title: Population level usage of health services, and HIV testing and care, prior to decentralization of antiretroviral therapy in Agago District in rural Northern Uganda.
abstract: BACKGROUND
  Decentralization of ART services scaled up significantly with the country wide roll out of option B plus in Uganda. Little work has been undertaken to examine population level access to HIV care particularly in hard to reach areas in rural Africa. Most work on ART scale up has been done at health facility level which omits people not accessing healthcare in the community. This study describes health service usage, particularly HIV testing and care in 2/6 parishes of Lapono sub-county of northern Uganda, prior to introduction of ART services in Lira Kato Health Centre (a local lower-level health centre III), as part of ART decentralization.
  
  
  METHODS
  Household and individual questionnaires were administered to household members (aged 15-59 years). Logit random effects models were used to test for differences in proportions (allowing for clustering within villages).
  
  
  RESULTS
  2124 adults from 1351 households were interviewed (755 [36%] males, 1369 [64 %] females). 2051 (97%) participants reported seeking care locally for fever, most on foot and over half at Lira Kato Health Centre. 574 (76%) men and 1156 (84%) women reported ever-testing for HIV (P < 0.001 for difference); 34/574 (6%) men and 102/1156 (9%) women reported testing positive (P = 0.04). 818/850 (96%) women who had given birth in the last 5 years had attended antenatal care in their last pregnancy: 7 women were already diagnosed with HIV (3 on ART) and 790 (97%) reported being tested for HIV (34 tested newly positive). 124/136 (91%) HIV-positive adults were in HIV-care, 123/136 (90 %) were taking cotrimoxazole and 74/136 (54%) were on ART. Of adults in HIV-care, most were seen at Kalongo hospital (n = 87), Patongo Health Centre (n = 7) or Lira Kato Health Centre (n = 23; no ART services). 58/87, 5/7 and 20/23 individuals walked to Kalongo hospital (56 km round-trip, District Health Office information), Patongo Health Centre (76 km round-trip, District Health Office information) and Lira Kato Health Centre (local) respectively. 8 HIV-infected children were reported; only 2 were diagnosed aged <24 months: 7/8 were in HIV-care including 3 on ART.
  
  
  CONCLUSIONS
  Higher proportions of women compared to men reported ever-testing for HIV and testing HIV-positive, similar to other surveys. HIV-infected men and women travelled considerable distances for ART services. Children appeared to be under-accessing testing and referral for treatment. Decentralization of ART services to a local health facility would decrease travel time and transport costs, making care and treatment more easily accessible.
authors.affiliation: Joint Clinical Research Centre, Kampala, Uganda. gabongomera@jcrc.org.ug.|University of Antwerp, Antwerp, Belgium. gabongomera@jcrc.org.ug.
authors.forename: G
authors.initials: G
authors.lastname: Abongomera
authors.affiliation: Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda. skiwuwa@yahoo.com.
authors.forename: S
authors.initials: S
authors.lastname: Kiwuwa-Muyingo
authors.affiliation: University of York, York, UK. paul.revill@york.ac.uk.
authors.forename: P
authors.initials: P
authors.lastname: Revill
authors.affiliation: Dignitas International, Zomba, Malawi. l.chiwaula@dignitasinternational.org.
authors.forename: L
authors.initials: L
authors.lastname: Chiwaula
authors.affiliation: University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe. travormabugu@yahoo.com.
authors.forename: T
authors.initials: T
authors.lastname: Mabugu
authors.affiliation: University College London, London, UK. andrew.phillips@ucl.ac.uk.
authors.forename: A
authors.initials: A
authors.lastname: Phillips
authors.affiliation: Infectious Diseases Institute, Makerere University, Kampala, Uganda. katabira@imul.com.
authors.forename: E
authors.initials: E
authors.lastname: Katabira
authors.affiliation: Joint Clinical Research Centre, Kampala, Uganda. vmusiime@jcrc.org.ug.|Makerere University College of Health Sciences, Kampala, Uganda. vmusiime@jcrc.org.ug.
authors.forename: V
authors.initials: V
authors.lastname: Musiime
authors.affiliation: Imperial College London, London, UK. c.gilks@uq.edu.au.|School of Population Health, University of Queensland, Brisbane, Australia. c.gilks@uq.edu.au.
authors.forename: C
authors.initials: C
authors.lastname: Gilks
authors.affiliation: Dignitas International, Zomba, Malawi. a.chan@dignitasinternational.org.|Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada. a.chan@dignitasinternational.org.
authors.forename: A
authors.initials: A
authors.lastname: Chan
authors.affiliation: University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe. jhakim@mweb.co.zw.
authors.forename: J
authors.initials: J
authors.lastname: Hakim
authors.affiliation: University of Antwerp, Antwerp, Belgium. bcoleb@itg.be.
authors.forename: R
authors.initials: R
authors.lastname: Colebunders
authors.affiliation: Joint Clinical Research Centre, Kampala, Uganda. ckityo@jcrc.org.ug.
authors.forename: C
authors.initials: C
authors.lastname: Kityo
authors.affiliation: Medical Research Council Clinical Trials Unit at UCL, London, UK. diana.gibb@ucl.ac.uk.
authors.forename: D M
authors.initials: DM
authors.lastname: Gibb
authors.affiliation: Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda. janet.seeley@mrcuganda.org.|London School of Hygiene and Tropical Medicine, London, UK. janet.seeley@mrcuganda.org.
authors.forename: J
authors.initials: J
authors.lastname: Seeley
authors.affiliation: Medical Research Council Clinical Trials Unit at UCL, London, UK. deborah.ford@ucl.ac.uk.
authors.forename: D
authors.initials: D
authors.lastname: Ford
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa; D044966:Anti-Retroviral Agents; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006296:Health Services / Q000706:statistics & numerical data*; D006801:Humans; D007880:Legislation, Drug; D008297:Male; D008875:Middle Aged; D011057:Politics; D011247:Pregnancy; D011295:Prenatal Care; D012424:Rural Population; D011795:Surveys and Questionnaires; D014195:Travel / Q000191:economics; D014454:Uganda; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents