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SEARCH (http://www.searchendaids.com/)

Sustainable East Africa Research of Community Health – Uganda and Kenya

Contact person: Diane Havlir, MD; dhavlir@php.ucsf.edu

Sustainable East Africa Research on Community Health (SEARCH) Collaboration was established in Vienna in 2010 to evaluate health and economic outcomes of bold community based health interventions for communicable and non-communicable diseases (NCD). The first proposed initiative of the SEARCH collaboration is a community cluster randomized trial in Uganda and Kenya of widespread early community wide antiretroviral therapy (ART), where primary endpoints will include both community health and community economic status. The SEARCH study is designed to inform the current debates on global health investments precipitated by a) mathematical models predicting the HIV epidemic can be halted with widespread ART; and b) the reality of diminishing resources and growing costs of existing programs. The study is designed to leverage investments in HIV to develop sustainable systems for other infectious and NCDs. By examining individual, household, and community level socio-economic outcomes, the SEARCH study will assess whether an integrated approach to addressing health problems serve as an economic development intervention as well. Unique elements of the study a) inclusion of diagnosis and linkage to care of multiple communicable (TB, malaria) and non- communicable disease (hypertension, diabetes) in study design; b) improving and building community health delivery for ART and other diseases using new and efficient care models; c) evaluations that measure the immediate, cumulative and downstream effects of the intervention in the health, education and economic sectors; and d) a focus on sustainability. Pilot studies are underway for the building blocks of SEARCH including:

Kakyerere Community Health Campaign

Two high through-put Community Health Campaign in Kakyerere parish, a rural area in southwestern Uganda, took place in May 2011 and May 2012. The primary aim of this activity is to test the feasibility of universal HIV voluntary testing and counseling coupled with early linkage to HIV clinical services within a community-wide public health campaign offering multi-disease care feasibility and assesses the uptake and re-uptake of the community population. Secondary outcomes include the feasibility of estimating multiple community health parameters (the incidence of acute HIV, community HIV viral load, and the prevalence of TB, malaria, diabetes, and hypertension) using a rapid, high through-put campaign, and determining the socioeconomic status of Kakyerere parish residents according to HIV status using a household economic survey among a random selection of community health campaign participants.

Early Antiretroviral Therapy in Resource Limited Settings in Patients with HIgh CD4+ Cell Counts (EARLI) study

EARLI is a non-randomized, non-controlled open-label pilot study of ART initiation in 400 ART-naïve patients with CD4+ cell counts ≥250 cells/uL. The purpose of this study will be to assess efficacy and costs associated with delivering ART to these patient populations under a “streamlined” model of care. It is being conducted at a peripherally-located, level IV health center (HC-IV) in Bwizibwera municipality, a town in rural western Uganda located near Mbarara, Uganda and started in August 2011.

Recapture study

This is an operational research protocol that describes a sporadic, cohort-based approach to assessing engagement in care for adult patients with high CD4 and not on ART. In short, the study seeks to identify outcomes in a simple random sample of 15% of patients who enrolled with high CD4 counts and who subsequently became lost to follow-up and took place between May – December 2011 at two clinics in Kampala and Mbarara, Uganda.

Pharmacy Only Visits (POV) study

An existing streamlined model of HIV care delivery based on pharmacy only visits (POV) is retrospectively evaluating the Mulago-Mbarara Teaching Hospitals Joint AIDS Program (MJAP) clinics. The standard model of HIV care in Uganda requires clinic visits with a medical officer every 2 months. This study evaluates clinic patients enrolled into and eligible, but not yet enrolled into an ongoing program of a streamlined model of health care delivery in which medical officer visits will occur at 6 month intervals, and pharmacy/nurse only visits will occur at 2 month intervals. Subjects participating in the POV care model are matched by ART status and CD4 nadir to subjects eligible for the POV care model, but not yet enrolled due to available capacity. This study started in February 2012 in Kampala and Mbarara, Uganda

Key Publications
  1. Chamie G, Kwarisiima D, Clark TD, Kabami J, Jain V, Geng E, Petersen ML, Thirumurthy H, Kamya MR, Havlir DV, Charlebois ED, and the SEARCH Collaboration. Leveraging rapid community-based HIV testing campaigns for non-communicable diseases in rural Uganda. PLoS One 2012;7(8):e43400. Epub 2012 Aug 20. PMID: 22916256
  2. Thirumurthy H, Jain V, Chamie G, Geng E, Kabami J, Kwarisiima D, Clark TD, Petersen ML, Kamya M, Charlebois E, Havlir D, and the SEARCH Collaboration. Improved employment, education, and economic outcomes in households of HIV-positive adults with high CD4 counts: evidence from a community-wide health campaign in Uganda. AIDS. 2013 Feb 20;27(4):627-634. PMID: 23169332
  3. Jain V, Liegler T, Kabami J, Chamie G, Clark TD, Black D, Geng E, Kwarisiima D, Wong J, Abdel-Mohsen M, Lizak P, Aweeka F, Thirumurthy H, Petersen ML, Charlebois ED, Kamya MR, Havlir DV, and the SEARCH Collaboration. Assessment of community viral load in a rural East African setting Using a fingerprick-based blood collection method. Clin Infect Dis. 2013 Feb;56(4):598-605. Epub 2012 Dec 12. PMID: 23243180
  4. Namusobya J, Semitala FC, Amanyire G, Kabami J, Chamie G, Bogere J, Jain V, Clark TD, Charlebois E, Havlir DV, Kamya M, Geng EH. High Retention in Care among HIV-infected Patients Entering Care with CD4 Levels > 350/μl under Routine Program Conditions in Uganda. Clin Infect Dis 2013 Aug 23. PMID: 23899683
  5. Jain V, Byonanebye D, Liegler, T, Kwarisiima D, Chamie G, Kabami J, Petersen ML, Balzer LB, Clark TD, Black D, Thirumurthy H, Geng E, Charlebois ED, Amanyire G, Kamya MR, Havlir DV, and the SEARCH Collaboration. Changes in Population HIV RNA Levels in Mbarara, Uganda During Scale-Up of HIV Antiretroviral Therapy Access. JAIDS. Epub (ahead of print) 2013 Oct 1. PMID: 24146022
  6. Chamie G, Kwarisiima D, Clark TD, Kabami J, Jain V, Geng E, Balzer LB, Petersen ML, Thirumurthy H, Charlebois E, Kamya MR, Havlir DV, and the SEARCH Consortium. Uptake of community-based HIV testing during a multi-disease health campaign in rural Uganda. PLoS One. 2014 Jan 2: 9(1): e84317. PMID 24392124
  7. Kotwani P, Kwarisiima D, Clark TD, Kabami J, Geng E, Jain V, Chamie G, Petersen ML, Thirumurthy H, Kamya MR, Charlebois E, Havlir DV, and the SEARCH Collaboration. Epidemiology and awareness of hypertension in a rural Ugandan community: a cross-sectional study. BMC Public Health. 2013 Dec 9: 13(1): 1151. PMID 24321133
  8. Kotwani P, Balzer LB, Kwarisiima D, Clark TD, Kabami J, Byonanebye DM, Bainomujuni B, Black D, Chamie G, Jain V, Thirumurthy H, Kamya MR, Geng EH, Petersen ML, Havlir DV, Charlebois ED, and the SEARCH Collaboration. Evaluating a hypertension linkage to care intervention following community-based screening in rural Uganda. Accepted at Tropical Medicine and International Health