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Nabukalu D, Calazans JA, Marston M, Calvert C, Nakawooya H, Nansereko B, Sekubugu R, Nakigozi G, Serwadda D, Sewankambo N, Kigozi G, Gray RH, Nalugoda F, Makumbi F, Lutalo T, Todd J. Estimation of cause-specific mortality in Rakai, Uganda, using verbal autopsy 1999-2019. Glob Health Action 2024; 17:2338635. [PMID: 38717826 PMCID: PMC11080674 DOI: 10.1080/16549716.2024.2338635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/31/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND There are scant data on the causes of adult deaths in sub-Saharan Africa. We estimated the level and trends in adult mortality, overall and by different causes, in rural Rakai, Uganda, by age, sex, and HIV status. OBJECTIVES To estimate and analyse adult cause-specific mortality trends in Rakai, Uganda. METHODOLOGY Mortality information by cause, age, sex, and HIV status was recorded in the Rakai Community Cohort study using verbal autopsy interviews, HIV serosurveys, and residency data. We estimated the average number of years lived in adulthood. Using demographic decomposition methods, we estimated the contribution of each cause of death to adult mortality based on the average number of years lived in adulthood. RESULTS Between 1999 and 2019, 63082 adults (15-60 years) were censused, with 1670 deaths registered. Of these, 1656 (99.2%) had completed cause of death data from verbal autopsy. The crude adult death rate was 5.60 (95% confidence interval (CI): 5.33-5.87) per 1000 person-years of observation (pyo). The crude death rate decreased from 11.41 (95% CI: 10.61-12.28) to 3.27 (95% CI: 2.89-3.68) per 1000 pyo between 1999-2004 and 2015-2019. The average number of years lived in adulthood increased in people living with HIV and decreased in HIV-negative individuals between 2000 and 2019. Communicable diseases, primarily HIV and Malaria, had the biggest decreases, which improved the average number of years lived by approximately extra 12 years of life in females and 6 years in males. There were increases in deaths due to non-communicable diseases and external causes, which reduced the average number of years lived in adulthood by 2.0 years and 1.5 years in females and males, respectively. CONCLUSION There has been a significant decline in overall mortality from 1999 to 2019, with the greatest decline seen in people living with HIV since the availability of antiretroviral therapy in 2004. By 2020, the predominant causes of death among females were non-communicable diseases, with external causes of death dominating in males.
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Affiliation(s)
- Dorean Nabukalu
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Júlia Almeida Calazans
- Centre for Demographic Studies (CED), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Milly Marston
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Clara Calvert
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Robert Sekubugu
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | | | - David Serwadda
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Nelson Sewankambo
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- College of Health Sciences, Makerere University School of Medicine, Kampala, Uganda
| | - Godfrey Kigozi
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | - Ronald H Gray
- Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Fred Nalugoda
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | - Fredrick Makumbi
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Tom Lutalo
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Jim Todd
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Kim S, Kigozi G, Martin MA, Galiwango RM, Quinn TC, Redd AD, Ssekubugu R, Bonsall D, Ssemwanga D, Rambaut A, Herbeck JT, Reynolds SJ, Foley B, Abeler-Dörner L, Fraser C, Ratmann O, Kagaayi J, Laeyendecker O, Grabowski MK. Increasing intra- and inter-subtype HIV diversity despite declining HIV incidence in Uganda. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.14.24303990. [PMID: 38558994 PMCID: PMC10980117 DOI: 10.1101/2024.03.14.24303990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
HIV incidence has been declining in Africa with scale-up of HIV interventions. However, there is limited data on HIV evolutionary trends in African populations with waning epidemics. We evaluated changes in HIV viral diversity and genetic divergence in southern Uganda over a twenty-five-year period spanning the introduction and scale-up of HIV prevention and treatment programs using HIV sequence and survey data from the Rakai Community Cohort Study, an open longitudinal population-based HIV surveillance cohort. Gag (p24) and env (gp41) HIV data were generated from persons living with HIV (PLHIV) in 31 inland semi-urban trading and agrarian communities (1994 to 2018) and four hyperendemic Lake Victoria fishing communities (2011 to 2018) under continuous surveillance. HIV subtype was assigned using the Recombination Identification Program with phylogenetic confirmation. Inter-subtype diversity was estimated using the Shannon diversity index and intra-subtype diversity with the nucleotide diversity and pairwise TN93 genetic distance. Genetic divergence was measured using root-to-tip distance and pairwise TN93 genetic distance analyses. Evolutionary dynamics were assessed among demographic and behavioral sub-groups, including by migration status. 9,931 HIV sequences were available from 4,999 PLHIV, including 3,060 and 1,939 persons residing in inland and fishing communities, respectively. In inland communities, subtype A1 viruses proportionately increased from 14.3% in 1995 to 25.9% in 2017 (p<0.001), while those of subtype D declined from 73.2% in 1995 to 28.2% in 2017 (p<0.001). The proportion of viruses classified as recombinants significantly increased by more than four-fold. Inter-subtype HIV diversity has generally increased. While p24 intra-subtype genetic diversity and divergence leveled off after 2014, diversity and divergence of gp41 increased through 2017. Inter- and intra-subtype viral diversity increased across all population sub-groups, including among individuals with no recent migration history or extra-community sexual partners. This study provides insights into population-level HIV evolutionary dynamics in declining African HIV epidemics following the scale-up of HIV prevention and treatment programs. Continued molecular surveillance may provide a better understanding of the dynamics driving population HIV evolution and yield important insights for epidemic control and vaccine development.
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Affiliation(s)
- Seungwon Kim
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Michael A. Martin
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Thomas C. Quinn
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - David Bonsall
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Deogratius Ssemwanga
- Medical Research Council (MRC)/Uganda Virus Research Institute (UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- Uganda Virus Research Institute, Entebbe, Uganda
| | - Andrew Rambaut
- Institute of Evolutionary Biology, University of Edinburgh, Edinburgh, UK
| | - Joshua T. Herbeck
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Steven J. Reynolds
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Brian Foley
- Theoretical Biology and Biophysics, Los Alamos National Laboratory, Los Alamos, New Mexico, USA
| | - Lucie Abeler-Dörner
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Christophe Fraser
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Oliver Ratmann
- Department of Mathematics, Imperial College London, London, England, United Kingdom
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Oliver Laeyendecker
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M. Kate Grabowski
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Wu D, Low N, Hawkes SJ. Understanding the factors affecting global political priority for controlling sexually transmitted infections: a qualitative policy analysis. BMJ Glob Health 2024; 9:e014237. [PMID: 38262682 PMCID: PMC10823925 DOI: 10.1136/bmjgh-2023-014237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/01/2024] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION Sexually transmitted infections (STIs) are a significant public health challenge, but there is a perceived lack of political priority in addressing STIs as a global health issue. Our study aimed to understand the determinants of global political priority for STIs since the 1980s and to discern implications for future prioritisation. METHODS Through semistructured interviews from July 2021 to February 2022, we engaged 20 key stakeholders (8 women, 12 men) from academia, United Nations agencies, international non-governmental organisations, philanthropic organisations and national public health agencies. A published policy framework was employed for thematic analysis, and findings triangulated with relevant literature and policy documents. We examined issue characteristics, prevailing ideas, actor power dynamics and political contexts. RESULTS A contrast in perspectives before and after the year 2000 emerged. STI control was high on the global health agenda during the late 1980s and 1990s, as a means to control HIV. A strong policy community agreed on evidence about the high burden of STIs and that STI management could reduce the incidence of HIV. The level of importance decreased when further research evidence did not find an impact of STI control interventions on HIV incidence. Since 2000, cohesion in the STI community has decreased. New framing for broad STI control has not emerged. Interventions that have been funded, such as human papillomavirus vaccination and congenital syphilis elimination have been framed as cancer control or improving newborn survival, rather than as STI control. CONCLUSION Globally, the perceived decline in STI control priority might stem from discrepancies between investment choices and experts' views on STI priorities. Addressing STIs requires understanding the intertwined nature of politics and empirical evidence in resource allocation. The ascent of universal health coverage presents an opportunity for integrated STI strategies but high-quality care, sustainable funding and strategic coordination are essential.
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Affiliation(s)
- Dadong Wu
- Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, China
- Center for World Health Organization Studies, Southern Medical University, Guangzhou, China
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sarah J Hawkes
- Institute for Global Health, University College London, London, UK
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Miller AP, Pitpitan EV, Kiene SM, Raj A, Jain S, Zúñiga ML, Nabulaku D, Nalugoda F, Ssekubugu R, Nantume B, Kigozi G, Sewankambo NK, Kagaayi J, Reynolds SJ, Wawer M, Wagman JA. In the era of universal test and treat in Uganda, recent intimate partner violence is not associated with subsequent ART use or viral suppression. AIDS Care 2023; 35:1291-1298. [PMID: 37170392 PMCID: PMC10524228 DOI: 10.1080/09540121.2023.2206092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/17/2023] [Indexed: 05/13/2023]
Abstract
Intimate partner violence (IPV) has been associated with delays throughout the HIV care continuum. This study explored prospective associations between experiences of past-year IPV and two HIV care outcomes in the context of current universal test and treat guidelines using two consecutive rounds of an ongoing HIV surveillance study conducted in the Rakai region of Uganda. Longitudinal logistic regression models examined associations between IPV, use of antiretroviral therapy (ART) and viral load suppression (VS), adjusting for outcome variables at baseline. To address differences in ART retention by IPV, propensity scores were used to create inverse-probability-of-treatment-and-censoring-weighted (IPTCW) models. At baseline, of 1923 women with HIV (WWH), 34.6%, 26.5%, 13.5% reported past-year verbal, physical and sexual IPV; a lower proportion of persons who experienced physical IPV (79.4%) were VS than those who did not (84.3%; p = 0.01). The proportion VS at baseline also significantly differed by exposure to verbal IPV (p = 0.03). However, in adjusted longitudinal models, IPV was not associated with lower odds of ART use or VS at follow-up. Among WWH in the Rakai region, IPV does not appear to be a barrier to subsequent ART use or VS. However, given the prevalence of IPV in this population, interventions are needed.
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Affiliation(s)
- Amanda P Miller
- Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
- San Diego State University School of Public Health, San Diego, CA, USA
| | - Eileen V Pitpitan
- San Diego State University School of Social Work, San Diego, CA, USA
| | - Susan M Kiene
- San Diego State University School of Public Health, San Diego, CA, USA
| | - Anita Raj
- Department of Medicine, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Sonia Jain
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | | | | | | | | | | | | | - Nelson K Sewankambo
- Rakai Health Sciences Program, Entebbe, Uganda
- Makerere University School of Medicine, Kampala, Uganda
| | | | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maria Wawer
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer A Wagman
- Department of Community Health Sciences, University of California, Los Angeles Fielding School of Public Health, Los Angeles, CA, USA
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Nabunya P, Sensoy Bahar O, Neilands TB, Nakasujja N, Namatovu P, Namuwonge F, Mwebembezi A, Ssewamala FM. Bridges-Round 2: A study protocol to examine the longitudinal HIV risk prevention and care continuum outcomes among orphaned youth transitioning to young adulthood. PLoS One 2023; 18:e0284572. [PMID: 37163564 PMCID: PMC10171655 DOI: 10.1371/journal.pone.0284572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 04/01/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Youth orphaned by HIV in sub-Saharan Africa experience immense hardships including social disadvantage, adverse childhood events and limited economic prospects. These adversities disrupt the normative developmental milestones and can gravely compromise their health and emotional wellbeing. The Bridges to the Future study (2012-2018) prospectively followed 1,383 adolescents, between 10-16 years, to evaluate the efficacy and cost-effectiveness of a family-based economic empowerment intervention comprising of child development accounts, financial literacy training, family income generating activities and peer mentorship. Study findings show efficacy of this contextually-driven intervention significantly improving mental health, school retention and performance and sexual health. However, critical questions, such as those related to the longitudinal impact of economic empowerment on HIV prevention and engagement in care remain. This paper presents a protocol for the follow-up phase titled, Bridges Round 2. METHODS The Original Bridges study participants will be tracked for an additional four years (2022-2026) to examine the longitudinal developmental and behavioral health outcomes and potential mechanisms of the effect of protective health behaviors of the Bridges cohort. The study will include a new qualitative component to examine participants' experiences with the intervention, the use of biomedical data to provide the most precise results of the highly relevant, but currently unknown sexual health outcomes among study participants, as well as a cost-benefit analysis to inform policy and scale-up. DISCUSSION Study findings may contribute to the scientific knowledge for low-resource communities on the potential value of providing modest economic resources to vulnerable boys and girls during childhood and early adolescence and how these resources may offer long-term protection against known HIV risks, poor mental health functioning and improve treatment among the HIV treatment care continuum.
