Timing Is Everything: International Variations in Historical Sexual Partnership Concurrency and HIV Prevalence

Higher prevalence of concurrent partnerships is one hypothesis for the severity of the HIV epidemic in the countries of Southern Africa. But measures of the prevalence of concurrency alone do not adequately capture the impact concurrency will have on transmission dynamics. The importance of overlap duration and coital exposure are examined here.We conducted a comparison of data from three studies of sexual behavior carried out in the early 1990s in Uganda, Thailand and the US. Using cumulative concurrency measures, the three countries appeared somewhat similar. Over 50% of both Thai and Ugandan men reported a concurrency within the last three partnerships and over 20% reported a concurrency in the last year, the corresponding rates among US men were nearly 20% for Blacks and Hispanics, and about 10% for other racial/ethnic groups. Concurrency measures that were more sensitive to overlap duration, however, showed large differences. The point prevalence of concurrency on the day of interview was over 10% among Ugandan men compared to 1% for Thai men. Ugandan concurrencies were much longer duration – a median of about two years – than either the Thai (1 day) or US concurrencies (4–9 months across all groups), and involved 5–10 times more coital risk exposure with the less frequent partner. In the US, Blacks and Hispanics reported higher prevalence, longer duration and greater coital exposure than Whites, but were lower than Ugandans on nearly every measure. Together, the differences in the prevalence, duration and coital exposure of concurrent partnerships observed align with the HIV prevalence differentials seen in these populations at the time the data were collected.There were substantial variations in the patterns of concurrent partnerships within and between populations. More long-term overlapping partnerships, with regular coital exposure, were found in populations with greater HIV epidemic severity

Does biological relatedness affect child survival?

Objective: We studied child survival in Rakai, Uganda where many children are fostered out or orphaned. Methods: Biological relatedness is measured as the average of the Wright’s coefficients between each household member and the child. Instrumental variables for fostering include proportion of adult males in household, age and gender of household head. Control variables include SES, religion, polygyny, household size, child age, child birth size, and child HIV status. Results: Presence of both parents in the household increased the odds of survival by 28%. After controlling for the endogeneity of child placement decisions in a multivariate model we found that lower biological relatedness of a child was associated with statistically significant reductions in child survival. The effects of biological relatedness on child survival tend to be stronger for both HIV- and HIV+ children of HIV+ mothers. Conclusions: Reductions in the numbers of close relatives caring for children of HIV+ mothers reduce child survival.AIDS/HIV, child survival, fostering, orphans, Uganda

Perceptions of Adolescent Pregnancy Among Teenage Girls in Rakai, Uganda.

The leading causes of death and disability among Ugandan female adolescents aged 15 to 19 years are pregnancy complications, unsafe abortions, and childbirth. Despite these statistics, our understanding of how girls perceive adolescent pregnancy is limited. This qualitative study explored the social and contextual factors shaping the perceptions of adolescent pregnancy and childbirth among a sample of 12 currently pregnant and 14 never pregnant girls living in the rural Rakai District of Uganda. Interviews were conducted to elicit perceived risk factors for pregnancy, associated community attitudes, and personal opinions on adolescent pregnancy. Findings indicate that notions of adolescent pregnancy are primarily influenced by perceptions of control over getting pregnant and readiness for childbearing. Premarital pregnancy was perceived as negative whereas postmarital pregnancy was regarded as positive. Greater understanding of the individual and contextual factors influencing perceptions can aid in development of salient, culturally appropriate policies and programs to mitigate unintended adolescent pregnancies

Peripheral neuropathy in HIV-infected and uninfected patients in Rakai, Uganda

OBJECTIVE: To determine the prevalence, risk factors, and functional impairment associated with peripheral neuropathy in a prospective cohort of adults in rural Uganda. METHODS: Eight hundred participants (400 HIV- and 400 antiretroviral-naive HIV+) in the Rakai Community Cohort Study underwent detailed neurologic evaluations including assessment of neuropathy symptoms, functional measures (Patient Assessment of Own Functioning Inventory and Karnofsky Performance Status scores), and neurologic evaluation by a trained medical officer. Neuropathy was defined as ≥1 subjective symptom and ≥1 sign of neuropathy on examination. Neuropathy risk factors were assessed using log binomial regression. RESULTS: Fifty-three percent of participants were men, with a mean (SD) age of 35 (8) years. Neuropathy was present in 13% of the cohort and was more common in HIV+ vs HIV- participants (19% vs 7%, p < 0.001). Older age (relative risk [RR] 1.04, 95% confidence interval [CI] 1.02-1.06), female sex (RR 1.49, 95% CI 1.04-2.15), HIV infection (RR 2.82, 95% CI 1.86-4.28), tobacco use (RR 1.59, 95% CI 1.02-2.48), and prior neurotoxic medication use (RR 2.08, 95% CI 1.07-4.05) were significant predictors of neuropathy in the overall cohort. Only older age was associated with neuropathy risk in the HIV+ (RR 1.03, 95% CI 1.01-1.05) and HIV- (RR 1.06, 95% CI 1.02-1.10) cohorts. Neuropathy was associated with impaired functional status on multiple measures across all participant groups. CONCLUSIONS: Peripheral neuropathy is relatively common and associated with impaired functional status among adults in rural Uganda. Older age, female sex, and HIV infection significantly increase the risk of neuropathy. Neuropathy may be an underrecognized but important condition in rural Uganda and warrants further study

Uganda’s HIV Prevention Success: The Role of Sexual Behavior Change and the National Response. Commentary on Green et al. (2006)

