Voluntary medical male circumcision for HIV prevention in fishing communities in Uganda: the influence of local beliefs and practice.

Local beliefs and practices about voluntary medical male circumcision (VMMC) may influence uptake and effectiveness. Data were gathered through interviews with 40 people from four ethnically mixed fishing communities in Uganda. Some men believed that wound healing could be promoted by contact with vaginal fluids while sex with non-regular partners could chase away spirits - practices which encouraged unsafe sexual practices. Information given by providers stressed that VMMC did not afford complete protection from sexually-transmitted infections, however, a number of male community members held the view that they were fully protected once circumcised. Both men and women said that VMMC was good not just for HIV prevention but also as a way of maintaining hygiene among the men. The implementation of VMMC in high-HIV prevalence settings needs to take account of local beliefs about circumcision, working with local religious/social group leaders, women and peers in the roll-out of the intervention

Feasibility of establishing an HIV vaccine preparedness cohort in a population of the Uganda Police Force: Lessons learnt from a prospective study.

BACKGROUND: Members of uniformed armed forces are considered to be at high risk for HIV infection and have been proposed as suitable candidates for participation in HIV intervention studies. We report on the feasibility of recruitment and follow up of individuals from the community of the Uganda Police Force (UPF) for an HIV vaccine preparedness study. METHODS: HIV-negative volunteers aged 18-49 years, were identified from UPF facilities situated in Kampala and Wakiso districts through community HIV counselling and testing. Potential volunteers were referred to the study clinic for screening, enrolment and quarterly visits for one year. HIV incidence, retention rates were estimated and expressed as cases per 100 person years of observation (PYO). Rate ratios were used to determine factors associated with retention using Poisson regression models. RESULTS: We screened 560 to enroll 500 volunteers between November 2015 and May 2016. One HIV seroconversion occurred among 431 PYO, for an incidence rate of 0.23/100 PYO (95% confidence interval [CI]: 0.03-1.64). Overall, retention rate was 87% at one year, and this was independently associated with residence duration (compared to 5 years aRR = 1.34, 95%CI: 0.95-1.37); absence of genital discharge in the last 3 months (aRR = 1.97, 95% CI: 1.38-2.83, absence of genital ulcers (aRR = 1.90, 95%CI: 1.26-2.87, reporting of new sexual partner in the last month (aRR = 0.57, 95%CI: 0.45-0.71, being away from home for more than two nights (aRR = 1.27, 95%CI: 1.04-1.56, compared to those who had not travelled) and absence of knowledge on HIV prevention (aRR = 2.67, 95%CI: 1.62-4.39). CONCLUSIONS: While our study demonstrates the feasibility of recruiting and retaining individuals from the UPF for HIV research, we did observe lower than anticipated HIV incidence, perhaps because individuals at lower risk of HIV infection may have been the first to come forward to participate or participants followed HIV risk reduction measures. Our findings suggest lessons for recruitment of populations at high risk of HIV infection

Chronic disease, risk factors and disability in adults aged 50 and above living with and without HIV: findings from the Wellbeing of Older People Study in Uganda.

BACKGROUND: Data on the prevalence of chronic conditions, their risk factors, and their associations with disability in older people living with and without HIV are scarce in sub-Saharan Africa. OBJECTIVES: In older people living with and without HIV in sub-Saharan Africa: 1) to describe the prevalence of chronic conditions and their risk factors and 2) to draw attention to associations between chronic conditions and disability. METHODS: Cross-sectional individual-level survey data from people aged 50 years and over living with and without HIV were analyzed from three study sites in Uganda. Diagnoses of chronic conditions were made through self-report, and disability was determined using the WHO Disability Assessment Schedule (WHODAS). We used ordered logistic regression and calculated predicted probabilities to show differences in the prevalence of multiple chronic conditions across HIV status, age groups, and locality. We used linear regression to determine associations between chronic conditions and the WHODAS. RESULTS: In total, 471 participants were surveyed; about half the respondents were living with HIV. The prevalence of chronic obstructive pulmonary disease and eye problems (except for those aged 60-69 years) was higher in the HIV-positive participants and increased with age. The prevalence of diabetes and angina was higher in HIV-negative participants. The odds of having one or more compared with no chronic conditions were higher in women (OR 1.6, 95% CI 1.1-2.3) and in those aged 70 years and above (OR 2.1, 95% CI 1.2-3.6). Sleep problems (coefficient 14.2, 95% CI 7.3-21.0) and depression (coefficient 9.4, 95% CI 1.2-17.0) were strongly associated with higher disability scores. CONCLUSION: Chronic conditions are common in older adults and affect their functioning. Many of these conditions are not currently addressed by health services in Uganda. There is a need to revise health care policy and practice in Uganda to consider the health needs of older people, particularly as the numbers of people living into older age with HIV and other chronic conditions are increasing

Acceptability and Predictors of Uptake of Anti-retroviral Pre-exposure Prophylaxis (PrEP) Among Fishing Communities in Uganda: A Cross-Sectional Discrete Choice Experiment Survey.