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Affiliation(s)
- Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development (ICHAD), Uganda Field Office, Masaka, Uganda
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development (ICHAD), Uganda Field Office, Masaka, Uganda
| | - Torsten B. Neilands
- Department of Medicine, Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, CA, United States of America
| | - Noeline Nakasujja
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Phionah Namatovu
- International Center for Child Health and Development (ICHAD), Uganda Field Office, Masaka, Uganda
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development (ICHAD), Uganda Field Office, Masaka, Uganda
| | | | - Fred M. Ssewamala
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development (ICHAD), Uganda Field Office, Masaka, Uganda
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Park E, Wolfe SJ, Nalugoda F, Stark L, Nakyanjo N, Ddaaki W, Ssekyewa C, Wagman JA. Examining Masculinities to Inform Gender-Transformative Violence Prevention Programs: Qualitative Findings From Rakai, Uganda. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00137. [PMID: 35044929 PMCID: PMC8885339 DOI: 10.9745/ghsp-d-21-00137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/22/2021] [Indexed: 11/15/2022]
Abstract
While the majority of men in rural Uganda upheld 2 conflicting masculine norms that are conceptualized as reputation (“cool man”) and respectability (“responsible man”), men in younger age groups who participated in a gender-transformative program expressed gender-equitable beliefs and attitudes. Introduction: Evidence-based programs are needed to engage men and boys that encourage the transformation of concepts of masculinity that uphold patterns of intimate partner violence (IPV). This study explores the constructs of masculinity and male gender norms surrounding sexual attitudes and IPV among men and boys living in Rakai, Uganda. Methods: Between April and August 2017, we conducted 38 interviews and 5 focus group discussions with men and boys aged 15 to 49 years and 4 focus groups with key stakeholders to understand how male use of violence is influenced by personal, community, and society-level concepts of masculinity. We adapted 2 constructs of masculinities, reputation and respectability, in the analysis to examine masculinities in relation to IPV in the rural Ugandan setting. Results: Findings suggest men and boys upheld 2 types of masculinities: respectability versus reputation. Masculine attributes related to respectability (referred to as “responsible men”) included having a job, house, wife, and many children and taking care of family. Masculine attributes related to reputation (referred to as “cool men”) included having sexual prowess, multiple sexual partners, and the resources to buy nice things. Both masculine norms were used to justify dominance over women and IPV. The divergence of masculinity was observed among youth and young adults who participated in a gender-transformative program, suggesting the effectiveness of the program. Discussion: The gender-transformative approach should provide men and boys a chance to reflect on dynamic, often conflicting, images of a man and should empower individuals to renegotiate and reconceptualize masculine norms. This critical reflection on masculinity, which resonates with men and boys, needs to be included when engaging men within HIV and IPV prevention programs.
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Affiliation(s)
- Eunhee Park
- Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA.
| | | | | | - Lindsay Stark
- Brown School, Washington University, St. Louis, MO, USA
| | | | | | | | - Jennifer A Wagman
- Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
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Young CR, Gill E, Bwana M, Muyindike W, Hock RS, Pratt MC, Owembabazi M, Tukwasibwe D, Najjuma A, Kalyebara P, Natukunda S, Kaida A, Matthews LT. Client and Provider Experiences in Uganda Suggest Demand for and Highlight the Importance of Addressing HIV Stigma and Gender Norms Within Safer Conception Care. AIDS Behav 2022; 26:76-87. [PMID: 34152530 PMCID: PMC8688584 DOI: 10.1007/s10461-021-03343-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 01/03/2023]
Abstract
Safer conception counseling supports HIV-serodifferent couples to meet reproductive goals while minimizing HIV transmission risk, but has not been integrated into routine HIV care. We piloted a novel safer conception program in an established public-sector HIV clinic in Uganda to inform future implementation. In-depth interviews and counseling observations explored experiences of program clients and healthcare providers to assess program acceptability, appropriateness, and feasibility. Fifteen index clients (8 women, 7 men), 10 pregnancy partners, and 10 providers completed interviews; 15 participants were living with HIV. Ten observations were conducted. We identified four emergent themes: (1) High demand for safer conception services integrated within routine HIV care, (2) Evolving messages of antiretroviral treatment as prevention contribute to confusion about HIV prevention options, (3) Gender and sexual relationship power inequities shape safer conception care, and (4) HIV-related stigma impacts safer conception care uptake. These findings confirm the need for safer conception care and suggest important implementation considerations.
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Affiliation(s)
- Cynthia R Young
- Division of Infectious Diseases, University of Kentucky, Lexington, KY
| | - Elizabeth Gill
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Mwebesa Bwana
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda,Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Winnie Muyindike
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda,Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Rebecca S. Hock
- Chester M. Pierce, MD, Division of Global Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Madeline C Pratt
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Moran Owembabazi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Deogratius Tukwasibwe
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Paul Kalyebara
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Silvia Natukunda
- Chester M. Pierce, MD, Division of Global Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Lynn T. Matthews
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL,Corresponding author:
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8
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Miller AP, Pitpitan EV, Kiene SM, Raj A, Jain S, Zúñiga ML, Nabulaku D, Nalugoda F, Ssekubugu R, Nantume B, Kigozi G, Sewankambo NK, Kagaayi J, Reynolds SJ, Grabowski K, Wawer M, Wagman JA. Alcohol use and alcohol-related consequences are associated with not being virally suppressed among persons living with HIV in the Rakai region of Uganda. Drug Alcohol Depend 2021; 228:109005. [PMID: 34600249 PMCID: PMC8628865 DOI: 10.1016/j.drugalcdep.2021.109005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Alcohol use is common among persons living with HIV (PWH) in Uganda and associated with poor HIV care outcomes; findings regarding the relationship between alcohol use and viral suppression (VS) have been inconclusive. METHODS Data from two rounds (2017-2020) of the Rakai Community Cohort Study, an open population-based cohort study in the Rakai region, Uganda, were analyzed. Two alcohol exposures were explored: past year alcohol use and alcohol-related consequences. Multivariable models (GEE) were used to estimate associations between alcohol exposures and VS for the overall sample and stratified by sex, adjusting for repeated measurement. Causal mediation by ART use was explored. RESULTS Over half (55 %) of participants (n = 3823 PWH) reported alcohol use at baseline; 37.8 % of those reporting alcohol use reported alcohol-related consequences. ART use and VS at baseline significantly differed by alcohol use with person reporting alcohol use being less likely to be on ART or VS. Alcohol use was significantly associated with decreased odds of VS among women but not men (adj. OR 0.72 95 % CI 0.58-0.89, p = 0.0031). However, among males who use alcohol, experiencing alcohol-related consequences was significantly associated with decreased odds of VS (adj. OR 0.69 95 % CI 0.54-0.88, p = 0.0034). The relationships between both alcohol exposures and VS were not significant in models restricted to persons on ART. CONCLUSIONS We provide sex-stratified estimates of associations between two alcohol measures and VS in the context of current HIV treatment guidelines. This study confirms that alcohol use is adversely associated with VS but ART use mediates this pathway, suggesting that initiation and retention on ART are critical steps to addressing alcohol-related disparities in VS.
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Affiliation(s)
- Amanda P Miller
- University of California, San Diego, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla, CA, 92093, United States; San Diego State University School of Public Health, San Diego, CA, United States.
| | - Eileen V Pitpitan
- San Diego State University School of Social Work, San Diego, CA, United States
| | - Susan M Kiene
- San Diego State University School of Public Health, San Diego, CA, United States
| | - Anita Raj
- University of California, San Diego School of Medicine, Division of Infectious Diseases and Global Public Health, La Jolla, CA, 92082, United States
| | - Sonia Jain
- University of California, San Diego, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla, CA, 92093, United States
| | - María Luisa Zúñiga
- San Diego State University School of Social Work, San Diego, CA, United States
| | | | | | | | | | | | - Nelson K Sewankambo
- Rakai Health Sciences Program, Entebbe, Uganda; Makerere University School of Medicine, Kampala, Uganda
| | | | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda; Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, United States; Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Kate Grabowski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, United States; Department of Pathology, Johns Hopkins School of Medicine, Baltimore, United States
| | - Maria Wawer
- Rakai Health Sciences Program, Entebbe, Uganda; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, United States; Department of Medicine, Johns Hopkins School of Medicine, United States
| | - Jennifer A Wagman
- University of California, Los Angeles Fielding School of Public Health, Department of Community Health Sciences, Los Angeles, CA, United States
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9
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Transactional Sex, Alcohol Use and Intimate Partner Violence Against Women in the Rakai Region of Uganda. AIDS Behav 2021; 25:1144-1158. [PMID: 33128109 DOI: 10.1007/s10461-020-03069-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 01/30/2023]
Abstract
Transactional sex (TS) is prevalent in sub-Saharan Africa. Women's engagement in TS is linked with HIV infection; little is known about the relationship between TS, intimate partner violence (IPV) and alcohol use-established HIV risk behaviors. Using modified Poisson regression, we assessed associations between TS and physical, verbal and sexual IPV among 8248 women (15-49 years) who participated in the Rakai Community Cohort Study across forty communities in Uganda. An interaction term assessed moderation between alcohol use and TS and no significant interaction effects were found. In adjusted analysis, alcohol use and TS were significantly associated with all forms of IPV. In stratified analysis, TS was only associated with IPV in agrarian communities; alcohol use was not associated with physical IPV in trade communities or sexual IPV in trade and fishing communities. Identifying differences in IPV risk factors by community type is critical for the development of tailored interventions.
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10
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Njau B, Damian DJ, Abdullahi L, Boulle A, Mathews C. The effects of HIV self-testing on the uptake of HIV testing, linkage to antiretroviral treatment and social harms among adults in Africa: A systematic review and meta-analysis. PLoS One 2021; 16:e0245498. [PMID: 33503050 PMCID: PMC7840047 DOI: 10.1371/journal.pone.0245498] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/31/2020] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION HIV infection is still a global public health problem. More than 75% of HIV-infected people are in Africa, and up to 54% are unaware of their HIV status, limiting access to antiretroviral treatment. CONTEXT AND PURPOSE OF THE STUDY This review aimed to determine whether HIV self-testing (HIVST) increases the uptake of testing, the yield of new HIV-positive diagnoses, and the linkage to antiretroviral treatment, and social harms among adults in Africa. METHODS PubMed, The Cochrane Central Register of Controlled Trials (CENTRAL), Pan African Clinical Trials Registry, The Cochrane Database of Systematic Reviews (CDSR), Databases of Abstracts of Reviews of Effectiveness (DARE), Social Sciences Citation Index, Web of Science and African Index Medicus databases were searched from 1998 to 2019 (updated in December 2019). Eligible trials employed randomized controlled trials (RCTs), before/after studies, and interrupted time series design comparing HIVST to standard HIV testing services or comparing different approaches to HIVST among adults living in Africa were systematically sought. RESULTS After searching 2,617 citations eleven trials were identified including 59,119 participants from four (4) African countries. Meta-analysis of seven trials showed a significant increase in the uptake of HIVST compared to standard HIV testing services: Both fixed-effects (Rate Ratio (RR) = 2.64, 95% CI: 2.51 to 2.79), and random-effects (RR) = 3.10, 95% CI: 1.80 to 5.37, and a significant increase in the uptake of couples' HIVST (RR = 2.50, 95% CI: 2.29 to 2.73 in fixed-effects models; and RR = 2.64, 95% CI: 2.01 to 3.49 in random-effects model). A decrease in linkage to care and ART was observed in HIVST compared to standard HIV testing services (RR = 0.88, 95% CI: 0.88 to 0.95 in fixed-effects models; and RR = 0.78, 95% CI: 0. 56 to 1.08 in random-effects models). Six RCTs measured social harms, with a total of ten reported cases related to HIVST. One RCT comparing two approaches to HIVST showed that offering home-based HIVST with optional home-initiation of antiretroviral treatment increased the reporting of a positive HIV test result (RR: 1.86; 95% CI: 1.16 to 2.98), and linkage to antiretroviral treatment (RR: 2.94; 95% CI: 2.10 to 4.12), compared with facility-based linkage to antiretroviral treatment. CONCLUSIONS HIVST has the potential to increase the uptake of HIV testing compared to standard HIV testing services. Offering HIVST with optional home initiation of HIV care compared to HIVST with facility-based HIV care increases HIV positivity and linkage to antiretroviral treatment. Reported incidences of intimate partner violence related to HIVST were rare. Future research should focus on the potential of HIVST to reach first-time testers, the effect of using different approaches to HIVST, and strategies for linkage to HIV services. SYSTEMATIC REVIEW REGISTRATION This systematic review was prospectively registered on the Prospero International Prospective Register of Systematic Review (CRD42015023935).
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Affiliation(s)
- Bernard Njau
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Damian J. Damian
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Leila Abdullahi
- Save the Children International SCI, Somalia/Somaliland Country Office, Nairobi, Kenya
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Mathews
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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11
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Prevalence and correlates of men's and women's alcohol use in agrarian, trading and fishing communities in Rakai, Uganda. PLoS One 2020; 15:e0240796. [PMID: 33125397 PMCID: PMC7598464 DOI: 10.1371/journal.pone.0240796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 10/03/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Uganda has one of the highest rates of alcohol use in sub-Saharan Africa but prevalence and correlates of drinking are undocumented in the Rakai region, one of the earliest epicenters of the HIV/AIDS epidemic in East Africa. METHODS We analyzed cross-sectional data from 18,700 persons (8,690 men, 10,010 women) aged 15-49 years, living in agrarian, trading and fishing communities and participating in the Rakai Community Cohort Study (RCCS) between March 2015 and September 2016. Logistic regression models assessed associations between past year alcohol use and sociodemographic characteristics, other drug use and HIV status, controlling for age, religion, education, occupation, marital status, and household socioeconomic status. RESULTS Past year alcohol prevalence was 45%. Odds of drinking were significantly higher in men (versus women) and fishing communities (versus agrarian areas). Odds of drinking increased with age, previous (versus current) marriage and past year drug use. By occupation, highest odds of drinking were among fishermen and (in women) bar/restaurant workers. Alcohol-related consequences were more commonly reported by male (vs. females) drinkers, among whom up to 35% reported alcohol dependence symptoms (e.g., unsteady gait). HIV status was strongly associated with alcohol use in unadjusted but not adjusted models. CONCLUSIONS Alcohol use differed by gender, community type and occupation. Being male, living in a fishing community and working as a fisherman or restaurant/bar worker (among women) were associated with higher odds of drinking. Alcohol reduction programs should be implemented in Uganda's fishing communities and among people working in high risk occupations (e.g., fishermen and restaurant/bar workers).
