Revisiting the ABC strategy: HIV prevention in Uganda in the era of antiretroviral therapy

Exploring Intervention Frameworks to Improve Utilization of Elimination of Mother-to-Child Transmission Services in Africa: A Scoping Review

BACKGROUND

Over the past two decades, intervention strategies to improve the use of the elimination of mother-to-child transmission (EMTCT) services have been implemented for several reasons. The reasons include elimination of HIV infections during pregnancy, delivery, breastfeeding, prevention of HIV, prevention of unintended pregnancies, and safer conception. Poor utilization of EMTCT services has been proven to put the child at risk of acquiring HIV, which could have been avoided.

OBJECTIVE

This study aims to explore and describe interventions to promote the elimination of mother-to-child transmission services among pregnant and nursing mothers in Africa.

METHOD

A scoping literature review technique was undertaken on research papers published in English that focused on EMTCT, barriers, interventions, and methods to address challenges to EMTCT utilization. These were screened independently and coded.

RESULTS

The analysis comprised 14 out of approximately 9029 literature sources. Intervention strategies to improve EMTCT service utilization, according to the findings, include accessibility and affordability, healthcare worker training, integrating the elimination of mother-to-child transmission into maternal and child health services, community-based interventions, family-centred approaches, and the use of technology.

CONCLUSIONS

Interventions that increase women's use of EMTCT services will contribute to the aim of HIV-free generation by reducing new HIV infections in children and saving lives.

Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa

The study investigates the statistical relationship between male circumcision and HIV prevalence in Africa, in the context of the Voluntary Medical Male Circumcision (VMMC) campaigns in place since 2008. Data from the Population-based HIV Impact Assessment (PHIA) surveys conducted in African countries in 2017-2018 were utilized. Six countries with high HIV prevalence, low traditional circumcision and large VMMC programs were selected: Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe. The statistical analysis investigated the relative risk (RR) of HIV prevalence by circumcision status (circumcised vs intact) among men age 20-59, and the age-incidence of HIV in the two groups among men age 20-49, defined as the linear-logistic slope of the relationship between prevalence and age. Results show that the standardized RR was not different from 1 at older ages (50-59): RR = 0.923, 95% CI = 0.769-1.108, P = 0.390. Furthermore, the age-incidence was at least as high or higher among the circumcised groups than among the intact groups. The standardized RR was lower than 1 at younger ages, and this could be explained by selection biases. HIV prevalence at age 40-59 (27.3%) was also the same in the four groups of circumcision status (intact, traditional, medical, unknown). Results matched earlier observations made in South Africa that circumcised and intact men had similar levels of HIV infection. The study questions the current strategy of large scale VMMC campaigns to control the HIV epidemic. These campaigns also raise a number of ethical issues.

Changing relationships between HIV prevalence and circumcision in Lesotho

The study investigates the complex relationships between circumcision and HIV prevalence in Lesotho, using Demographic and Health surveys (DHS) conducted in 2004, 2009 and 2014. Before the HIV epidemic, about half of the male adult population was circumcised as part of a traditional custom, and this proportion increased markedly after 2008 with the campaigns of Voluntary Medical Male Circumcision (VMMC), while HIV prevalence stayed at the same level. In 2004, HIV prevalence was higher in circumcised groups than in intact groups (RR=1.49, 95% CI=1.20-1.86). This relationship changed over time, and was inversed in 2014 (RR=0.86; 95% CI=0.70-1.06). The changing relationship seems to be due to an interaction with education, with more educated men being more circumcised and having less HIV over time. A multivariate analysis showed no net effect of circumcision on HIV, after controlling for wealth, education, and indicators of marriage and sexual behaviour. A small net effect of VMMC was found, probably due to condom use. In couple studies, the effect of circumcision and VMMC on HIV was not significant, with similar transmission from female to male and male to female. The study questions the amount of effort and money spent on VMMC in Lesotho.

Barriers and facilitators to oral PrEP uptake among high-risk men after HIV testing at workplaces in Uganda: a qualitative study

BACKGROUND

Men in Uganda contribute significantly to new HIV infections annually yet PrEP uptake among them is low and those initiated are likely to discontinue usage. We explored the barriers and facilitators to PrEP uptake among high-risk men employed in private security services with negative HIV results after testing at workplaces in Uganda.

