Kidney disease screening among adults with HIV in Uganda: a missed priority for a high-risk population

Abstract Chronic kidney disease affects 850 million people worldwide, with Sub-Saharan Africa bearing a significant burden. People living with HIV (PWH) are at increased risk due to nephrotoxicity of antiretroviral therapy (ART), in part due to widespread use of tenofovir disoproxil fumarate. In response, Uganda recommends routine kidney disease screening at ART initiation. However, the extent of adherence to these guidelines remains poorly understood. We extracted clinical data for adults initiating ART between 2017 and 2024 at three large-volume HIV clinics in Uganda. To determine if kidney disease screening rates had increased appropriately over time, we divided the observation period into three eras as per national guidelines: (1) Test and Treat (2017-2019), that recommended screening only PWH and diabetes or hypertension; (2) DTG rollout/COVID-19 (2020-2022); and (3) creatinine-for-all (2023-2024), recommending screening everyone initiating ART. Logistic regression models were fit to identify correlates of renal screening. Of the 17,485 participants, only 22.4% (3,909/17,485) were screened for kidney disease. Screening was more common at the urban site (54.2%) compared to rural sites (10.0%). At rural sites, screening declined over time and individuals were 83% less likely to be screened in the creatinine-for-all era compared to the baseline era (aOR 0.17, 95% CI: 0.13–0.22) while it increased at urban site (aOR 9.27, 95% CI: 7.37–11.66). Male sex (aOR 1.37, 95% CI: 1.20– 1.57), older age (>45 years), hypertension, and non–TDF-based ART regimens were associated with higher screening odds at rural sites. Diabetes, opportunistic infections, and TDF use were not significantly associated with screening likelihood at any site. Kidney disease screening at ART initiation remains poor in Uganda, particularly in rural clinics, highlighting critical challenges in translating national guidelines into practice. Future research should focus on understanding multilevel barriers to screening and evaluating strategies to improve guideline uptake. Competing Interest Statement The authors have declared no competing interest. Funding Statement This Research project was supported by the Fogarty International Center of the National Institutes of Health (NIH) under Award Number D43TW010543. MJS acknowledges additional support from the NIH (K24 HL166024). This article has arisen, in whole or in part by the National Institutes of Health (NIH), and is subject to the NIH's Plan to Enhance Public Access to the Results of NIH-Supported Research [2024 NIH Public Access Policy], NOT-OD-25-047. As a result, the author retains the rights necessary to comply with this policy, including the right to submit, or have submitted to the National Library of Medicine’s PubMed Central an electronic version of the final, peer-reviewed manuscript to be made available in PubMed Central on the official date of publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was reviewed and approved by the Mbarara University Review and Ethics Committee (MUST ID: 2024-1667) and received a waiver of informed consent. Additionally, we obtained approval from the Uganda National Council of Science and Technology (HS5305ES), and administrative clearances from all the study sites I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable Footnotes Funding: This Research project was supported by the Fogarty International Center of the National Institutes of Health (NIH) under Award Number D43TW010543. MJS acknowledges additional support from the NIH (K24 HL166024). This article has arisen, in whole or in part by the National Institutes of Health (NIH), and is subject to the NIH’s Plan to Enhance Public Access to the Results of NIH-Supported Research [2024 NIH Public Access Policy], NOT- OD-25-047. As a result, the author retains the rights necessary to comply with this policy, including the right to submit, or have submitted to the National Library of Medicine’s PubMed Central an electronic version of the final, peer-reviewed manuscript to be made available in PubMed Central on the official date of publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Conflicts of Interest: All authors report no conflict of interest. Data Availability All data used in this manuscript preparation is available from the corresponding author upon reasonable request.