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12
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Tibuakuu M, Jjingo C, Kirk GD, Thomas DL, Gray R, Ssempijja V, Nalugoda F, Serwadda D, Ocama P, Opio CK, Kleiner DE, Quinn TC, Reynolds SJ. Elevated liver stiffness without histological evidence of liver fibrosis in rural Ugandans. J Viral Hepat 2020; 27:1022-1031. [PMID: 32388879 PMCID: PMC8919060 DOI: 10.1111/jvh.13320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/20/2020] [Accepted: 04/12/2020] [Indexed: 12/09/2022]
Abstract
Liver fibrosis may be assessed noninvasively with transient electrography (TE). Data on the performance of TE for detecting liver fibrosis in sub-Saharan Africa are limited. We evaluated the diagnostic accuracy of TE by performing liver biopsies on persons with liver fibrosis indicated by TE. We enrolled HIV-infected and HIV-uninfected participants with TE scores consistent with at least minimal disease (liver stiffness measurement [LSM]≥7.1 kPa). Biopsies were performed and staged using the Ishak scoring system. A concordant result was defined using accepted thresholds for significant fibrosis by TE (LSM ≥ 9.3 kPa) and liver biopsy (Ishak score ≥ 2). We used modified Poisson regression methods to quantify the univariate and adjusted prevalence risk ratios (PRR) of the association between covariates and the concordance status of TE and liver biopsy in defining the presence of liver fibrosis. Of 131 participants with valid liver biopsy and TE data, only 5 participants (3.8%) had Ishak score ≥ 2 of whom 4 had LSM ≥ 9.3 kPa (sensitivity = 80%); of the 126 (96.2%) with Ishak score < 2, 76 had LSM < 9.3 kPa (specificity = 61%). In multivariable analysis, discordance was associated with female gender (adjPRR = 1.80, 95%CI 1.1-2.9; P = .019), herbal medicine use (adjPRR 1.64, 95% CI = 1.0-2.5; P = .022), exposure to lake or river water (adjPRR 2.05, 95% CI = 1.1-3.7; P = .016), and current smoking (adjPRR 1.72, 95%CI 1.0-2.9; P = .045). These data suggest that TE among rural Ugandans has low specificity for detection of histologically confirmed liver fibrosis. Caution should be exercised when using this tool to confirm significant liver fibrosis.
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Affiliation(s)
- Martin Tibuakuu
- Department of Medicine, St. Luke’s Hospital, Chesterfield, Missouri
| | - Caroline Jjingo
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Gregory Dale Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David Lee Thomas
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ronald Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Rakai Health Sciences Program, Entebbe, Uganda
| | - Victor Ssempijja
- Clinical Research Directorate/Clinical Monitoring Research Program, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, Maryland
| | | | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda,School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ponsiano Ocama
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - Thomas Charles Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland,Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven James Reynolds
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland,Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland,Rakai Health Sciences Program, Entebbe, Uganda
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13
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Thoma ME, Brotman RM, Gray RH, Sewankambo NK, Wawer MJ. Risk and protective factors associated with BV chronicity among women in Rakai, Uganda. Sex Transm Infect 2020; 96:380-386. [PMID: 31601641 PMCID: PMC8162762 DOI: 10.1136/sextrans-2019-054145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess risk and protective factors associated with bacterial vaginosis (BV) chronicity ascertained by Nugent score criteria. METHODS A longitudinal cohort study included 255 sexually experienced, postmenarcheal women who provided weekly self-collected vaginal swabs for up to 2 years. Vaginal swabs were scored using Nugent criteria and classified as normal (≤3), intermediate (4-6) and Nugent-BV (≥7). Detailed behavioural/health information were assessed every 6 months. A per-woman longitudinal summary measure of BV chronicity was defined as the percentage of each woman's weekly vaginal assessments scored as Nugent-BV over a 6-month interval. Risk and protective factors associated with BV chronicity were assessed using multiple linear regression with generalised estimating equations. RESULTS Average BV chronicity was 39% across all follow-up periods. After adjustment, factors associated with BV chronicity included baseline Nugent-BV (β=35.3, 95% CI 28.6 to 42.0) compared with normal baseline Nugent scores and use of unprotected water for bathing (ie, rainwater, pond, lake/stream) (β=12.0, 95% CI 3.4 to 20.5) compared with protected water sources (ie, well, tap, borehole). Women had fewer BV occurrences if they were currently pregnant (β=-6.6, 95% CI -12.1 to 1.1), reported consistent condom use (β=-7.7, 95% CI -14.2 to 1.3) or their partner was circumcised (β=-5.8, 95% CI -11.3 to 0.3). CONCLUSIONS Factors associated with higher and lower values of BV chronicity were multifactorial. Notably, higher values of BV chronicity were associated with potentially contaminated bathing water. Future studies should examine the role of waterborne microbial agents in the pathogenesis of BV.
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Affiliation(s)
- Marie E Thoma
- Family Science, University of Maryland School of Public Health, College Park, Maryland, USA
| | - Rebecca M Brotman
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ronald H Gray
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nelson K Sewankambo
- Department of Medicine, Makerere University School of Medicine, College of Helath Sciences, Kampala, Uganda
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Maria J Wawer
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Cell Phones, Sexual Behaviors and HIV Prevalence in Rakai, Uganda: A Cross Sectional Analysis of Longitudinal Data. AIDS Behav 2020; 24:1574-1584. [PMID: 31520238 DOI: 10.1007/s10461-019-02665-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cell phones have increased communication and connection across the globe and particularly in sub-Saharan Africa-with potential consequences for the HIV epidemic. We examined the association among ownership of cell phones, sexual behaviors (number of sexual partners, alcohol use before sex, inconsistent condom use), and HIV prevalence. Data were from four rounds (2010-2016) of the Rakai Community Cohort Study (N = 58,275). Sexual behaviors and HIV prevalence were compared between people who owned a cell phone to people who did not own a cell phone. We stratified analysis by younger (15-24 years) and older (25+ years) age groups and by gender. Using logistic regression and after adjusting for sociodemographic characteristics, we found cell phone ownership was independently associated with increased odds of having two or more sexual partners in the past 12 months across age and gender groups (young men AOR 1.67, 95% CI 1.47-1.90; young women AOR 1.28 95% CI 1.08-1.53; older men AOR 1.54 95% CI 1.41-1.69; older women AOR 1.44 95% CI 1.26-1.65). Interestingly, young men who owned cell phones had decreased odds of using condoms inconsistently (AOR 0.66, 95% CI 0.57-0.75). For young women, cell phone ownership was associated with increased odds of using alcohol before sex (AOR 1.38 95% CI 1.17-1.63) and increased odds of inconsistent condom use (AOR 1.40, 95% 1.17-1.67). After adjusting for sociodemographic characteristics, only young women who owned cell phones had increased odds of being HIV positive (AOR 1.27 95% CI 1.07-1.50). This association was not mediated by sexual behaviors (Adjusted for sociodemographic characteristics and sexual behaviors AOR 1.24, 95% CI 1.05-1.46). While cell phone ownership appears to be associated with increased HIV risk for young women, we also see a potential opportunity for future cell phone-based health interventions.
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15
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Bonnevie E, Kigozi G, Kairania R, Ssemanda JB, Nakyanjo N, Ddaaki WG, Ssekyewa C, Wagman JA. Alcohol use in fishing communities and men's willingness to participate in an alcohol, violence and HIV risk reduction intervention: qualitative findings from Rakai, Uganda. CULTURE, HEALTH & SEXUALITY 2020; 22:275-291. [PMID: 30957702 DOI: 10.1080/13691058.2019.1587002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 02/19/2019] [Indexed: 06/09/2023]
Abstract
Alcohol use, intimate partner violence (IPV) and HIV infection are associated, but few programmes and interventions have addressed their synergistic relationship or been evaluated for effectiveness and acceptability. This is a critical gap in populations with high rates of alcohol use, HIV and IPV, such as Uganda's fishing communities. This study examined drinking norms, barriers and facilitators to engagement in a risk reduction programme, and ideas for tailoring. Results showed that alcohol use is common in fishing villages. While men and women drink, gendered notions of femininity deem alcohol largely unacceptable for women. Plastic sachets of liquor were the most common alcoholic drink. Participants did not understand the definition of 'hazardous drinking', but recognised connections between drinking, violence and sexual risk-taking. The idea of an alcohol, IPV and HIV risk reduction intervention was supported, but barriers need to be addressed, including how best to help those uninterested in reducing their drinking, addressing normalisation of drinking and how best to inform those who truly need intervention. Intervention to people living with HIV around the time of diagnosis and treatment may be warranted. Study findings highlight the potential to integrate alcohol and IPV reduction programmes into an HIV service provision.
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Affiliation(s)
- Erika Bonnevie
- Center on Gender Equity and Health, University of California San Diego, San Diego, CA, USA
| | | | | | | | | | | | | | - Jennifer A Wagman
- Center on Gender Equity and Health, University of California San Diego, San Diego, CA, USA
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16
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Nabukalu D, Reniers G, Risher KA, Blom S, Slaymaker E, Kabudula C, Zaba B, Nalugoda F, Kigozi G, Makumbi F, Serwadda D, Reynolds SJ, Marston M, Eaton JW, Gray R, Wawer M, Sewankambo N, Lutalo T. Population-level adult mortality following the expansion of antiretroviral therapy in Rakai, Uganda. POPULATION STUDIES 2020; 74:93-102. [PMID: 31117928 PMCID: PMC6891159 DOI: 10.1080/00324728.2019.1595099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 02/01/2019] [Indexed: 12/03/2022]
Abstract
There are limited data on the impact of antiretroviral therapy (ART) on population-level adult mortality in sub-Saharan Africa. We analysed data for 2000-14 from the Rakai Community Cohort Study (RCCS) in Uganda, where free ART was scaled up after 2004. Using non-parametric and parametric (Weibull) survival analysis, we estimated trends in average person-years lived between exact ages 15 and 50, per capita life-years lost to HIV, and the mortality hazards of people living with HIV (PLHIV). Between 2000 and 2014, average adult life-years lived before age 50 increased significantly, from 26.4 to 33.5 years for all women and from 28.6 to 33.8 years for all men. As of 2014, life-years lost to HIV had declined significantly, to 1.3 years among women and 0.4 years among men. Following the roll-out of ART, mortality reductions among PLHIV were initially larger in women than men, but this is no longer the case.
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Affiliation(s)
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine
- University of the Witwatersrand
| | | | - Sylvia Blom
- London School of Hygiene and Tropical Medicine
| | | | | | - Basia Zaba
- London School of Hygiene and Tropical Medicine
| | | | | | - Fred Makumbi
- Rakai Health Sciences Program
- Makerere University
| | | | - Steven J Reynolds
- National Institutes of Health
- Johns Hopkins Bloomberg School of Public Health
| | | | | | - Ron Gray
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
| | - Maria Wawer
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
| | | | - Tom Lutalo
- Rakai Health Sciences Program
- Uganda Virus Research Institute
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17
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Kenyon C. To What Extent Should We Rely on Antibiotics to Reduce High Gonococcal Prevalence? Historical Insights from Mass-Meningococcal Campaigns. Pathogens 2020; 9:pathogens9020134. [PMID: 32085650 PMCID: PMC7168587 DOI: 10.3390/pathogens9020134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 12/22/2022] Open
Abstract
In the absence of a vaccine, current antibiotic-dependent efforts to reduce the prevalence of Neisseria gonorrhoeae in high prevalence populations have been shown to result in extremely high levels of antibiotic consumption. No randomized controlled trials have been conducted to validate this strategy and an important concern of this approach is that it may induce antimicrobial resistance. To contribute to this debate, we assessed if mass treatment in the related species, Neisseria meningitidis, was associated with the emergence of antimicrobial resistance. To this end, we conducted a historical review of the effect of mass meningococcal treatment programmes on the prevalence of N. meningitidis and the emergence of antimicrobial resistance. We found evidence that mass treatment programmes were associated with the emergence of antimicrobial resistance.
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Affiliation(s)
- Chris Kenyon
- HIV/STI Unit, Institute of Tropical Medicine, 2000 Antwerp, Belgium; ; Tel.: +32-3-2480796; Fax: +32-3-2480831
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Anzio Road, Observatory 7700, South Africa
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18
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Pregnancy Incidence and Fertility Desires Among Couples by HIV Status in Rakai, Uganda. J Acquir Immune Defic Syndr 2019; 80:494-502. [PMID: 30664614 DOI: 10.1097/qai.0000000000001951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The desire for more children and pregnancy rates are influenced by many relationship dynamics and HIV serostatus of couples. SETTING Rakai Community Cohort Study in Uganda. METHODS Couple data were retrospectively linked from survey rounds between 2007 and 2015 to assess drivers of fertility desire and pregnancy incidence by HIV status (M-F-; M+F+; M-F+; and M+F-). Multivariable modified Poisson regression was used to estimate prevalence ratios of fertility desire, whereas multivariable Poisson regression was used to estimate incidence rate ratios of pregnancy associated with couple characteristics. RESULTS Six thousand six hundred forty-seven couples contributed to 7656 person-years. Approximately 40% of couples (where at least 1 HIV+) desired more children. Unmet need for family planning was evident; couples of medium or low Socioeconomic status and with coresident children had lower fertility desires but higher pregnancy rates. Older age, being in a polygamous union, and having a HIV+ spouse in care were associated with lower fertility desire while having an older male partner was associated with higher fertility desire. Pregnancy incidence was lower with older age, among women using hormonal contraception and condoms, HIV+ concordant couples and couples where the HIV+ spouse was in care while pregnancy incidence were higher among women who desired more children, and serodiscordant couples (M-F+). CONCLUSIONS There are many drivers of fertility desires and pregnancy rates, and HIV does not diminish the desire for more children. Unmet need for family planning was evident and highlighted the need to understand and meet the contraceptive needs of couples.