METHODS

An explorative qualitative study comprising in-depth participant interviews. Data were collected via telephone calls and manually analyzed by inductive content analysis.

RESULTS

Fifty-six (56) men participated, 27(48.21%) had heard about PrEP, and 29(51.79%) were willing to initiate it. Four categories emerged for the facilitators of PrEP uptake including the perceived need for HIV prevention, awareness creation, availability, and sexual freedom. Six categories emerged for the barriers to PrEP uptake. These were: Inaccessibility of PrEP services, Misinformation, Knowledge deficit, Medication-related barriers, Potential for increased risky sexual behavior, and Perceptions about PrEP use.

CONCLUSION

The findings suggest the need for healthcare providers to offer information regarding PrEP and HIV prevention services and mass sensitization campaigns to facilitate uptake. Participants recommend mass roll-out of PrEP to lower-level facilities and accessible pick-up points for men such as workplaces. The men also suggested the use of longer-acting PrEP modalities such as an injectable option or an option that is utilized specifically by the female partner. Finally, the stigma surrounding PrEP use could be reduced by the separation of PrEP and ART services at health facilities, or special pick-up days to reduce waiting times.

Stigma of infidelity associated with condom use explains low rates of condom uptake: qualitative data from Uganda and Tanzania

Despite widespread messaging supporting male (external) condom use to prevent HIV in endemic settings, utilization of condoms is low across sub-Saharan Africa. A thorough understanding of barriers to condom use as a form of HIV prevention is necessary to reduce HIV transmission. Here, we present qualitative data from rural eastern Africa to explain low utilization of condoms among heterosexual adults. Focus groups and interviews were conducted in Tanzania and Uganda between 2016 and 2019. A content analysis approach was used to identify attitudes about condoms and factors related to use/non-use. We found that strategies such as abstinence and being faithful to one's partner are perceived as ideal but rarely achievable methods of HIV prevention. Condoms are used in the setting of "failure" to abstain or be faithful and are therefore stigmatized as markers of infidelity. As such, use within cohabiting and long-term relationships is low. Our data suggest that negative perceptions of condoms may stem from persistent effects of the formerly applied "ABC" HIV prevention approach, a public health messaging strategy that described A-abstinence, B-be faithful, and C-use a condom as tiered prevention tools. Condom uptake could increase if HIV prevention messaging acknowledges existing stigma and reframes condom use for proactive health prevention. These studies were approved by Weill Cornell Medicine (Protocols 1803019105 and 1604017171), Mbarara University of Science and Technology (Protocol 16/0117), Uganda National Council of Science and Technology (Protocol SS-4338), and the Tanzania National Institute for Medical Research (Protocol NIMR/HQ/R.8c/Vol.I/1330).

HPV Vaccination in Kenya: The Challenges Faced and Strategies to Increase Uptake

Human papilloma virus (HPV) is the leading cause of ano-genital cancers globally with cervical cancer as the top cause of cancer- related deaths in women. Over 90% of these deaths occur in low income countries where cancer control strategies remain inadequate. HPV vaccination provides protection against HPV types 16 and 18 which are responsible for approximately 70% of cervical cancer cases. The optimal age of vaccination is in the early adolescent period, before sexual debut with possible HPV infection. Studies have shown that children residing in low income settlements are at risk of early initiation of sexual activity. Adolescent vaccination programs would provide an avenue to link other health promotion strategies targeting this age group that has hitherto been left out of many health interventions in 2019, Kenya introduced HPV vaccine to be given to 10 year old girls. Uptake has been sub-optimal with only 33% of targeted population receiving the first dose in 2020 and 16% returning for the 2nd dose. While disruption of immunization programs by the COVID-19 pandemic contributed to the low coverage, other factors such as low demand fuelled by misinformation have also played a role.

