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Infection and Global Health Research Division

Research at the University of St Andrews School of Medicine


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Holistic Approach to Unravel Antibacterial Resistance in East Africa

PI: Prof Matthew Holden, School of Medicine

The potential harm that increasing levels of antibacterial resistance (ABR) will have on human health is vast.

It is predicted that by 2050, 10 million lives per year and a cumulative 100 trillion US Dollars of economic output may be lost worldwide. In order to address this looming problem a co-ordinated global response is required to try and halt the rise of ABR. HATUA is an interdisciplinary study which is exploring the burden and drivers of antibacterial resistance (ABR) associated with urinary tract infections (UTIs) across East Africa.

Whilst the biological drivers of ABR in pathogens are well explored, the extent to which these are modulated by human behaviour in and around antibiotics is less understood; cultural, social, economic and clinical factors potentially play a part in shaping the way people source, consume, use and distribute antibiotics. The interdisciplinary consortium brings together clinical microbiological, pathogen genomic, social science and modelling data to create a unique combined ABR data set, with which to investigate the drivers of resistance.

The project is establishing a surveillance network across Uganda, Kenya and Tanzania and will recruit 1800 UTI positive patients from nine study areas.

We are conducting quantitative interviews in the clinic, and then the homestead, and recording the treatment seeking behaviour of individuals and influencing factors. Whole genome sequencing will be used to characterize the pathogens we isolate from the patients, investigating their evolution and the genetic basis of resistance in UTI causing bacteria. Combining this social science data with the microbiology and genomic pathogen data, we will construct patient pathways that capture the treatment-seeking and antibiotic-use behaviour for our cohort. Using this construct, we aim to identify ways in which people can be influenced to follow more antibiotic friendly pathways, and disrupt the prevailing spread of ABR across the region.


HATUA Consortium Team Members and Institutions:


HATUA Publications and Impact

Decano, A.G.; Pettigrew, K.; Sabiiti, W.; Sloan, D.J.; Neema, S.; Bazira, J.; Kiiru, J.; Onyango, H.; Asiimwe, B.; Holden, M.T.G. Pan-Resistome Characterization of Uropathogenic Escherichia coli and Klebsiella pneumoniae Strains Circulating in Uganda and Kenya, Isolated from 2017–2018. Antibiotics 2021, 10, 1547.

Green, Dominique L.; Keenan, Katherine; Huque, Sarah I.; Kesby, Mike; Mushi, Martha F.; Kansiime, Catherine; Asiimwe, Benon; Kiiru, John; Mshana, Stephen E.; Neema, Stella; Mwanga, Joseph R.; Fredricks, Kathryn J.; Lynch,;y G.; Worthington, Hannah; Olamijuwon, Emmanuel; Ahad, Mary Abed Al; Aduda, Annette; Mmbaga, Blandina T.; Bazira, Joel; Sandeman, Alison; Stelling, John; Gillespie, Stephen Henry; Kibiki, Gibson; Sabiti, Wilber; Sloan, Derek J.; Holden, Matthew T. G.; Consortium, HATUA, The Role of Multidimensional Poverty in Antibiotic Misuse: A Study of Self-Medication and Non-Adherence in Kenya, Tanzania, and Uganda. Available at SSRN: or

Ndaki, P.M.; Mushi, M.F.; Mwanga, J.R.; Konje, E.T.; Ntinginya, N.E.; Mmbaga, B.T.; Keenan, K.; Sabiiti, W.; Kesby, M.; Benitez-Paez, F.; Sandeman, A.; Holden, M.T.G.; Mshana, S.E.; HATUA Consortium. Dispensing Antibiotics without Prescription at Community Pharmacies and Accredited Drug Dispensing Outlets in Tanzania: A Cross-Sectional Study. Antibiotics 2021, 10, 1025.