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Lemos MP, Lazarus E, Isaacs A, Dietrich J, Morgan C, Huang Y, Grove D, Andrasik M, Laher F, Hural J, Chung E, Dragavon J, Puren A, Gulati RK, Coombs R, McElrath MJ, Gray G, Kublin JG. Daily Vaginal Swabs and Mobile Phone Sex Report for Assessing HIV Virion Exposure Prospectively Among a Cohort of Young Sexually Active Women in South Africa (HVTN 915). J Acquir Immune Defic Syndr 2019; 81:e39-e48. [PMID: 31095007 PMCID: PMC6743720 DOI: 10.1097/qai.0000000000002015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Measurements of HIV exposure could help identify subpopulations at highest risk of acquisition and improve the design of HIV prevention efficacy trials and public health interventions. The HVTN 915 study evaluated the feasibility of self-administered vaginal swabs for detection of HIV virions to assess exposure. METHODS Fifty 18- to 25-year-old sexually active HIV-seronegative women using contraception were enrolled in Soweto, South Africa. Participants self-administered daily vaginal swabs and answered sexual behavior questions through mobile phone for 90 days. Clinician-administered vaginal swabs, behavioral questionnaires, HIV diagnostic testing, and counseling were performed at 8 clinic visits. Glycogen concentrations assessed adherence to swabbing. Y-chromosome DNA (Yc-DNA) assessed the accuracy of reported condom use. HIV exposure was measured by virion polymerase chain reaction in swabs from 41 women who reported unprotected vaginal sex during follow-up. RESULTS Glycogen was detected in 315/336 (93.8%) participant-collected and in all clinician-collected swabs. Approximately 20/39 daily swabs (51.3%) linked to mobile reports of unprotected sex tested positive for Yc-DNA, whereas 10/187 swabs collected after 3 days of abstinence or protected sex (5.3%) had detectable Yc-DNA. No participant became HIV infected during the study; yet, exposure to HIV was detected by nucleic acids in 2 vaginal swabs from 1 participant, collected less than 1 hour after coitus. CONCLUSION There was high adherence to daily vaginal swabbing. Daily mobile surveys had accurate reporting of unprotected sex. Detection of HIV in self-collected vaginal swabs from an uninfected participant demonstrated it was possible to measure HIV exposure, but the detection rate was lower than expected.
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Affiliation(s)
- Maria P Lemos
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Erica Lazarus
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Abby Isaacs
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Janan Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Cecilia Morgan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yunda Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Doug Grove
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Michele Andrasik
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Fatima Laher
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - John Hural
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Eva Chung
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Joan Dragavon
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Adrian Puren
- Centre of HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Reena K Gulati
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Robert Coombs
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Margaret Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Laboratory Medicine, University of Washington, Seattle, WA
- Global Health, University of Washington, Seattle, WA
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - James G Kublin
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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20
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Intimate partner violence, HIV and sexually transmitted infections in fishing, trading and agrarian communities in Rakai, Uganda. BMC Public Health 2019; 19:594. [PMID: 31101045 PMCID: PMC6525432 DOI: 10.1186/s12889-019-6909-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intimate partner violence (IPV), HIV and sexually transmitted infections (STI) can contribute to disparities in population health, depending on the individual, social and environmental factors characterizing a setting. To better understand the place-based determinants and patterns of these key interrelated public health problems in Uganda, we compared risk factors for IPV, HIV and STI in fishing, trading and agrarian communities in Rakai, Uganda by gender. METHOD This study used cross-sectional data collected from 14,464 sexually active men (n = 6531) and women (n = 7933) as part of the Rakai Community Cohort Study, a population-based open cohort study of men and women aged 15-49 years. We used multilevel modified poisson regression models, which incorporated random intercepts for community and households. Factors associated with IPV, HIV and STI were assessed separately for men and women in fishing, trading and agrarian communities. RESULTS A larger proportion of participants in the fishing communities than those in trading and agrarian communities were HIV positive, engaged in HIV risk behaviors, had STI symptoms and reported perpetration of or victimization by IPV. Female gender was a shared correlate of IPV, HIV and STI in the fishing communities. Engagement in multiple sexual relationships or partner's engagement in multiple relationships were shared correlates of IPV, and HIV in agrarian communities and IPV and STI in trading communities. CONCLUSION Programs should target factors at multiple levels to reduce risk for syndemic conditions of HIV, STI and IPV in Rakai, Uganda particularly among men and women in fishing communities.
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Boon D, Redd AD, Laeyendecker O, Engle RE, Nguyen H, Ocama P, Boaz I, Ndyanabo A, Kiggundu V, Reynolds SJ, Gray RH, Wawer MJ, Purcell RH, Kirk GD, Quinn TC, Stabinski L. Hepatitis E Virus Seroprevalence and Correlates of Anti-HEV IgG Antibodies in the Rakai District, Uganda. J Infect Dis 2019; 217:785-789. [PMID: 29186448 DOI: 10.1093/infdis/jix610] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 11/22/2017] [Indexed: 11/14/2022] Open
Abstract
A cross-sectional study was conducted of 500 human immunodeficiency virus (HIV)-infected adults frequency matched on age, sex, and community to 500 HIV-uninfected individuals in the Rakai District, Uganda to evaluate seroprevalence of anti-hepatitis E virus (HEV) IgG antibodies. HEV seroprevalence was 47%, and 1 HIV-infected individual was actively infected with a genotype 3 virus. Using modified Poisson regression, male sex (prevalence ratios [PR] = 1.247; 95% confidence interval [CI], 1.071-1.450) and chronic hepatitis B virus infection (PR = 1.377; 95% CI, 1.090-1.738) were associated with HEV seroprevalence. HIV infection status (PR = 0.973; 95% CI, 0.852-1.111) was not associated with HEV seroprevalence. These data suggest there is a large burden of prior exposure to HEV in rural Uganda.
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Affiliation(s)
- Denali Boon
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Andrew D Redd
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland.,Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ronald E Engle
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Hanh Nguyen
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Ponsiano Ocama
- Department of Medicine Makerere University, Kampala, Uganda
| | - Iga Boaz
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | - Steven J Reynolds
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland.,Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ronald H Gray
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Rakai Health Sciences Program, Entebbe, Uganda
| | - Maria J Wawer
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Rakai Health Sciences Program, Entebbe, Uganda
| | - Robert H Purcell
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Gregory D Kirk
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Thomas C Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Lara Stabinski
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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22
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Song X, Grilo SA, Mathur S, Lutalo T, Ssekubugu R, Nalugoda F, Santelli JS. Differential Impacts of HIV status on short-term fertility desires among couples in Rakai, Uganda. PLoS One 2019; 14:e0210935. [PMID: 30677068 PMCID: PMC6345474 DOI: 10.1371/journal.pone.0210935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 01/06/2019] [Indexed: 11/18/2022] Open
Abstract
Background Fertility desires of female and male partners in current relationships are often correlated. We examined the influence of HIV seropositive status of female and male partners on short-term fertility desires in Rakai, Uganda, a setting with high fertility and HIV infection rates. Methods Participants were couples (15–49 years old) enrolled in the Rakai Community Cohort Study, from 2011 to 2013 (n = 2,291). Cohen’s kappa coefficient was used to measure the correlation of female and male partners’ short-term fertility desires (measured as ‘wanting a child in the next 12 months’), in both total sample and stratified serostatus groups. HIV serostatus and additional characteristics of female and male partners were included in Poisson regression models to estimate the rate ratios (RR) for each partner’s short-term fertility desires. Individual and partner characteristics included HIV status, partner HIV status, age in years, partner age in years, educational attainment, number of living children, community of residence, and socioeconomic status (SES). Results Short-term fertility desires among female and male partners were moderately associated (Kappa = 0.37, p-value<0.001). The association was weakest among female sero-positive and male sero-negative couples (Kappa = 0.29, p-value<0.001). When adjusting for parity and other covariates in the model, women’s short-term fertility desires were significantly associated with their positive sero-status regardless of male partners’ sero-status (adjRR = 1.58, p<0.001 for F+M-; adjRR = 1.33, p = 0.001 for F+M+; in comparison with F-M-). Men’s short-term fertility desires were significantly associated with their positive sero-status, in addition to their female partners’ positive sero-status (adjRR = 1.23 with p-value = 0.022 for F-M+; adjRR = 1.42 with p-value<0.001 for F+M-; adjRR = 1.26 with p-value<0.001 for F+M+; in comparison with F-M-). When the differential effect of parity was included in the model, similar associations remained for both female and male partners when the number of living children was small, but largely reduced when the number of living children was large (3 or more). Conclusion Female and male partners in couple dyads demonstrated moderate agreements about short-term fertility desires. The HIV seropositive status of female partners was most strongly associated with short-term fertility desires of both genders, and this association was even stronger for women who had few or no living children.
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Affiliation(s)
- Xiaoyu Song
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Stephanie A. Grilo
- Columbia University Mailman School of Public Health, Heilbrunn Department of Population and Family Health, New York, NY, United States of America
- Columbia University Mailman School of Public health, Department of Sociomedical Sciences, New York, NY, United States of America
- * E-mail:
| | - Sanyukta Mathur
- Population Council, Washington D.C., United States of America
| | - Tom Lutalo
- Rakai Health Sciences Program (RHSP), Rakai District, Uganda
| | | | - Fred Nalugoda
- Rakai Health Sciences Program (RHSP), Rakai District, Uganda
| | - John S. Santelli
- Columbia University Mailman School of Public Health, Heilbrunn Department of Population and Family Health, New York, NY, United States of America
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Breur C, Bloom B, Miller AP, Kigozi G, Nakyanjo N, Ddaaki W, Nalugoda F, Wagman JA. "The Bottle Is My Wife": Exploring Reasons Why Men Drink Alcohol in Ugandan Fishing Communities. SOCIAL WORK IN PUBLIC HEALTH 2019; 34:657-672. [PMID: 31570062 PMCID: PMC6952172 DOI: 10.1080/19371918.2019.1666072] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Fishing communities in Uganda have high rates of excessive alcohol consumption and negative health outcomes related to alcohol consumption, such as HIV acquisition and transmission and intimate partner violence victimization and perpetration. Research lacks understanding of alcohol use in Ugandan fishing communities, underlying reasons for excessive drinking among fishermen or how their community perceives negative health outcomes linked to excessive alcohol consumption. This qualitative study was conducted among Ugandan fisherfolk to determine why excessive alcohol consumption has overtaken their communities. Through analyzing in-depth interviews and focus group discussions, reasons for drinking and community perceptions of drinking were explored using the Socio Ecological Model and the Time Perspective Theory. Interviews were coded into two content themes: social influences on drinking and using alcohol to cope with stress. Participants acknowledged links between excessive alcohol consumption and negative health outcomes within their families and communities. These findings highlight the need for alcohol-related reduction interventions that are sensitive to contextual factors and self-identified contributors to problematic alcohol use within individuals and their communities. Such interventions must consider the social, ecological and economic conditions within fishing sites, focusing not only on individual-level behavioral change but also challenging the underlying structures that foster excessive alcohol consumption.
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Affiliation(s)
- Celia Breur
- Siku Njema Kesho Community-Based Organization, Nakuru, Kenya
| | - Brittnie Bloom
- University of California San Diego, School of Medicine, Department of Medicine, La Jolla, California
| | - Amanda P Miller
- University of California San Diego, School of Medicine, Department of Medicine, La Jolla, California
| | - Godfrey Kigozi
- Rakai Health Sciences Program, Kalisizo, Uganda
- Uganda Virus Research Institute, Entebbe, Uganda
| | - Neema Nakyanjo
- Rakai Health Sciences Program, Kalisizo, Uganda
- Uganda Virus Research Institute, Entebbe, Uganda
| | - William Ddaaki
- Rakai Health Sciences Program, Kalisizo, Uganda
- Uganda Virus Research Institute, Entebbe, Uganda
| | - Fred Nalugoda
- Rakai Health Sciences Program, Kalisizo, Uganda
- Uganda Virus Research Institute, Entebbe, Uganda
| | - Jennifer A. Wagman
- University of California San Diego, School of Medicine, Department of Medicine, La Jolla, California
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Matthews LT, Beyeza-Kashesya J, Cooke I, Davies N, Heffron R, Kaida A, Kinuthia J, Mmeje O, Semprini AE, Weber S. Consensus statement: Supporting Safer Conception and Pregnancy For Men And Women Living with and Affected by HIV. AIDS Behav 2018; 22:1713-1724. [PMID: 28501964 PMCID: PMC5683943 DOI: 10.1007/s10461-017-1777-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Safer conception interventions reduce HIV incidence while supporting the reproductive goals of people living with or affected by HIV. We developed a consensus statement to address demand, summarize science, identify information gaps, outline research and policy priorities, and advocate for safer conception services. This statement emerged from a process incorporating consultation from meetings, literature, and key stakeholders. Three co-authors developed an outline which was discussed and modified with co-authors, working group members, and additional clinical, policy, and community experts in safer conception, HIV, and fertility. Co-authors and working group members developed and approved the final manuscript. Consensus across themes of demand, safer conception strategies, and implementation were identified. There is demand for safer conception services. Access is limited by stigma towards PLWH having children and limits to provider knowledge. Efficacy, effectiveness, safety, and acceptability data support a range of safer conception strategies including ART, PrEP, limiting condomless sex to peak fertility, home insemination, male circumcision, STI treatment, couples-based HIV testing, semen processing, and fertility care. Lack of guidelines and training limit implementation. Key outstanding questions within each theme are identified. Consumer demand, scientific data, and global goals to reduce HIV incidence support safer conception service implementation. We recommend that providers offer services to HIV-affected men and women, and program administrators integrate safer conception care into HIV and reproductive health programs. Answers to outstanding questions will refine services but should not hinder steps to empower people to adopt safer conception strategies to meet reproductive goals.
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Affiliation(s)
- Lynn T. Matthews
- MGH Global Health and Division of Infectious Diseases, 125 Nashua Street, Suite 722, Boston, MA 02114 USA
| | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynaecology, Mulago National Referral Hospital, Kampala, Uganda
| | - Ian Cooke
- University of Sheffield, Sheffield, UK
| | - Natasha Davies
- University of the Witwatersrand, WITS RHI, Johannesburg, South Africa
| | | | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia Canada
| | - John Kinuthia
- University of Washington, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | | | | | - Shannon Weber
- University of California at San Francisco, Zukerberg San Francisco General Hospital, San Francisco, USA
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Lutalo T, Gray R, Santelli J, Guwatudde D, Brahmbhatt H, Mathur S, Serwadda D, Nalugoda F, Makumbi F. Unfulfilled need for contraception among women with unmet need but with the intention to use contraception in Rakai, Uganda: a longitudinal study. BMC WOMENS HEALTH 2018; 18:60. [PMID: 29699548 PMCID: PMC5921782 DOI: 10.1186/s12905-018-0551-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 04/15/2018] [Indexed: 11/10/2022]
Abstract
Background Longitudinal data from a rural Ugandan cohort was used to estimate rates of unfulfilled need for contraception, defined as having unmet need and intent to use contraception at baseline but having an unintended pregnancy or with persistent unmet need for contraception at follow up. Methods Between 2002 and 2009 (5 survey rounds), a total of 2610 sexually active non-pregnant women with unmet need for contraception at the start of an inter-survey period were asked whether they intended to use any method of contraception until they desired a child. Modified Poisson multivariate regression was used to estimate unadjusted and adjusted prevalence ratios (PR) and 95% CI of unfulfilled need for contraception. Results The proportion of women with unmet need at the start of an interval who intended to use contraception significantly increased from 61 to 69.1% (p < 0.05). However the majority of women who said they intended to use contraception had unfulfilled need for contraception at the subsequent survey (64.8 to 56.8%). In the adjusted analysis, significant predictors of unfulfilled need for contraception included age 40–49 years (PR = 1.34; 95% CI 1.04–1.74) and those with unknown HIV status (PR = 1.16; 95% CI 1.06–1.26). Conclusions There is a significant discrepancy between women’s intent to use contraception (> 60%) and subsequent initiation of use (< 30%) with many having unintended pregnancies which might explain the persistent high fertility in Uganda. Future research needs to address unfulfilled need for contraception among women at risk of unintended pregnancies.
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Affiliation(s)
- Tom Lutalo
- Rakai Health Sciences Program, Uganda Virus Research Institute, P.O Box 49, Entebbe, Uganda.
| | - Ron Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John Santelli
- Joseph L Mailman School of Public Health, Columbia University, New York, USA
| | - David Guwatudde
- Makerere University School of Public Health, Kampala, Uganda
| | - Heena Brahmbhatt
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sanyukta Mathur
- Joseph L Mailman School of Public Health, Columbia University, New York, USA
| | - David Serwadda
- Makerere University School of Public Health, Kampala, Uganda
| | - Fred Nalugoda
- Rakai Health Sciences Program, Uganda Virus Research Institute, P.O Box 49, Entebbe, Uganda
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Nakiganda LJ, Agardh A, Asamoah BO. Cross-sectional study on the prevalence and predictors of pregnancy among women living in HIV discordant relationships in a rural Rakai cohort, Uganda. BMJ Open 2018; 8:e019818. [PMID: 29691244 PMCID: PMC5922486 DOI: 10.1136/bmjopen-2017-019818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study examines the prevalence of pregnancy in serodiscordant couples and identifies predictors associated with pregnancy in rural Rakai, Uganda. STUDY DESIGN A population-based cross-sectional study that used data from the Rakai Community Cohort Study (RCCS). SETTING AND PARTICIPANTS We used data from the RCCS survey round 17 (2015-2016), which included 488 women in serodiscordant relationships. This study was conducted in Rakai district, located in south-western Uganda. PRIMARY OUTCOMES Pregnancy status. STATISTICAL ANALYSIS Multivariable modified Poisson regression using stepwise selection was used to determine characteristics and behaviours associated with pregnancy status. RESULTS The prevalence of pregnancy was 12% in women among serodiscordant couples. HIV-negative women in serodiscordant couples had a slightly higher pregnancy prevalence rate (13.6%) compared with HIV-positive women in serodiscordant couples (11%). Factors significantly associated with higher prevalence of pregnancy were; younger age 15-24 years (prevalence risk ratio (PRR)=4.04; 95% CI 1.72 to 9.50), middle age 25-34 years (PRR=2.49; 95% CI 1.05 to 5.89), Christian religion (PRR=2.26; 95% CI 1.41 to 3.63) and inconsistent condom use in the last 12 months (PRR=4.38, 95% CI 1.09 to 17.53). Neither HIV status nor HIV status disclosure was significantly associated with risk of getting pregnant. CONCLUSION Nearly 12% of women in serodiscordant relationships were pregnant, highlighting the need for integrated services to prevent unintended pregnancies and reduce conceptional related risks for those choosing to conceive. Association with younger age and inconsistent condom use suggests a role for early and continued couple-based conception counselling.
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Affiliation(s)
- Lydia Jacenta Nakiganda
- International Master Programme in Public Health, Faculty of Medicine, Lund University, Lund, Sweden
| | - Anette Agardh
- Social Medicine and Global Health, Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
| | - Benedict Oppong Asamoah
- Social Medicine and Global Health, Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
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Wagman JA, Gray RH, Nakyanjo N, McClendon KA, Bonnevie E, Namatovu F, Kigozi G, Kagaayi J, Wawer MJ, Nalugoda F. Process evaluation of the SHARE intervention for preventing intimate partner violence and HIV infection in Rakai, Uganda. EVALUATION AND PROGRAM PLANNING 2018; 67:129-137. [PMID: 29310019 PMCID: PMC6821387 DOI: 10.1016/j.evalprogplan.2017.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 12/11/2017] [Accepted: 12/19/2017] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Jennifer A Wagman
- University of California San Diego, Center on Gender Equity and Health, Department of Medicine, 9500 Gilman Drive, MC 0507, La Jolla, CA 92093-0507, US.
| | - Ronald H Gray
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 627N. Washington Street, 2nd Floor, Baltimore, MD 21205, United States.
| | - Neema Nakyanjo
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, P.O. Box 49, Entebbe, Uganda.
| | - Katherine A McClendon
- University of California Los Angeles, School of Nursing, 700 Tiverton Avenue, Los Angeles, CA 90095, United States.
| | - Erika Bonnevie
- University of California San Diego, Center on Gender Equity and Health, Department of Medicine, 9500 Gilman Drive, MC 0507, La Jolla, CA 92093-0507, US.
| | - Fredinah Namatovu
- Department of Historical, Philosophical and Religious Studies, Umeå University, SE-901 87 Umeå, Sweden.
| | - Grace Kigozi
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, P.O. Box 49, Entebbe, Uganda.
| | - Joseph Kagaayi
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, P.O. Box 49, Entebbe, Uganda.
| | - Maria J Wawer
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 627N. Washington Street, 2nd Floor, Baltimore, MD 21205, United States.
| | - Fred Nalugoda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, P.O. Box 49, Entebbe, Uganda.
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Mullinax M, Grilo SA, Song XS, Wagman J, Mathur S, Nalugoda F, Lutalo T, Santelli J. HIV-Risk Behaviors of Men Who Perpetrate Intimate Partner Violence in Rakai, Uganda. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2017; 29:527-539. [PMID: 29283273 PMCID: PMC6710836 DOI: 10.1521/aeap.2017.29.6.527] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Little is known about men who perpetrate IPV in communities also at risk for HIV infection. Using data from the Rakai Community Cohort Study (RCCS), five survey rounds were used (n = 21,157, observation from n = 10,618 men) to examine HIV risk and prevention behaviors among men who reported acts of violence against their wife/primary partner in the past 12 months. Overall, 10.4% men reported perpetrating physical violence and 17.3% perpetrating verbal violence, 3.1% reported sexual violence, 3.1% used violence to have sex with their wife/partner, and 1.1% used verbal coercion. Factors associated with IPV were: age 20-24 years, lower socio-economic status, being married, no male circumcision, drinking alcohol before sex, no consistent condom use, multiple sex partners in the past 12 months, multiple partners ever, and working in a bar. Protective HIV behaviors predicted fewer reports of perpetration and HIV-risk behaviors predicted more reports of perpetrating IPV.
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Affiliation(s)
| | - Stephanie A Grilo
- Columbia University Mailman School of Public Health, Sociomedical Sciences, New York, New York
| | - Xiaoyu S Song
- Department of Population Health Science and Policy and the Tisch Cancer Center, both at Icahn School of Medicine at Mount Sinai, New York
| | - Jennifer Wagman
- University of San Diego School of Medicine, Division of Global Public Health, San Diego, California
| | | | | | - Tom Lutalo
- Rakai Health Sciences Program, Rakai, Uganda
| | - John Santelli
- Columbia University Mailman School of Public Health, Population and Family Health, New York, New York
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29
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Thummalachetty N, Mathur S, Mullinax M, DeCosta K, Nakyanjo N, Lutalo T, Brahmbhatt H, Santelli JS. Contraceptive knowledge, perceptions, and concerns among men in Uganda. BMC Public Health 2017; 17:792. [PMID: 29017539 PMCID: PMC5633881 DOI: 10.1186/s12889-017-4815-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 10/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low contraceptive uptake and high unmet need for contraception remain significant issues in Uganda compared to neighboring countries such as Kenya, Ethiopia, and Rwanda. Although prior research on contraceptive uptake has indicated that male partners strongly influence women's decisions around contraceptive use, there is limited in-depth qualitative research on knowledge and concerns regarding modern contraceptive methods among Ugandan men. METHODS Using in-depth interviews (N = 41), this qualitative study investigated major sources of knowledge about contraception and perceptions of contraceptive side effects among married Ugandan men. RESULTS Men primarily reported knowledge of contraceptives based on partner's experience of side effects, partner's knowledge from health providers and mass media campaigns, and partner's knowledge from her peers. Men were less likely to report contraceptive knowledge from health care providers, mass media campaigns, or peers. Men's concerns about various contraceptive methods were broadly associated with failure of the method to work properly, adverse health effects on women, and severe adverse health effects on children. Own or partner's human immunodeficiency virus (HIV) status did not impact on contraceptive knowledge. CONCLUSIONS Overall, we found limited accurate knowledge about contraceptive methods among men in Uganda. Moreover, fears about the side effects of modern contraceptive methods appeared to be common among men. Family planning services in Uganda could be significantly strengthened by renewed efforts to focus on men's knowledge, fears, and misconceptions.
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Affiliation(s)
- Nityanjali Thummalachetty
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, 60 Haven Ave., B-2, New York, NY 10032 USA
| | - Sanyukta Mathur
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, 60 Haven Ave., B-2, New York, NY 10032 USA
| | - Margo Mullinax
- HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute, New York, NY USA
| | - Kelsea DeCosta
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, 60 Haven Ave., B-2, New York, NY 10032 USA
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - Heena Brahmbhatt
- Department of Population, Family and Reproductive Health, John Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - John S. Santelli
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, 60 Haven Ave., B-2, New York, NY 10032 USA
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Carrillo-Ávila JA, Serrano-García ML, Fernández-Parra J, Sorlózano-Puerto A, Navarro-Marí JM, Stensvold CR, Gutiérrez-Fernández J. Prevalence and genetic diversity of Trichomonas vaginalis in the general population of Granada and co-infections with Gardnerella vaginalis and Candida species. J Med Microbiol 2017; 66:1436-1442. [PMID: 28972465 DOI: 10.1099/jmm.0.000603] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Purulent or exudative genitourinary infections are a frequent cause of consultation in primary and specialized healthcare. The objectives of this study were: to determine the prevalence of Trichomonas vaginalis and co-infections with Candida spp. and Gardnerella vaginalis in vaginal secretion; and to use multilocus sequence typing (MLST) to analyse the genetic diversity of T. vaginalis strains. METHODOLOGY The samples were submitted for analysis (n=5230) to a third-level hospital in Granada (Southern Spain) between 2011 and 2014; eight T. vaginalis strains isolated during 2015 were randomly selected for MLST analysis. Culture and nucleic acid hybridization techniques were used to detect microorganisms in the samples. RESULTS The prevalence of T. vaginalis was 2.4 % between 2011 and 2014, being higher during the first few months of both 2011 and 2012. Among samples positive for T. vaginalis, co-infection with G. vaginalis was detected in 29 samples and co-infection with Candida spp. in 6, while co-infection with all three pathogens was observed in 3 samples. The only statistically significant between-year difference in co-infection rates was observed for T. vaginalis with G. vaginalis due to an elevated rate in 2011. MLST analysis results demonstrated a high genetic variability among strains circulating in our setting. CONCLUSION These findings emphasize the need for the routine application of diagnostic procedures to avoid the spread of this sexually transmitted infection.
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Affiliation(s)
| | | | - Jorge Fernández-Parra
- Department of Obstetrics and Gynaecology, Virgen de las Nieves University Hospital -ibs Granada, Granada, Spain
| | | | - José María Navarro-Marí
- Microbiology Laboratory, Virgen de las Nieves University Hospital -ibs Granada, Granada, Spain
| | - C Rune Stensvold
- Department of Microbiology and Infection, Statens Serum Institut, Copenhagen, Denmark
| | - Jose Gutiérrez-Fernández
- Microbiology Laboratory, Virgen de las Nieves University Hospital -ibs Granada, Granada, Spain.,Department of Microbiology, University of Granada-ibs Granada, Granada, Spain
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Delivering safer conception services to HIV serodiscordant couples in Kenya: perspectives from healthcare providers and HIV serodiscordant couples. J Int AIDS Soc 2017; 20:21309. [PMID: 28361508 PMCID: PMC5577704 DOI: 10.7448/ias.20.2.21309] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: For HIV serodiscordant couples in resource-limited settings, pregnancy is common despite the risk of sexual and/or perinatal HIV transmission. Some safer conception strategies to reduce HIV transmission during pregnancy attempts are available but often not used for reasons including knowledge, accessibility, preference and others. We sought to understand Kenyan health providers’ and HIV serodiscordant couples’ perspectives and experiences with safer conception. Methods: Between August 2015 and March 2016, we conducted key informant interviews (KIIs) with health providers from public and private HIV care and fertility clinics and in-depth interviews (IDIs) and focus group discussions (FGDs) with HIV serodiscordant couples participating in an open-label study of integrated pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for HIV prevention (the Partners Demonstration Project). An inductive analytic approach identified a number of themes related to experiences with and perceptions of safer conception strategies. Results: We conducted 20 KIIs with health providers, and 21 IDIs and 4 FGDs with HIV serodiscordant couples. HIV clinic providers frequently discussed timed condomless sex and antiretroviral medications while providers at private fertility care centres were more comfortable recommending medically assisted reproduction. Couples experienced with ART and PrEP reported that they were comfortable using these strategies to reduce HIV risk when attempting pregnancy. Timed condomless sex in conjunction with ART and PrEP was a preferred strategy, often owing to them being available for free in public and research clinics, as well as most widely known; however, couples often held inaccurate knowledge of how to identify days with peak fertility in the upcoming menstrual cycle. Conclusions: Antiretroviral-based HIV prevention is acceptable and accessible to meet the growing demand for safer conception services in Kenya, since medically assisted interventions are currently cost prohibitive. Cross-disciplinary training for health providers would expand confidence in all prevention options and foster the tailoring of counselling to couples’ preferences.
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Nakiganda LJ, Nakigozi G, Kagaayi J, Nalugoda F, Serwadda D, Sewankambo N, Gray R, Ndyanabo A, Muwanika R, Asamoah BO. Cross-sectional comparative study of risky sexual behaviours among HIV-infected persons initiated and waiting to start antiretroviral therapy in rural Rakai, Uganda. BMJ Open 2017; 7:e016954. [PMID: 28893749 PMCID: PMC5722091 DOI: 10.1136/bmjopen-2017-016954] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To compare risky sexual behaviours between HIV-positive persons initiated on antiretroviral therapy (ART) (ART-experienced) and persons waiting to start on ART (ART-naive) and assess predictors of risky sexual behaviours among HIV-infected patients in rural Rakai district, Uganda. STUDY DESIGN This is a cross-sectional study that used data from the Rakai Community Cohort Study (RCCS) database between 2013 and 2014. A structured questionnaire was used for data collection. We used stepwise logistic regression as an index to estimate the adjusted ORs for the association between risky sexual behaviours and ART treatment status. STUDY SETTING This study was conducted in Rakai district, located in south-western Uganda. The data for this study were extracted from the RCCS. RCCS is an open prospective cohort of approximately 15 000 consenting participants aged 15-49 years. PARTICIPANTS HIV-positive participants aged 18-49 years who had sex at least once a month with any partner prior to the start of the study. MAIN OUTCOME MEASURES Inconsistent/no condom use in the last 12 months, alcohol use at last sexual encounter, and two or more sexual partners. RESULTS ART-naive participants were more likely to report inconsistent condom use (OR=1.74, 95% CI 1.11 to 2.73) and more likely to drink alcohol at last sexual encounter (OR=1.65, 95% CI 1.11 to 2.46), compared with ART-experienced patients. ART treatment status (p<0.001) was a significant predictor of risky sexual behaviours. Both marital status (p=0.016) and occupation level (p=0.009) were positively associated with inconsistent condom use, while sex (p<0.001) correlated with alcohol use at last sexual encounter. CONCLUSION ART-naive participants were more likely to exhibit risky sexual behaviours than the ART-experienced participants. The intensity of risk reduction counselling should be increased for HIV-positive persons waiting to start ART but already in HIV care.
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Affiliation(s)
- Lydia Jacenta Nakiganda
- International Master Programme in Public Health, Faculty of Medicine, Lund University, Malmö, Sweden
| | | | | | | | - David Serwadda
- Makerere University School of Public Health, Kampala, Uganda
| | | | - Ronald Gray
- School of Public Health, John Hopkins University, Maryland, USA
| | | | | | - Benedict Oppong Asamoah
- Department of Clinical Sciences, Division of Social Medicine and Global Health, Lund University, Malmö, Sweden
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Matthews LT, Burns BF, Bajunirwe F, Kabakyenga J, Bwana M, Ng C, Kastner J, Kembabazi A, Sanyu N, Kusasira A, Haberer JE, Bangsberg DR, Kaida A. Beyond HIV-serodiscordance: Partnership communication dynamics that affect engagement in safer conception care. PLoS One 2017; 12:e0183131. [PMID: 28880892 PMCID: PMC5589112 DOI: 10.1371/journal.pone.0183131] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/31/2017] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION We explored acceptability and feasibility of safer conception methods among HIV-affected couples in Uganda. METHODS We recruited HIV-positive men and women on antiretroviral therapy (ART) ('index') from the Uganda Antiretroviral Rural Treatment Outcomes cohort who reported an HIV-negative or unknown-serostatus partner ('partner'), HIV-serostatus disclosure to partner, and personal or partner desire for a child within two years. We conducted in-depth interviews with 40 individuals from 20 couples, using a narrative approach with tailored images to assess acceptability of five safer conception strategies: ART for the infected partner, pre-exposure prophylaxis (PrEP) for the uninfected partner, condomless sex timed to peak fertility, manual insemination, and male circumcision. Translated and transcribed data were analyzed using thematic analysis. RESULTS 11/20 index participants were women, median age of 32.5 years, median of 2 living children, and 80% had HIV-RNA <400 copies/mL. Awareness of HIV prevention strategies beyond condoms and abstinence was limited and precluded opportunity to explore or validly assess acceptability or feasibility of safer conception methods. Four key partnership communication challenges emerged as primary barriers to engagement in safer conception care, including: (1) HIV-serostatus disclosure: Although disclosure was an inclusion criterion, partners commonly reported not knowing the index partner's HIV status. Similarly, the partner's HIV-serostatus, as reported by the index, was frequently inaccurate. (2) Childbearing intention: Many couples had divergent childbearing intentions and made incorrect assumptions about their partner's desires. (3) HIV risk perception: Participants had disparate understandings of HIV transmission and disagreed on the acceptable level of HIV risk to meet reproductive goals. (4) Partnership commitment: Participants revealed significant discord in perceptions of partnership commitment. All four types of partnership miscommunication introduced constraints to autonomous reproductive decision-making, particularly for women. Such miscommunication was common, as only 2 of 20 partnerships in our sample were mutually-disclosed with agreement across all four communication themes. CONCLUSIONS Enthusiasm for safer conception programming is growing. Our findings highlight the importance of addressing gendered partnership communication regarding HIV disclosure, reproductive goals, acceptable HIV risk, and commitment, alongside technical safer conception advice. Failing to consider partnership dynamics across these domains risks limiting reach, uptake, adherence to, and retention in safer conception programming.
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Affiliation(s)
- Lynn T. Matthews
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, United States of America
| | - Bridget F. Burns
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
| | | | | | - Mwebesa Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Courtney Ng
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Jasmine Kastner
- Research Institute McGill University Health Centre, Montreal, Canada
| | - Annet Kembabazi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Naomi Sanyu
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adrine Kusasira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - David R. Bangsberg
- OHSU-PSU School of Public Health, Portland, OR, United States of America
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Impact of HIV and Atiretroviral Therapy on Neurocognitive Outcomes Among School-Aged Children. J Acquir Immune Defic Syndr 2017; 75:1-8. [PMID: 28169874 DOI: 10.1097/qai.0000000000001305] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The impact of HIV infection and antiretroviral therapy (ART) on neurocognitive outcomes among children aged 7-14 years was assessed. We hypothesized that ART would ameliorate neurocognitive sequelae of HIV infection. METHODS HIV-positive and HIV-negative mother-child pairs from the Rakai Community Cohort Study and ART clinics in Rakai, Uganda, were followed prospectively for 4 years. Exposures were stratified as: perinatally HIV infected, perinatally HIV exposed but uninfected, and HIV unexposed and uninfected. The Kaufman Assessment Battery for Children assessed sequential and simultaneous processing, learning, planning, knowledge, and fluid crystalized index for overall functioning. Multivariable generalized linear models estimated adjusted prevalence rate ratios by age. RESULTS Of the 370 mother-child pairs, 55% were HIV unexposed and uninfected, 7% were perinatally HIV exposed but uninfected, and 37.9% were perinatally HIV infected. Among HIV-infected children, longer duration of ART was associated with a significant improvement of sequential processing skills (adjusted prevalence rate ratios 25-36 months: 0.55, 95% confidence interval [CI]: 0.34 to 0.9; 37-48 months: 0.39, 95% CI: 0.2 to 0.76; 49+ months: 0.23, 95% CI: 0.1 to 0.54). Each additional year of schooling was associated with a 30%-40% decrease of impairment for all neurocognitive measures assessed. Healthier children (higher age-standardized height and weight) had improved sequential and simultaneous processing and overall fluid crystalized index. CONCLUSIONS Sequential processing skills of working memory improved with prolonged ART, and increased duration of schooling was associated with a reduction of neurocognitive impairment. Early initiation and sustained use of ARTs and longer schooling are needed to reduce neurocognitive impairment among HIV-infected school-aged children.
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Krishnaratne S, Hensen B, Cordes J, Enstone J, Hargreaves JR. Interventions to strengthen the HIV prevention cascade: a systematic review of reviews. Lancet HIV 2017; 3:e307-17. [PMID: 27365205 DOI: 10.1016/s2352-3018(16)30038-8] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/22/2016] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade. METHODS We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence. FINDINGS From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories. INTERPRETATION There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Shari Krishnaratne
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK; Centre for Evaluation, London School of Hygiene & Tropical Medicine, London, UK.
| | - Bernadette Hensen
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Jillian Cordes
- Department of Global Health, Emory University, Atlanta, GA, USA
| | - Joanne Enstone
- Public Health and Epidemiology, School of Medicine, Nottingham University, Nottingham, UK
| | - James R Hargreaves
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
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Mafigiri R, Matovu JKB, Makumbi FE, Ndyanabo A, Nabukalu D, Sakor M, Kigozi G, Nalugoda F, Wanyenze RK. HIV prevalence and uptake of HIV/AIDS services among youths (15-24 Years) in fishing and neighboring communities of Kasensero, Rakai District, South Western Uganda. BMC Public Health 2017; 17:251. [PMID: 28288604 PMCID: PMC5348807 DOI: 10.1186/s12889-017-4166-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 03/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although fishing communities have a significantly higher HIV prevalence than the general population, there is paucity of data on the burden of HIV and service utilization, particularly among the youth. We assessed the HIV prevalence and utilization of HIV prevention and treatment services among youth in Kasensero fishing community and the neighboring communities. METHOD Data were derived from the Rakai Community Cohort Study (RCCS) surveys conducted between 2013 and 2014. The RCCS is a population-based household survey that collects data annually from individuals aged 15-49 years, resident in 48 communities in Rakai and neighboring districts in Uganda. For this analysis, socio-demographic, behavioral and HIV-related data were obtained for 792 individuals aged 15-24 years. We used logistic regression to conduct bivariate and multivariable analysis to determine the factors that are independently associated with HIV-positive status and their corresponding 95% confidence intervals. Data were analyzed using STATA version 13. RESULTS Overall HIV prevalence was 19.7% (n = 155); higher in Kasensero (n = 141; 25.1%) and Gwanda (n = 8; 11%) than in Kyebe (n = 6; 3.9%), p < 0.001 and among females (n = 112; 26.0%) than males (n = 43; 12.0%), p < 0.001. Uptake of HIV testing was high in both HIV-positive (n = 136; 89.5%) and HIV-negative youth (n = 435; 92%). Consistent condom use was virtually non-existent in HIV-positive youth (n = 1; 0.6%) compared to HIV-negative youth (n = 20; 4.2%). Only 22.4% (n = 34) of the HIV-positive youth were receiving antiretroviral therapy (ART) in 2013-2014; higher in the HIV-positive females (n = 31; 28.4%) than HIV-positive males (n = 03; 6.7%). Slightly more than half of males (n = 134; 53.8%) reported that they were circumcised; the proportion of circumcised youth was higher among HIV-negative males (n = 122; 58%) than HIV-positive males (n = 12; 27.9%). Factors significantly associated with HIV-positive status included living in Kasensero landing site (adjusted Odds Ratio [aOR] = 5.0; 95%CI: 2.22-13.01) and reporting one (aOR = 5.0; 95%CI: 1.33-15.80) or 2+ sexual partners in the past 12 months (aOR = 11.0; 95% CI; 3.04-36.72). CONCLUSION The prevalence of HIV is high especially among young females and in landing site communities than in the peripheral communities. Uptake of HIV prevention and treatment services is very low. There is an urgent need for youth-friendly services in these communities.
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Affiliation(s)
- Richardson Mafigiri
- Public Health Fellowship Program (PHFP) – Field Epidemiology Track, Ministry of Health-Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Joseph K. B. Matovu
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fredrick Edward Makumbi
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
- Rakai Health Sciences Program, Kampala, Uganda
| | | | | | - Moses Sakor
- Rakai Health Sciences Program, Kampala, Uganda
| | | | | | - Rhoda K. Wanyenze
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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Matovu JKB, Makumbi F, Wanyenze RK, Serwadda D. Determinants of fertility desire among married or cohabiting individuals in Rakai, Uganda: a cross-sectional study. Reprod Health 2017; 14:2. [PMID: 28069056 PMCID: PMC5223449 DOI: 10.1186/s12978-016-0272-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 12/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent trends in fertility rates indicate declines in total fertility rate (TFR) in some sub-Saharan African countries. However, countries such as Uganda continue to have a persistently high TFR partly attributed to strong preferences for large family sizes. We explored the factors that influence fertility desire among married or cohabiting individuals in Rakai, a rural district in southwestern Uganda. METHODS This cross-sectional study of fertility desire (desire to have another child) was nested in a cluster-randomized demand-creation intervention trial for the promotion of couples' HIV counseling and testing uptake among married or cohabiting individuals that was conducted in Rakai district between March 1 and April 30, 2015. A total of 1490 married or cohabiting individuals, resident in three study regions with differing background HIV prevalence, were enrolled into the study. Data were collected on socio-demographic, behavioral and fertility-related characteristics. We used a modified Poisson regression model to generate prevalence ratio (PR) as a measure of association for factors that were independently associated with fertility desire. We adjusted for clustering at community level and used STATA version 14.0 for all analyses. RESULTS Overall, fertility desire was high (63.1%, n = 940); higher in men (69.9%, n = 489) than women (57.1%, n = 451). More than three-quarters (78.8%, n = 1174) had 3+ biological children while slightly more than two-thirds (68.5%, n = 1020) reported an ideal family size of 5+ children. Only 30% (n = 452) reported that they had attained their desired family size. After adjusting for potential and suspected confounders, the factors that were negatively associated with fertility desire were: age 30-39 (adjusted prevalence ratio [aPR] = 0.82, 95% CI: 0.78, 0.86) and 40+ years (aPR = 0.65, 95% CI: 0.60, 0.71); having six or more biological children (aPR = 0.88, 95% CI: 0.80, 0.97); being HIV-positive (aPR = 0.86, 95% CI: 0.78, 0.95) and ever use of any family planning methods (aPR = 0.93, 95% CI: 0.87, 0.99). Being male (aPR = 1.19, 95% CI: 1.07, 1.33); having primary education (aPR = 1.21, 95% CI: 1.01, 1.44) and having not yet attained the desired family size (aPR = 4.34, 95% CI: 3.50, 5.38) were positively associated with fertility desire. CONCLUSION Having not yet attained one's desired family size, being male and having primary education were positively associated with fertility desire in this population. Targeting individuals who have not yet attained their desired family size, men and less educated individuals with fertility regulation interventions may help to reduce fertility desire in this population.
