Uganda’s Disease Detectives Increase Contributions to Critical PEPFAR Priority Areas
The Field Epidemiology Training Program (FETP) not only increases countries ability to detect and respond to public health emergencies such as Ebola and COVID-19, but it helps countries build their pool of public health professionals to effectively prevent and control other public health threats and epidemics such as HIV, malaria, and noncommunicable diseases. Below, we highlight how disease detectives are having an impact on HIV prevention and control in Uganda.
The advanced-level of the Uganda Field Epidemiology Training Program (FETP) began in 1994, as a “Public Health School Without Walls”. As the program progressed, it evolved into more of an academic masters-level public health program (MPH). Despite the strong academic value, the graduates and the country saw that more field work and hands-on learning was needed, a strength of FETP. For this reason, the Public Health Fellowship Program (PHFP) was created, as a post-graduate program for MPH graduates who wanted specific, expert-level training in field epidemiology.
Primarily funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), PHFP fellows conduct at least one — and often more than one — applied epidemiologic study on topics related to HIV and tuberculosis. The fellows identify gaps in evaluation and implementing practices, and share results to improve programming, working directly with the AIDS Control Program (ACP) at the Ministry of Health, the Uganda National Tuberculosis and Leprosy Control Program (NTLP), PEPFAR implementing partners, and CDC staff.
CDC staff provide direct mentorship to the fellows on these projects. This proactive support is key to the success of the project, as fellows receive coaching to allow them to complete the projects successfully. According to Julie Harris, the CDC Resident Advisor for the PHFP program, “the strong and consistent support from the Ministry of Health programs, as well as the mentorship and scientific input from partner staff means that we can identify and carry out HIV and TB projects that are actually meaningful and have real impact in Uganda.”
Applying Disease Detective Skills to Improve HIV Testing and Treatment in Prisons
The World Health Organization (WHO) considers prisoners a ‘key population’ group for HIV control efforts. In Uganda, the HIV prevalence among prisoners is quite high (15%, versus the national prevalence of 6.2%), and most prisoners are men. Several PHFP fellows have worked on prisoner-focused HIV evaluations. One such project, led by PHFP fellow Gloria Bahizi, evaluated HIV care and testing among 6,803 incarcerated men and women in four prisons. The team compared two prisons employing in-house HIV testing and treatment programs with two other prisons using outside referral services.
Gloria and her team compared the HIV care cascade, also known at the ’90-90-90’ targets, between prisoners housed under both models (see sidebar). The team examined data from January 2017 to December 2018 and found that neither in-house nor referral service models were able to reach the 90-90-90 targets. However, for inmates with in-house treatment services, the rates were 91-79-98, while for inmates in prisons with referral service, the rates were 62-43-50. These data clearly show that prisons with in-house treatment services yielded much better results in reaching HIV care cascade targets than prisons with referral services.
The HIV treatment cascade (also called HIV cascade or HIV/AIDS care continuum) is used worldwide to diagnose, treat, and care for patients living with HIV. This public health model outlines the sequential steps that people with HIV go through from initial diagnosis to achieving and maintaining viral suppression (having a very low or undetectable amount of HIV in the body). Specific goals, known as the 90-90-90 goals, are tied to the cascade: 90% of people who are HIV positive know their status; 90% of people who are diagnosed are on antiretroviral therapy (ART); and 90% of those who receive ART are virally suppressed. Those who stay virally suppressed effectively have no risk of transmitting HIV to their HIV-negative sexual partners. Countries that achieve 90-90-90 are said to have the epidemic under control.
* Linked to care is calculated differently from other steps in the continuum, and cannot be directly compared to other steps. See Table 1 on page 5 of the Understanding the HIV Care Continuum fact sheet, located at https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdfpdf icon.
** Receipt of medical care was defined as ≥1 test (CD4 or viral load [VL]) in 2016.
*** Retained in continuous medical care was defined as ≥2 tests (CD4 or VL) ≥3 months apart in 2016. Viral suppression was defined as <200 copies/mL on the most recent VL test in 2016. See Table 1 on page 5 of the Understanding the HIV Care Continuum fact sheet for details.
The team also identified several barriers hindering the success of the cascade in both HIV care models. These challenges included inadequate clinic space, insufficient staffing, lack of staff training, and limited funding. In addition, viral load testing is sent to a central laboratory, which creates transportation and turnaround time issues. Logistical challenges, including limited paper and electronic records and uncoordinated prisoner releases and transfers made keeping track of patients difficult. Finally, security issues arose from transporting inmates to outside referral services.
The team made several recommendations, including providing in-house testing and ART in all prisons, moving to full electronic medical records to improve continuity of care, and decentralizing viral load testing to increase the number of prisoners tested and treated.
CDC Uganda Associate Director for Science Dr. Lisa Mills, who mentored this project team, noted the impact of this study. According to Dr. Mills, “the Uganda Prisons Service PEPFAR program strategy has been revised, enabling direct government-to-government funding for more than 200 prisons to provide HIV testing, care, and treatment services for all prisoners within the prison system using the hub-and-spoke model.” This model decentralizes ART management and serves patients efficiently and effectively. “More than 30 Uganda Prisons Service sites will receive accreditation to administer antiretroviral therapy directly,” said Dr. Mills.
This work also highlights the importance of including prisoners as key populations for HIV services to accomplish Uganda’s 90-90-90 targets. HIV testing and treatment services in prisons are particularly crucial for reaching men, who are generally underserved by HIV programs in many sub-Saharan African countries, including Uganda.
Projects such as the one conducted by Gloria and her team illustrate the crucial value FETPs provide to Uganda’s health system.