Has the relationship between wealth and HIV risk in Sub-Saharan Africa changed over time? A temporal, gendered and hierarchical analysis

This study examines the relationship between wealth and HIV infection in Sub-Saharan Africa to determine whether and how this relationship has varied over time, within and across countries, by gender, and urban environment. The analysis draws on DHS and AIS data from 27 Sub-Saharan African countries, which spanned the 14 years between 2003 and 2016. We first use logistic regression analyses to assess the relationship between individual wealth, HIV infection and gender by country and year stratified on urban environment. We then use meta-regression analyses to assess the relationship between country level measures of wealth and the odds of HIV infection by gender and individual level wealth, stratified on urban environment. We find that there is a persistent and positive relationship between wealth and the odds of HIV infection across countries, but that the strength of this association has weakened over time. The rate of attenuation does not appear to differ between urban/rural strata. Likewise, we also find that these associations were most pronounced for women and that this relationship was persistent over the study period and across urban and rural strata. Overall, our findings suggest that the relationship between wealth and HIV infection is beginning to reverse and that in the coming years, the relationship between wealth and HIV infection in Sub-Saharan Africa may more clearly mirror the predominant global picture.

Messaging matters: achieving equity in the HIV response through public health communication

Public health messages shape how the world understands the HIV epidemic. Considerable inequalities remain in HIV care continuum indicators by subpopulation and geography (eg, highest infection and mortality burden among men who have sex with men and people who live in sub-Saharan Africa). Health equity-focused approaches are necessary in this next decade to close gaps in the HIV epidemic. Between 1981 and 1989, HIV messages triggered fear and victim blaming, and highlighted behaviours of a few marginalised groups as deviant. Between 1990 and 1999, messages signalled that HIV was a growing challenge for the world and required multisector approaches that addressed structural drivers of inequality. Between 2000 and 2009, messages highlighted universal testing, while advances in HIV testing made these messages easier for individuals to respond to than in previous decades. Currently, messages signal that ending HIV is possible, people can live productive lives with HIV, and transmission to people without HIV can be eliminated. Public health messaging about the HIV epidemic has evolved substantially over the past 40 years. Future HIV messaging should be driven by health equity principles that include an increased representation of key populations in message design and dissemination, transparency of funding, and communicating any impact that campaigns have had on closing health inequalities.

Assessment of an HIV-prevention intervention for couples in peri-urban Uganda: pervasive challenges to relationship quality also challenge intervention effectiveness

Reducing multiple and concurrent partnerships has been identified as a priority in generalised HIV epidemics, yet developing successful interventions to bring about such behaviour change has proven challenging. We offered a three-session intervention aimed to improve couple relationship quality and address HIV risk factors, particularly concurrent sexual partnerships (CSP), in a peri-urban community of Kampala, Uganda. Before launching the intervention, a different group of community members participated in eight single-gender focus group discussions (FGDs) which explored issues of couple relationship quality and satisfaction. Findings from the FGDs guided the intervention. All 162 couples invited to the intervention completed a survey pre- and post-intervention. In FGDs, women and men discussed challenges faced in their relationships, including pervasive dissatisfaction, financial constraints, deception and lack of trust, poor communication, lack of sexual satisfaction, and concurrent sexual partnerships. A difference-in-difference analysis showed no measurable impact of the intervention on relationship quality or sexual risk behaviours over a six-month follow-up among 183 individuals who participated in the intervention, although many stated in response to open-ended questions that they had experienced positive relationship changes. Qualitative findings suggest high demand for couple-focused interventions but also reveal many individual-, couple-, community- and structural-level factors which contribute to women and men seeking concurrent sexual partnerships. More intensive interventions may be needed to overcome these barriers to behaviour change and reduce HIV risk. These findings also raise questions about how to interpret divergent qualitative and quantitative data, a topic which has received little attention in the literature.