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Affiliation(s)
- Joseph K B Matovu
- Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, Kampala, Uganda. .,Makerere University College of Health Sciences, School of Public Health, P.O. Box 7072, Kampala, Uganda.
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda.,Family Health Research and Development Center, Makerere University School of Public Health, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - David Serwadda
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Mathur S, Romo D, Rasmussen M, Nakyanjo N, Nalugoda F, Santelli JS. Re-focusing HIV prevention messages: a qualitative study in rural Uganda. AIDS Res Ther 2016; 13:37. [PMID: 27857775 PMCID: PMC5105323 DOI: 10.1186/s12981-016-0123-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 11/01/2016] [Indexed: 11/10/2022] Open
Abstract
Background After 30 years, the human immunodeficiency virus (HIV) remains an epidemic of global concern. To support the increasing emphasis on biomedical interventions for prevention requires a renewed and reframed focus on HIV prevention messages to motivate engagement in risk-reduction activities. This paper examines youth and adult perceptions of HIV prevention messages and HIV risk assessment in a generalized HIV epidemic context in Uganda. Methods We conducted 24 focus group discussions and 24 in-depth interviews with 15–45 year olds (n = 218) from three communities in the Rakai district of Uganda in 2012. Results We found generational differences in the how people viewed HIV, skepticism around introduction of new interventions, continued misconceptions and fears about condoms, and gender differences in content and salience of HIV prevention messages. Conclusions Shifts in HIV education are needed to address gaps in HIV messaging to foster engagement in risk reduction strategies and adoption of newer biomedical approaches to HIV prevention.
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Intimate partner violence as a predictor of marital disruption in rural Rakai, Uganda: a longitudinal study. Int J Public Health 2016; 61:961-970. [PMID: 27624624 DOI: 10.1007/s00038-016-0891-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 08/18/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES We assessed the association between intimate partner violence (IPV) and union disruption (divorce or separation) in the rural Ugandan setting of Rakai District. METHODS We 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. RESULTS Past 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. CONCLUSIONS IPV, 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.
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King EJ, Maman S, Namatovu F, Kiwanuka D, Kairania R, Ssemanda JB, Nalugoda F, Wagman JA. Addressing Intimate Partner Violence Among Female Clients Accessing HIV Testing and Counseling Services: Pilot Testing Tools in Rakai, Uganda. Violence Against Women 2016; 23:1656-1668. [PMID: 27586170 DOI: 10.1177/1077801216663657] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The World Health Organization recommends that HIV counseling and testing (HCT) programs implement strategies to address how intimate partner violence (IPV) influences women's ability to protect themselves from and seek care and treatment for HIV infection. We discuss the process used to adapt a screening and brief intervention (SBI) for female clients of HCT services in Rakai, Uganda-a setting with high prevalence of both HIV and IPV. By outlining our collaborative process for adapting and implementing the SBI in Rakai and training counselors for its use, we hope other HCT programs will consider replicating the approach in their settings.
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Affiliation(s)
| | | | | | - Deus Kiwanuka
- 4 Rakai Health Sciences Program, Uganda Virus Research Institute
| | - Robert Kairania
- 4 Rakai Health Sciences Program, Uganda Virus Research Institute
| | - John B Ssemanda
- 4 Rakai Health Sciences Program, Uganda Virus Research Institute
| | - Fred Nalugoda
- 4 Rakai Health Sciences Program, Uganda Virus Research Institute
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Self-selection of male circumcision clients and behaviors following circumcision in a service program in Uganda. AIDS 2016; 30:2125-9. [PMID: 27203716 DOI: 10.1097/qad.0000000000001169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Sub-Saharan African countries have substantially scaled-up safe male circumcision (SMC) services. However, it is unclear whether services are reaching men most at risk of HIV and whether there is behavioral disinhibition after SMC. We compared characteristics of SMC acceptors and nonacceptors in Rakai, Uganda. DESIGN Cohort design. METHODS Through the Rakai Community Cohort Study, baseline characteristics of 587 non-Muslim men who subsequently accepted SMC were compared with those of 4907 uncircumcised non-Muslim men. Behaviors after SMC were compared with those of men who remained uncircumcised. Poisson multivariable regression was used to estimate adjusted prevalence rate ratios of behaviors in circumcised versus uncircumcised men. RESULTS At baseline (pre-SMC), men subsequently circumcised were younger (mean = 26.1 years), as compared with the uncircumcised (mean = 28.5 years, P < 0.001), more likely to live in urban areas (21.1 versus 12.4%, P < 0.001), less likely to have been currently or previously married (36.5 versus 45.8%, P < 0.001) and more likely to report multiple sexual partners (48.3 versus 41.6%, P = 0.05) and genital discharge (7.4 versus 4.4%, P = 0.03). At follow-up (post-SMC), behaviors and genital discharge did not differ between the groups. Genital ulcers were less reported among circumcised (6.8%) compared with uncircumcised men (10.5%; adjusted prevalence rate ratios = 0.60, 95% confidence interval = 0.42-0.87, P = 0.007). CONCLUSION In Rakai district, Uganda, the circumcision service program is attracting sexually active men at higher risk of HIV and we find no evidence of behavioral disinhibition following circumcision. The SMC program in this setting has the potential to reduce the HIV epidemic among men.
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Matovu JKB, Todd J, Wanyenze RK, Kairania R, Serwadda D, Wabwire-Mangen F. Evaluation of a demand-creation intervention for couples' HIV testing services among married or cohabiting individuals in Rakai, Uganda: a cluster-randomized intervention trial. BMC Infect Dis 2016; 16:379. [PMID: 27502776 PMCID: PMC4977664 DOI: 10.1186/s12879-016-1720-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 07/15/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Uptake of couples' HIV counseling and testing (couples' HCT) services remains largely low in most settings. We report the effect of a demand-creation intervention trial on couples' HCT uptake among married or cohabiting individuals who had never received couples' HCT. METHODS This was a cluster-randomized intervention trial implemented in three study regions with differing HIV prevalence levels (range: 9-43 %) in Rakai district, southwestern Uganda, between February and September 2014. We randomly assigned six clusters (1:1) to receive the intervention or serve as the comparison arm using computer-generated random numbers. In the intervention clusters, individuals attended small group, couple and male-focused interactive sessions, reinforced with testimonies from 'expert couples', and received invitation coupons to test together with their partners at designated health facilities. In the comparison clusters, participants attended general adult health education sessions but received no invitation coupons. The primary outcome was couples' HCT uptake, measured 12 months post-baseline. Baseline data were collected between November 2013 and February 2014 while follow-up data were collected between March and April 2015. We conducted intention-to-treat analysis using a mixed effects Poisson regression model to assess for differences in couples' HCT uptake between the intervention and comparison clusters. Data analysis was conducted using STATA statistical software, version 14.1. RESULTS Of 2135 married or cohabiting individuals interviewed at baseline, 42 % (n = 846) had ever received couples' HCT. Of those who had never received couples' HCT (n = 1,174), 697 were interviewed in the intervention clusters while 477 were interviewed in the comparison clusters. 73.6 % (n = 513) of those interviewed in the intervention and 82.6 % (n = 394) of those interviewed in the comparison cluster were interviewed at follow-up. Of those interviewed, 72.3 % (n = 371) in the intervention and 65.2 % (n = 257) in the comparison clusters received HCT. Couples' HCT uptake was higher in the intervention than in the comparison clusters (20.3 % versus 13.7 %; adjusted prevalence ratio (aPR) = 1.43, 95 % CI: 1.02, 2.01, P = 0.04). CONCLUSION Our findings show that a small group, couple and male-focused, demand-creation intervention reinforced with testimonies from 'expert couples', improved uptake of couples' HCT in this rural setting. TRIAL REGISTRATION ClinicalTrials.gov, NCT02492061 . Date of registration: June 14, 2015.
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Affiliation(s)
- Joseph K B Matovu
- Department of Community Health and Behavioral Sciences, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
| | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Robert Kairania
- Rakai Health Sciences Program/Uganda Virus Research Institute, Kalisizo, Uganda
| | - David Serwadda
- Department of Disease Control and Environmental Health, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Fred Wabwire-Mangen
- Regional Center for Quality of Health Care, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
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MacPhail C, Campbell C. Evaluating HIV/STD Interventions in Developing Countries: Do Current Indicators Do Justice to Advances in Intervention Approaches? SOUTH AFRICAN JOURNAL OF PSYCHOLOGY 2016. [DOI: 10.1177/008124639902900401] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
HIV continues to spread unabated in many developing countries. Here we consider the interventions that are currently in place and critically discuss the methods that are being used to evaluate them as reported in the published literature. In recent years there has been a move away from highly individual-oriented interventions towards more participatory approaches that emphasise techniques such as community-led peer education and group discussions. However, this move towards more community orientated intervention techniques has not been matched by the development of evaluation methods with which to capture and explain the community and social changes which are often necessary preconditions for health-enhancing behaviour change. Evaluation research continues to rely on quantitative methodologies that fail to elucidate the complex changes that the newer interventions seek to promote within target communities. In addition, these methods of evaluation tend to rely on the use of highly individualistic and quantitative biomedical indicators such as HIV/STD rates, or knowledge, attitude, perception and behaviour (KAPB) survey questionnaires. We argue that such approaches are inadequate for the task of tracking and measuring important determinants of programme success such as psycho-social changes, features of the community-intervention interface and the degree of trust and identification with which members of target communities regard particular interventions. Rigorously conducted qualitative process evaluations taking account of the above factors could make a key contribution to the development of more successful HIV-prevention interventions.
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Affiliation(s)
- Catherine MacPhail
- CSIR Mining Technology, P.O. Box 91230, Auckland Park 2006, South Africa
| | - Catherine Campbell
- Department of Social Psychology, London School of Economics, Houghton Street, London WC2A 2AE, Britain
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Kong X, Kigozi G, Ssekasanvu J, Nalugoda F, Nakigozi G, Ndyanabo A, Lutalo T, Reynolds SJ, Ssekubugu R, Kagaayi J, Bugos E, Chang LW, Nanlesta P, Mary G, Berman A, Quinn TC, Serwadda D, Wawer MJ, Gray RH. Association of Medical Male Circumcision and Antiretroviral Therapy Scale-up With Community HIV Incidence in Rakai, Uganda. JAMA 2016; 316:182-90. [PMID: 27404186 PMCID: PMC5027874 DOI: 10.1001/jama.2016.7292] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Medical male circumcision (MMC) and antiretroviral therapy (ART) are proven HIV prevention interventions, but there are limited data on the population-level effect of scale-up of these interventions in sub-Saharan Africa. Such evaluation is important for planning and resource allocation. OBJECTIVE To examine whether increasing community MMC and ART coverage was associated with reduced community HIV incidence in Rakai District, Uganda. DESIGN, SETTING, AND PARTICIPANTS Using person-level data from population-based surveys conducted from 1999 through 2013 in 45 rural Rakai communities, community-level ART and MMC coverage, sociodemographics, sexual behaviors, and HIV prevalence and incidence were estimated in 3 periods: prior to the availability of ART and MMC (1999-2004), during early availability of ART and MMC (2004-2007), and during mature program scale-up (2007-2013). EXPOSURES Community MMC coverage in males and ART coverage in HIV-positive persons of the opposite sex based on self-reported MMC status and ART use. MAIN OUTCOMES AND MEASURES Adjusted incidence rate ratios (IRRs) for sex-specific community HIV incidence estimated using multivariable Poisson regression with generalized estimating equations. RESULTS From 1999 through 2013, 44,688 persons participated in 1 or more surveys (mean age at the first survey, 24.6 years [range, 15-49]; female, 56.5%; mean survey participation rate, 92.6% [95% CI, 92.4%-92.7%]). Median community MMC coverage increased from 19% to 39%, and median community ART coverage rose from 0% to 21% in males and from 0% to 26% in females. Median community HIV incidence declined from 1.25 to 0.84 per 100 person-years in males, and from 1.25 to 0.99 per 100 person-years in females. Among males, each 10% increase in community MMC coverage was associated with an adjusted IRR of 0.87 (95% CI, 0.82-0.93). Comparing communities with MMC coverage more than 40% (mean male community incidence, 1.03 per 100 person-years) with communities with coverage of 10% or less (mean male incidence, 1.69 per 100 person-years), the adjusted IRR was 0.61 (95% CI, 0.43-0.88). For each 10% increase in female self-reported ART coverage, there was no significant reduction in male HIV incidence (adjusted IRR, 0.95 [95% CI, 0.81-1.13]). Comparing communities with female ART coverage more than 20% (mean male incidence, 0.87 per 100 person-years) to communities with female ART coverage of 20% or less (mean male incidence, 1.17 per 100 person-years), the adjusted IRR was 0.77 (95% CI, 0.61-0.98). Neither MMC nor male ART coverage was associated with lower female community HIV incidence. CONCLUSIONS AND RELEVANCE In Rakai, Uganda, increasing community MMC and female ART coverage was associated with lower community HIV incidence in males. If similar associations are found elsewhere, this would support further scale-up of MMC and ART for HIV prevention in sub-Saharan Africa.