We used a discrete choice experiment to assess the acceptability and potential uptake of HIV pre-exposure prophylaxis (PrEP) among 713 HIV-negative members of fishing communities in Uganda. Participants were asked to choose between oral pill, injection, implant, condoms, vaginal ring (women), and men circumcision. Product attributes were HIV prevention effectiveness, sexually transmitted infection (STI) prevention, contraception, waiting time, and secrecy of use. Data were analysed using mixed multinomial logit and latent class models. HIV prevention effectiveness was viewed as the most important attribute. Both genders preferred oral PrEP. Women least preferred the vaginal ring and men the implant. Condom use was predicted to decrease by one third among men, and not to change amongst women. Oral PrEP and other new prevention technologies are acceptable among fishing communities and may have substantial demand. Future work should explore utility of multiple product technologies that combine contraception with HIV and other STI prevention

Multi-level experiences and determinants of alcohol misuse and illicit drug use among occupational groups at high-risk of HIV in sub-Saharan Africa: A thematic synthesis of qualitative findings.

Occupational groups at high-risk of HIV in sub-Saharan Africa (SSA) may be at increased risk of substance use because of occupation-related factors. We synthesised qualitative data on determinants and context of alcohol misuse and illicit drug use in these groups. We systematically searched five databases for qualitative studies reporting on alcohol misuse or illicit drug use in fisherfolk, uniformed personnel, miners, truckers, motorcycle taxi riders, and sex workers in SSA. Qualitative data and interpretations were extracted and synthesised using a systematic iterative process to capture themes and overarching concepts. We searched for papers published prior to January 2018. We identified 5692 papers, and included 21 papers in our review, published from 1993 to 2017. Most studies were conducted among fisherfolk (n = 4) or sex workers (n = 12). Ten papers reported on alcohol use alone, three on illicit drug use alone and eight on both. Substance use was commonly examined in the context of work and risky behaviour, key drivers identified included transactional sex, availability of disposable income, poverty, gender inequalities and work/living environments. Substance use was linked to risky behaviour and reduced perceived susceptibility to HIV. Our review underscores the importance of multilevel, integrated HIV prevention and harm reduction interventions in these settings

HIV Combination Prevention study - Data at months 0, 9 and 15

Dataset and supporting documentation collected as part of the HIV combination prevention study, a cluster randomised trial investigating the feasibility of conducting HIV combination prevention interventions in fishing communities in Uganda. The dataset contains participant-provided responses including condom use, HIV prevention practices, and intervention take-up

Experiences of HIV-related stigma among HIV-positive older persons in Uganda--a mixed methods analysis.

There is limited data on stigma among older HIV-infected adults in sub-Saharan Africa. We describe the experiences of stigma and disclosure in a cohort of HIV-positive older people in Uganda. Using data from the Wellbeing of Older Peoples' Study of Kalungu (rural site) and Wakiso district (peri-urban site) residents, we measured self-reported stigma levels for 183 respondents (94 on antiretroviral therapy (ART); 88, not on ART) using a stigma score generated using three questions on stigma perceptions where 0 meant no stigma at all and 100 was maximum stigma. Based on two questions on disclosure, an overall score was computed. High disclosure was assigned to those who often or very often disclosed to the family and were never or seldom afraid to disclose elsewhere. We examined the experiences of HIV stigma of 25 adults (52% females) using semi-structured, open-ended interviews and monthly oral diaries over one year. Mean age of the respondents was 70 years (range 60-80 years) and 80% of all respondents were enrolled in ART. Interview transcripts were analysed using thematic content analysis. Overall, 55% of respondents had a high disclosure score, meaning they disclosed easily, and 47% had a high stigma score. The stigma scores were similar among those with high and low disclosure scores. In multivariate analyses with disclosure and stigma scores as dependent variables none of the respondents' characteristics had a significant effect at the 5% level. Qualitative data revealed that stigma ranges from: (1) perceptions (relatively passive, but leading to behaviour such as gossip, especially if not intended maliciously); to (2) discriminatory behaviour (active or enacted stigma; from malicious gossip to outright discrimination). Despite the relatively high levels of disclosure, older people suffer from high levels of stigma of various forms apart from HIV-related stigma. Efforts to assess for different forms of stigma at an individual level deserve greater attention from service providers and researchers, and must be context specific

Feasibility of conducting HIV combination prevention interventions in fishing communities in Uganda : A pilot cluster randomised trial

Objective We assessed feasibility of an HIV-combination-prevention trial among fishing communities in Uganda. Design Cluster randomised trial in four fishing communities on Lake Victoria, Uganda. Two intervention communities received a combination-prevention-package (behaviour change communication, condom promotion, HIV testing, voluntary male medical circumcision and referral for anti-retroviral therapy if HIV-positive). All four communities received routine government HIV care services. Methods Using household census data we randomly selected a cohort of consenting residents aged 18 years. A baseline sero-survey in July 2014 was followed by two repeat surveys in March and December 2015. We measured uptake of HIV prevention methods, loss-to-follow-up and HIV incidence, accounting for multistage survey design. Results A total of 862 participants were enrolled and followed for 15 months. Participation was 62% and 74% in the control and intervention arms respectively; Overall loss to follow up (LTFU) was 21.6% and was similar by arm. Self-reported abstinence/faithfulness increased between baseline and endline in both arms from 53% to 73% in the control arm, and 55% to 67% in the intervention arm. Reported condom use throughout the study period was 36% in the intervention arm vs 28% in the control arm; number of male participants reporting cir-cumsicion in both arms from 58% to 79% in the intervention arm, and 39% to 46% in the control arm. Independent baseline predictors of loss-to-follow-up were: being HIV positive, residence in the community for 1 month/year Conclusions Recruitment and retention of participants in longitudinal trials in highly mobile HIV fishing communities is challenging. Future research should investigate modes for locating and retaining participants, and delivery of HIV-combination prevention

Sexual Behavior of Older Adults Living with HIV in Uganda.

Sexual behavior among older adults with HIV in Sub-Saharan Africa has been understudied despite the burgeoning of this population. We examined sexual behavior among older adults living with HIV in Uganda. Participants were eligible for the study if they were 50 years of age or older and living with HIV. Quantitative data were collected through face-to-face interviews, including demographic characteristics, health, sexual behavior and function, and mental health. Of respondents, 42 were men and 59 women. More than one-quarter of these HIV-positive older adults were sexually active. A greater proportion of older HIV-positive men reported being sexually active compared to women (54 vs. 15%). Among those who are sexually active, a majority never use condoms. Sixty-one percent of men regarded sex as at least somewhat important (42%), while few women shared this opinion (20%). Multivariate logistic regression analyses revealed that odds of sexual activity in the past year were significantly increased by the availability of a partner (married/cohabitating), better physical functioning, and male gender. As more adults live longer with HIV, it is critical to understand their sexual behavior and related psychosocial variables in order to improve prevention efforts

Epidemiology of Alcohol Misuse and Illicit Drug Use Among Young People Aged 15-24 Years in Fishing Communities in Uganda.

BACKGROUND: We determined the prevalence of and risk factors for alcohol misuse and illicit drug use among young Ugandans in fishing communities, a recognised "key population" for human immunodeficiency virus (HIV) infection. METHODS: We conducted a cross-sectional survey among young people (15-24 years) in fishing communities in Koome, Uganda, in December 2017-July 2018. Using Audio-Assisted Self-Interviewing, we collected data on socio-demographic characteristics and alcohol use, including the Alcohol Use Disorders Identification Test (AUDIT) and timeline follow-back calendar (TLFB). Blood samples were analysed for HIV, herpes simplex virus 2 (HSV2), and Phosphatidyl ethanol (PEth 16:0/18:1). Urine samples were analysed for illicit drugs. RESULTS: Among 1281 participants (52.7% male, mean age 20 years), 659 (51.4%) reported ever drinking alcohol, 248 (19.4%) had 12-month-AUDIT ≥ 8, and 261 (20.5%) had whole-blood PEth 16:0/18:1 concentration ≥ 20 ng/mL, indicating significant consumption. In multivariable analyses, PEth 16:0/18:1 ≥ 20ng/mL, AUDIT ≥ 8 and binge drinking (≥6 standard drinks per drinking occasion in the previous month from TLFB) were all strongly associated with older age, low education, smoking, and HSV2. Illicit drug use prevalence was 5.2% and was associated with older age, low education, being single, and smoking. CONCLUSION: Levels of alcohol misuse were high among young people in fishing communities and associated with HSV2, a proxy for risky sexual behaviour. Alcohol and illicit drug harm reduction services and HIV prevention programs in Uganda should prioritise young fisherfolk