Asiimwe BB, Kiiru J, Mshana SE HATUA Consortium, et al. Protocol for an interdisciplinary cross-sectional study investigating the social, biological and community-level drivers of antimicrobial resistance (AMR): Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA): BMJ Open 2021;11:e041418. doi:10.1136/bmjopen-2020-041418

Arun Gonzales Decano, Kerry Pettigrew, Wilber Sabiiti, Derek Sloan, Stella Neema, Joel Bazira, John Kiiru, Hellen Atieno Onyango, Benon Asiimwe, Matthew T. G. Holden. Pan-resistome characterization of uropathogenic Escherichia coli and Klebsiella pneumoniae strains circulating in Uganda and Kenya isolated from 2017-2018. medRxiv 2020.03.11.20034389; doi:

Conference Abstracts and Events

March 2022: the HATUA and CARE consortia held a hugely successful dissemination event in Arusha, Tanzania. After two years of COVID-19 enforced Zoom and Team connectivity, it was a pleasure to meet in person and discuss the tremendous work undertaken by the research teams in Tanzania, Uganda and Kenya. Excellent presentations across the full breadth of HATUA’s holistic vision included talks on the genomic analysis of the pathogens responsible for causing disease in UTI patients, improvements in antimicrobial resistance (AMR) surveillance and capacity building, limitations of current drug dispensing practices, and unravelling the relationship between socioeconomic and behavioural factors and AMR. Great insights also from stakeholders and policymakers on how to translate research findings into impact on AMR policy.

The HATUA Consortium was awarded a dedicated scientific session to share findings at the 8th East African Health and Scientific Conference held on 18th November 2021. Nine members of the consortium presented research and together provided a very positive overview of the holistic approach taken by HATUA. The talks were followed by a lively panel session with a large and engaged audience of over 60 attendees.

The HATUA consortium, in partnership with Makerere University/UVRI Centre of Excellence in Infection and Immunity Research and Training (MUII-Plus) in Uganda, organised a one-day symposium on Friday 22nd October 2021 to showcase success stories and highlights of Infection and Immunity research in Uganda. The symposium was organised by Prof Alison Elliott, one of the HATUA Co-Is, based at UVRI and LSHTM. HATUA partners from St Andrews, Uganda, Tanzania and Kenya attended and presented findings from HATUA.

The role of multidimensional poverty in antibiotic misuse in East Africa: A mixed-methods study. Submitted to ASTMH Annual Meeting, 2021.Dominique L. Green, Sarah Huque, Mary Abed Al Ahad, Mike Kesby, Stephen E. Mshana, Benon B.Asiimwe, John Kiiru, Stella Neema, Joseph R. Mwanga, Annette Aduda, Wilber Sabiiti, Derek J. Sloan, Katherine Keenan, Matthew T. Holden.

Complex treatment-seeking for symptoms of urinary tract infection in East Africa and links to antibiotic misuse: A mixed-methods study. Submitted to ASTMH Annual Meeting, 2021. Mary Abed Al Ahad, Sarah Huque, Dominique L. Green, Mike Kesby, Stephen E. Mshana, Benon B. Asiimwe, John Kiiru, Stella Neema, Joseph R. Mwanga, Annette Aduda, Wilber Sabiiti, Derek J. Sloan, Katherine Keenan, Matthew T. Holden.

Kesby M, Neema S, Asiimwe B, HATUA Consortium. (2020). Talking back to the WHO: How grassroots communities in Uganda used Participatory Action Research (PAR) to produce ‘glocally’ meaningful health information on AMR. World One Health Congress, 2020.

Influence on Policy and Practice

HATUA citation in national clinical guidelines. Standard Treatment Guidelines and National Essential Medicines List (STG/NEMLIT), 5th edition 2021

Dissemination Reports

HATUA Dissemination in Kilimanjaro 15th May 2021

HATUA Community Dialogue in Mbarara, Uganda, November 2020

HATUA Funders

HATUA is a £2.8M, three-year Global Context Consortia Award, funded by the National Institute for Health Research (NIHR), Medical Research Council (MRC) and the Department of Health and Social Care (DHSC). The award is also part of the EDCTP2 programme supported by the European Union.


St Andrew’s Team


Principal Investigator


School of Medicine


Dr Alison Sandeman

Programme Manager - HATUA Consortium


Prof Stephen Gillespie


Prof Andrew Lynch

Professor of Statistics in Bioscience


Dr Derek Sloan

Senior Lecturer/Consultant in Infectious Diseases


School of Geography and Sustainable Development


Dr Michael Kesby

Senior Lecturer


School of Biology