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Affiliation(s)
- Xiangrong Kong
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Department of Biostatistics, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | | | - Joseph Ssekasanvu
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | - Tom Lutalo
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Eva Bugos
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Larry W. Chang
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Grabowski Mary
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Amanda Berman
- Center for Communications Programs, Johns Hopkins University, Baltimore, MD
| | - Thomas C. Quinn
- Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- School of Public Health, Makerere University, Kampala, Uganda
| | - Maria J. Wawer
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Ronald H. Gray
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
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Marston M, Nakiyingi-Miiro J, Hosegood V, Lutalo T, Mtenga B, Zaba B. Measuring the Impact of Antiretroviral Therapy Roll-Out on Population Level Fertility in Three African Countries. PLoS One 2016; 11:e0151877. [PMID: 27015522 PMCID: PMC4807830 DOI: 10.1371/journal.pone.0151877] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 03/04/2016] [Indexed: 11/18/2022] Open
Abstract
Background UNAIDS official estimates of national HIV prevalence are based on trends observed in antenatal clinic surveillance, after adjustment for the reduced fertility of HIV positive women. Uptake of ART may impact on the fertility of HIV positive women, implying a need to re-estimate the adjustment factors used in these calculations. We analyse the effect of antiretroviral therapy (ART) provision on population-level fertility in Southern and East Africa, comparing trends in HIV infected women against the secular trends observed in uninfected women. Methods We used fertility data from four community-based demographic and HIV surveillance sites: Kisesa (Tanzania), Masaka and Rakai (Uganda) and uMkhanyakude (South Africa). All births to women aged 15–44 years old were included in the analysis, classified by mother’s age and HIV status at time of birth, and ART availability in the community. Calendar time period of data availability relative to ART Introduction varied across the sites, from 5 years prior to ART roll-out, to 9 years after. Calendar time was classified according to ART availability, grouped into pre ART, ART introduction (available in at least one health facility serving study site) and ART available (available in all designated health facilities serving study site). We used Poisson regression to calculate age adjusted fertility rate ratios over time by HIV status, and investigated the interaction between ART period and HIV status to ascertain whether trends over time were different for HIV positive and negative women. Results Age-adjusted fertility rates declined significantly over time for HIV negative women in all four studies. However HIV positives either had no change in fertility (Masaka, Rakai) or experienced a significant increase over the same period (Kisesa, uMkhanyakude). HIV positive fertility was significantly lower than negative in both the pre ART period (age adjusted fertility rate ratio (FRR) range 0.51 95%CI 0.42–0.61 to 0.73 95%CI 0.64–0.83) and when ART was widely available (FRR range 0.57 95%CI 0.52–0.62 to 0.83 95%CI 0.78–0.87), but the difference has narrowed. The interaction terms describing the difference in trends between HIV positives and negatives are generally significant. Conclusions Differences in fertility between HIV positive and HIV negative women are narrowing over time as ART becomes more widely available in these communities. Routine adjustment of ANC data for estimating national HIV prevalence will need to allow for the impact of treatment.
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Affiliation(s)
- Milly Marston
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | | | - Victoria Hosegood
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Faculty of Medicine, Faculty of Social and Human Sciences, University of Southampton, Southampton, United Kingdom
| | - Tom Lutalo
- TAZAMA Project, National Institute of Medical Research, Mwanza, Tanzania
| | | | - Basia Zaba
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Mathur S, Higgins J, Thummalachetty N, Rasmussen M, Kelley L, Nakyanjo N, Nalugoda F, Santelli JS. Fatherhood, marriage and HIV risk among young men in rural Uganda. CULTURE, HEALTH & SEXUALITY 2015; 18:538-52. [PMID: 26540470 PMCID: PMC4897968 DOI: 10.1080/13691058.2015.1091508] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Compared to a large body of work on how gender may affect young women's vulnerability to HIV, we know little about how masculine ideals and practices relating to marriage and fertility desires shape young men's HIV risk. Using life-history interview data with 30 HIV-positive and HIV-negative young men aged 15-24 years, this analysis offers an in-depth perspective on young men's transition through adolescence, the desire for fatherhood and experience of sexual partnerships in rural Uganda. Young men consistently reported the desire for fatherhood as a cornerstone of masculinity and transition to adulthood. Ideally young men wanted children within socially sanctioned unions. Yet, most young men were unable to realise their marital intentions. Gendered expectations to be economic providers combined with structural constraints, such as limited access to educational and income-generating opportunities, led some young men to engage in a variety of HIV-risk behaviours. Multiple partnerships and limited condom use were at times an attempt by some young men to attain some part of their aspirations related to fatherhood and marriage. Our findings suggest that young men possess relationship and parenthood aspirations that - in an environment of economic scarcity - may influence HIV-related risk.
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Affiliation(s)
- Sanyukta Mathur
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York
| | - Jenny Higgins
- Department of Gender and Women’s Studies, University of Wisconsin-Madison, Madison
| | - Nityanjali Thummalachetty
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York
| | - Mariko Rasmussen
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York
| | | | | | | | - John S. Santelli
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York
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Lutalo T, Gray R, Mathur S, Wawer M, Guwatudde D, Santelli J, Nalugoda F, Makumbi F. Desire for female sterilization among women wishing to limit births in rural Rakai, Uganda. Contraception 2015; 92:482-7. [PMID: 26232377 PMCID: PMC4615543 DOI: 10.1016/j.contraception.2015.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 07/21/2015] [Accepted: 07/21/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Uganda has an unmet need for family planning of 34% and a total fertility rate of 6.2. We assessed the desire for female sterilization among sexually active women who wanted to stop childbearing in rural Rakai district, Uganda. STUDY DESIGN 7192 sexually active women enrolled in a community cohort between 2002 and 2008 were asked about fertility intentions. Those stating that they did not want another child (limiters) were asked whether they would be willing to accept female sterilization, if available. Trends in desire for sterilization were determined by chi-square test for trend, and Modified Poisson regression was used to estimate prevalence rate ratios and 95% confidence intervals of the associations between desire for sterilization and socio-demographic characteristics and HIV status. RESULTS From 2002 to 2008, the proportion of limiters dropped (from 47.2% to 43.7%; p<.01). Use of pills and injectables among limiters significantly increased, 38.9% to 50.3% (p<.0001), while use of intrauterine devices and implants declined from 3.3% to 1.7% (p<0.001). The desire for sterilization significantly increased from 54.2% to 63.1% (p<0.0001), and this was consistently higher among the HIV-positive (63.6-70.9%, p<0.01) than HIV-negative women (53.3-61.2%, p<0.0001). Factors significantly associated with the desire for sterilization included higher number of living children (>=3), being HIV-infected and having received HIV counseling and testing. CONCLUSION There is latent and growing desire for sterilization in this population. Our findings suggest a need to increase permanent contraception services for women who want to limit childbearing in this setting. IMPLICATIONS A large unmet need for permanent female contraception services exists in Uganda. Efforts to increase the method mix by increasing permanent contraception services could reduce fertility rates and undesired births.
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Affiliation(s)
- Tom Lutalo
- Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda.
| | - Ron Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sanyukta Mathur
- Joseph L Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Maria Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Guwatudde
- Makerere University School of Public Health, Kampala, Uganda
| | - John Santelli
- Joseph L Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Fred Nalugoda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda
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Santelli JS, Song X, Holden IK, Wunder K, Zhong X, Wei Y, Mathur S, Lutalo T, Nalugoda F, Gray RH, Serwadda DM. Prevalence of Sexual Experience and Initiation of Sexual Intercourse Among Adolescents, Rakai District, Uganda, 1994-2011. J Adolesc Health 2015; 57:496-505. [PMID: 26499857 PMCID: PMC4671201 DOI: 10.1016/j.jadohealth.2015.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 07/24/2015] [Accepted: 07/25/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of the study was to identify risk factors and time trends for sexual experience and sexual debut in rural Uganda. METHODS Using population-based, longitudinal data from 15- to 19-year olds in Rakai, Uganda, we examined temporal trends in the prevalence of sexual experience and potential risk factors for sexual experience (n = 31,517 person-round observations) using logistic regression. We then identified factors associated with initiation of sex between survey rounds, using Poisson regression to estimate incidence rate ratios (IRR; n = 5,126 person-year observations). RESULTS Sexual experience was more common among adolescent women than men. The prevalence of sexual experience rose for most age-gender groups after 1994 and then declined after 2002. Factors associated with higher prevalence of sexual experience (without adjustment for other factors) included age, not enrolled in school, orphanhood, lower socioeconomic status, and drinking alcohol in the past 30 days; similar factors were associated with initiation of sex. Factors independently associated with initiation of sex included older age, nonenrollment in school (IRR = 1.7 for women and 1.8 for men), alcohol use (IRR = 1.3 for women and men), and being a double orphan among men (IRR = 1.2). Sexual experience began to decline around 2000, whereas increases in school enrollment began as early as 1994 and declines in orphanhood occurred after 2004 (as antiretroviral therapy became available). CONCLUSIONS Sexual experience among youth in Rakai was associated with social factors particularly school enrollment. Changes in these social factors also appear to influence change over time in sexual experience.
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Affiliation(s)
- John S. Santelli
- Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, 60 Haven Avenue B-2, New York, NY 10032
| | - Xiaoyu Song
- Department of Biostatistics, Mailman School of Public Health, Columbia University, 722 West 168 Street, 6 Floor, New York, NY 10032
| | - Inge K. Holden
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168 Street, New York, NY 10032
| | - Kristin Wunder
- Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, 60 Haven Avenue B-2, New York, NY 10032
| | - Xiaobo Zhong
- Department of Biostatistics, Mailman School of Public Health, Columbia University 722 West 168 Street, 6 Floor, New York, NY 10032
| | - Ying Wei
- Department of Biostatistics, Mailman School of Public Health, Columbia University, 722 West 168 Street, 6 Floor, New York, NY 10032
| | - Sanyukta Mathur
- Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, 60 Haven Avenue B-2, New York, NY 10032
| | - Tom Lutalo
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, P.O. Box 49, Entebbe, Uganda
| | - Fred Nalugoda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, P.O. Box 49, Entebbe, Uganda
| | - Ron H. Gray
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe St #5041, Baltimore, MD 21205
| | - David M. Serwadda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, P.O. Box 49, Entebbe, Uganda
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Impact of Availability and Use of ART/PMTCT Services on Fertility Desires of Previously Pregnant Women in Rakai, Uganda: A Retrospective Cohort Study. J Acquir Immune Defic Syndr 2015; 69:377-84. [PMID: 25835605 DOI: 10.1097/qai.0000000000000612] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess fertility desires by availability and use of antiretroviral therapy and prevention of mother-to-child transmission (ART/PMTCT) services in Rakai, Uganda. DESIGN Retrospective analyses of longitudinal data from the Rakai Community Cohort Study. METHODS Study participants were retrospectively identified and categorized by HIV status. Availability of ART/PMTCT services in Rakai was defined in three periods: (1) pre-ART/PMTCT (<2005), (2) ART/PMTCT rollout (2005-2006), and (3) universal ART/PMTCT (>2006); and use of ART/PMTCT was coded as yes if the woman received services. Trends in fertility desires were assessed by χ. "Modified" Poisson regression was performed using generalized linear models with a log link and Poisson family to estimate prevalence rate ratios (PRRs) and 95% confidence intervals (CIs) of desire for another child among previously and currently pregnant women; PRRs were adjusted for demographic and behavioral factors. RESULTS A total of 4227 sexually active women in Rakai, including 436 HIV+ women, contributed 13,970 observations over 5 survey rounds. Fertility desires increased in the population in the ART/PMTCT rollout [adjusted (adj.) PRR: 1.08, 95% CI: 1.04 to 1.13] and the universal availability periods (adj. PRR: 1.11, 95% CI: 1.08 to 1.14) compared with pre-ART/PMTCT period. A total of 862 woman observations used ART/PMTCT services. Fertility desires were similar among ART/PMTCT service users and nonusers in cross-sectional analysis (adj. PRR: 0.84, 95% CI: 0.62 to 1.14) and 1 year after ART/PMTCT use (adj. PRR: 1.27, 95% CI: 0.83 to 1.94). CONCLUSIONS Availability of ART/PMTCT may increase fertility desires of previously pregnant women in Rakai, Uganda. Use of ART/PMTCT services was not correlated with fertility desires of previously or current pregnant women.
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Antiretroviral Therapy Availability and HIV Disclosure to Spouse in Rakai, Uganda: A Longitudinal Population-Based Study. J Acquir Immune Defic Syndr 2015; 69:241-7. [PMID: 26009833 DOI: 10.1097/qai.0000000000000600] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A decade after the rollout of antiretroviral therapy (ART) in sub-Saharan Africa, the effects of this structural change on social aspects of HIV, such as rates of HIV disclosure to partners, remain largely unmeasured. We evaluated whether the introduction of ART was associated with disclosure of HIV diagnosis to spouses in Rakai, Uganda, using longitudinal, population-based data. METHODS We identified individuals in marital/cohabitating unions who were newly diagnosed with HIV in Rakai Community Cohort Study surveys between 2000 and 2008, where ART was introduced in mid-2004. Using discrete-time survival analysis, we assessed the hazard of self-reported HIV disclosure to spouse after diagnosis pre-ART and post-ART rollout, adjusting for individual and union characteristics. Disclosure in the ART period was further stratified by ART initiation. RESULTS The analysis included 557 married adults, 264 of whom were diagnosed with HIV before ART was available (2000-2004), and 293 diagnosed after ART was introduced (2005-2008). The cumulative incidence of self-reported disclosure was 75.2% in the post-ART period, compared with 58.3% before ART availability [P < 0.001, adjusted hazard ratio: 1.46 (95% confidence interval: 1.16 to 1.83)]. In the post-ART period, observed disclosure rates were 39% (72 of 184) among those not in HIV care, 65% (82 of 126) among those in pre-ART care, and 85% (64 of 75) among persons on ART (P < 0.001). CONCLUSIONS Treatment availability and use, especially ART initiation, was associated with increased self-disclosure of HIV diagnosis to partners. ART access may facilitate the prevention of transmission to uninfected partners and linkage to treatment for infected couples.
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