52) improved. Conclusion The study showed that partner support was associated with improvements in ANC visit frequency and attendance of four or more ANC visits, among married adolescents in northwestern Uganda. Interventions aimed at improving ANC utilization should consider engaging and educating partners, as their support positively influences ANC utilization.
Effect of prior TB preventive therapy on allcause mortality during TB treatment among people with HIV/TB in rural eastern Uganda: an observational causal analysis
(Springer Nature, 2026-06-08) Izudi, Jonathan; Bajunirwe, Francis; Ssentongo, Saadick Mugerwa; Appeli, Saidi; Cattamanchi, Adithya
Background Tuberculosis preventive therapy (TPT) is the cornerstone for preventing TB disease. However, it is uncertain whether prior TPT completion improves survival once TB disease develops in people with human immunodeficiency virus (PWH) while on anti-retroviral therapy (ART). We evaluated the effect of prior TPT completion on all-cause mortality during TB treatment among PWH who developed TB disease while on ART in rural eastern Uganda. Prior TPT completion served as a marker of sustained engagement in HIV care. Methods We applied inverse probability of treatment weighting using propensity scores, a causal inference analysis approach, to mimic a randomized controlled trial using real-world retrospective cohort data. Inverse probability of treatment weighting addresses design flaws in observational studies, such as selection and confounding biases, providing less biased causal effect estimates. Individuals who had completed a full course of TPT before the start of the index TB treatment episode formed the intervention group, while the control group comprised those with no history of TPT before the index TB treatment initiation. Inverse probability of treatment weighting ensured balanced baseline covariates between the exposure groups. We estimated all-cause mortality rates using person-time methods and Kaplan-Meier curves and performed propensity-score weighted Cox proportional hazards analysis for cause-effect estimation. We reported adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Results Of 719 participants, 296 (41.2%) had completed a full course of TPT before the start of the index TB treatment episode, and 83 (11.5%) had died. The mortality rate was 7.13 per 10,000 person-days, higher among participants without prior TPT than those with prior TPT completion (18.0% vs. 2.4%, log-rank χ²(1) = 35.3, p < 0.001). Median survival was 277 days (95% CI: 213–689). Prior TPT completion was associated with an 87% lower hazard of all-cause mortality (aHR 0.13, 95% CI: 0.06–0.29). Conclusion Prior TPT completion substantially reduced all-cause mortality among PWH who developed drug-susceptible TB disease while on ART. Therefore, there is a need to strengthen TPT completion and engagement in HIV care across HIV programs to lower all-cause mortality among PWH.
Risk factors for cryptococcal infection among people with HIV receiving care at a referral hospital in Uganda: a nested case–control study
(Springer Nature, 2026-04-27) Namuyanja, Sarah; Appeli, Saidi; Izudi, Jonathan
Background Cryptococcal infection is a major cause of morbidity and mortality among people with HIV (PWH), particularly those with advanced immunosuppression. Cryptococcal infection, detected by a laboratory-confirmed positive serum cryptococcal antigen (CrAg) test (cryptococcal antigenemia), typically precedes cryptococcal meningitis and provides a critical window for prevention. However, recent data on its risk factors in Uganda are limited. We assessed the risk factors for cryptococcal infection among PWH with non-suppressed viral load and severe immunosuppression receiving care at a referral hospital in midwestern Uganda. Methods We conducted a facility-based nested case-control study among PWH with non-suppressed viral load (viral load ≥ 1,000 copies/mL) and severe immunosuppression (CD4 < 200 cells/µL) at the Fort Portal Regional Referral Hospital in midwestern Uganda. Cases were PWH with a positive serum CrAg test, and controls were those with a negative serum CrAg test in a 1:2 case-to-control ratio, respectively. Socio-demographic and clinical data were retrospectively extracted from routine records. Multivariable binary logistic regression analysis was used to identify factors independently associated with cryptococcal infection. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported. Results We included 89 cases and 178 controls, with comparable mean age between the groups: 40.3 ± 12.4 years vs. 40.4 ± 11.7 years, respectively; p = 0.952. In the multivariable analysis, PWH with advanced World Health Organization (WHO) clinical stages III/IV compared to WHO clinical stages I/II (aOR 3.45, 95% CI 1.28–9.97), and those with missed clinic visits within three months before the serum CrAg testing compared to those without any missed clinic visits (aOR 2.39, 95% CI 1.14–5.02) had higher odds of cryptococcal infection. Conclusion This study showed that among PWH with non-suppressed viral load and severe immunosuppression, cryptococcal infection is strongly associated with markers of advanced HIV disease and gaps in care engagement. Strengthening retention in care, improving clinic appointment tracking, and ensuring timely serum CrAg screening among PWH with non-suppressed viral load may reduce cryptococcal disease burden through early diagnosis and treatment.

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