The paper by Green et al. (vol. 10, this issue

HIV infection in rural households, Rakai district, Uganda

The Rakai Project conducted a population-based cohort study in rural Rakai District, Uganda, a region with high rates of HIV prevalence. The cohort population described here was followed between 1990 and 1992 and consisted of all residents aged 15 years or more living in 1945 households in 31 community clusters. A detailed census was conducted at baseline in every study household. Census data were updated annually, and all inter-survey deaths, births, and migrations were recorded. Immediately following each annual census, all consenting adults were administered a socio-demographic, behavioural and health survey, and provided a blood sample for HIV testing. HIV prevalence in the study population was high, with 19.1 per cent of adults aged 15 or more years being HIV-positive. By household, the burden of infection was even more pronounced: 31.3 per cent of households had at least one HIV-infected resident adult. Twenty seven per cent of heads of households were also HIV-positive. Overall, 3.6 per cent of study households experienced the death of an HIV-positive adult per year, and another two per cent lost an HIV-negative adult. HIV-related adult mortality had substantially more effect on subsequent household dependency ratio and on material possessions than the death of an HIV-uninfected adult, in part because the former deaths were concentrated in adults aged 15-49, the most economically active age group in this rural population. Just under 15 per cent of children aged 14 years or less had lost one or both parents, and approximately half of these parental losses are estimated to be associated with HIV infection. Nineteen per cent of study households reported at least one resident child who had lost one or both parents. Although there is evidence that loss of a parent is associated with lower school attendance, orphans overall continue to be absorbed by community households which are headed by adults. HIV infection is very prevalent among adults in Rakai and the associated mortality imposes a substantial social and economic burden on households in the district

Associations between HIV Antiretroviral Therapy and the Prevalence and Incidence of Pregnancy in Rakai, Uganda

Background. Use of antiretroviral therapy (ART) may be associated with higher pregnancy rates. Methods. The prevalence and incidence of pregnancy was assessed in 712 HIV+ pre-ART women of reproductive age (WRA) (15–45) and 244 HIV+ WRA initiating ART. Prevalence rate ratios (PRR), incidence rate ratios (IRR), and 95% confidence interval (CI) were assessed. Results. The incidence of pregnancy was 13.1/100 py among women in pre-ART care compared to 24.6/100 py among women on ART (IRR = 0.54; 95% CI 0.37, 0.81, p < 0.0017). The prevalence of pregnancy at ART initiation was 12.0% with CD4 counts 100–250 compared with 3.2% with CD4 <100 (PRR = 3.24, CI 1.51–6.93), and the incidence of pregnancy while on ART was highest in women with a good immunologic response. Desire for more children was a very important factor in fertility. Conclusion. ART was associated with increased pregnancy rates in HIV+ women, particularly those with higher CD4 counts and good immunologic response to therapy, suggesting a need to strengthen reproductive health services for both women and their partners that could address their fertility decisions/intentions particularly after ART initiation

Process evaluation of the SHARE intervention for preventing intimate partner violence and HIV infection in Rakai, Uganda.

The Safe Homes And Respect for Everyone (SHARE) intervention introduced an intimate partner violence (IPV) prevention approach into Rakai Health Sciences Program, an established HIV research and service organization in Uganda. A trial found exposure to SHARE was associated with reductions in IPV and HIV incidence. This mixed methods process evaluation was conducted between August 2007 and December 2009, with people living in SHARE intervention clusters, to assess awareness about/participation in SHARE, motivators and barriers to involvement, and perceptions of how SHARE contributed to behavior change. Surveys were conducted with 1407 Rakai Community Cohort Study participants. Qualitative interviews were conducted with 20 key informants. Most (77%) were aware of SHARE, among whom 73% participated in intervention activities. Two-thirds of those who participated in SHARE felt it influenced behavior change related to IPV. While some felt confident to take part in new IPV-focused activities of a well-established program, others were suspicious of SHARE's motivations, implying awareness raising is critical. Many activities appealed to the majority (e.g., community drama) while interest in some activities was limited to men (e.g., film shows), suggesting multiple intervention components is ideal for wide-reaching programming. The SHARE model offers a promising, acceptable approach for integrating IPV prevention into HIV and other established health programs in sub-Saharan Africa

Intimate partner violence as a predictor of marital disruption in rural Rakai, Uganda: a longitudinal study.

ObjectivesWe assessed the association between intimate partner violence (IPV) and union disruption (divorce or separation) in the rural Ugandan setting of Rakai District.MethodsWe analyzed longitudinal data collected from April 1999 to June 2006, from 6834 women (15-49 years) living in 50 communities in Rakai. Participants were either officially married, traditionally married or in a consensual union during one or more surveys and completed at least one follow-up survey. The primary outcome was union disruption through divorce or separation from the primary sexual partner.ResultsPast year IPV ranged from 6.49 % (severe physical abuse) to 31.99 % (emotional abuse). Severe physical IPV was significantly associated with divorce/separation, after adjusting for other covariates (aOR = 1.80, 95 % CI 1.01-3.22). Another predictor of union disruption was a woman having two or more sexual partners in the past year (aOR = 8.42, 95 % CI 5.97-11.89). Factors protecting against divorce/separation included an increasing number of co-resident biological children and longer duration of union.ConclusionsIPV, particularly severe physical abuse, is an important risk factor for union disruption. Marital counseling, health education and interventions should address the role of IPV on the wellbeing of women and the stability of couples in Uganda