ASSOCIATION BETWEEN HIV AWARENESS FACTORS, HEALTH FACILITY CHARACTERISTICS AND RISKY SEXUAL BEHAVIOUR AMONG YOUNG WOMEN IN ZOMBA DISTRICT, MALAWI

The objective of this study was to examine the association between multilevel factors related to HIV awareness and risky sexual behaviour among young women in Zomba district, Malawi. Secondary analyses of the Schooling, Income, and Health Risk (SIHR) study were undertaken. Four outcomes related to risky sexual behaviour were examined among young women: if participants had ever had sex, consistent condom use and two scores measuring risk related to partner history and age during sexual activity. Independent variables included individual-level factors such as education and rural/urban residence, as well as higher-level factors such as household's highest level of education and health facility characteristics. Regression models with cluster-robust standard errors and multilevel regression models were used to estimate associations; analyses were stratified into two strata by school enrolment status, i.e. whether the women were in school (N=1407) or had dropped out of school (N=407) at baseline of the SIHR study. For both strata, increasing age and residing within 16 km of an urban centre ('near rural' residence) increased the odds of ever having sex; lower educational achievement was associated with lower age during sexual activity. A history of pregnancy was associated with lower odds of condom use and riskier partner history. For women in school at baseline, lower household education was associated with higher odds of ever having sex (OR=1.48; 95% CI: 1.06, 2.07); near-rural and far-rural (≤16 km and >16km from urban centre, respectively) residence were associated with decreased odds of condom use (OR=0.47; 95% CI: 0.28, 0.78; and OR=0.27; 95% CI: 0.11, 0.65, respectively). For those not in school at baseline, lower household education was associated with lower age during sexual activity (β=0.31, 95% CI: 0.05, 0.58). Also for women not in school, the use of private or non-governmental health facilities was associated with decreased odds of condom use (OR=0.51, 95% CI: 0.39, 0.67) and higher age during sexual activity (β=-0.30, 95% CI: -0.52, -0.09). While individual factors were associated with risky sexual behaviour in both strata, contextual factors differed.

Male condom use, multiple sexual partners and HIV: a prospective case-control study in Kinshasa (DRC)

In the Democratic Republic of Congo no previous studies have assessed the factors associated with different patterns of condom use and with multiple sexual partners, and the association between condom use simultaneously taking into account multiple sexual partnerships, and HIV infection. We carried out a prospective case-control study. From December 2010 until June 2012, 1630 participants aged 15-49 getting HIV Voluntary Counseling and Testing in a hospital in Kinshasa were selected. Cases were new HIV diagnosis and controls were HIV-negative participants detected along the study period. We recruited 274 cases and 1340 controls that were interviewed about HIV-related knowledge, attitudes and behaviours. Among cases there was a high prevalence of multiple lifetime and concurrent sexual partnerships (89.8% and 20.4%, respectively) and most cases never used condoms with only 1.5% using them consistently. Condom use and multiple partnerships were associated with male, single and high-educated participants. An association was found between multiple lifetime partners and 'any condom use' (OR = 2.99; 95%CI: 2.14-4.19) but not with consistent use. Both having two or more multiple concurrent sexual partners or not using condoms were variables similarly and highly associated to HIV risk. The association found between having two or more concurrent sexual partners and HIV was slightly higher (OR = 3.58, 95%CI:2.31-5.56) than the association found between never condom use and HIV (OR = 3.38, 95%CI:1.15-9.93). We found a high prevalence of multiple lifetime sexual partners and an extremely high prevalence of inconsistent condom use, both strongly associated with HIV seropositivity. Local programmes would benefit from comprehensive interventions targeting all behavioural and sociocultural determinants.

Prevalence and correlates of HIV-risky sexual behaviors among students attending the Medical and Social Welfare Center of the University of Maroua, Cameroon

BACKGROUND

Data on sexual behaviors in Cameroonian youths are needed to design and implement effective preventive strategies against HIV/AIDS. This study aimed at assessing sociodemographic and religious factors associated with sexual behaviors among university students in Cameroon.

METHODS

In 2011, 411 university students were surveyed by a self-administered questionnaire at the Medical and Social Welfare Center of the University of Maroua. Logistic regression analyses were used to determine correlates of sexual behaviors.

RESULTS

80.8 % of students were sexually active. The mean age at sexual debut was 18.1 years (SD = 3.1). The frequency of premarital sex was 92.8 %. Pornography viewing [adjusted odds ratio (aOR): 4.0, 95 % CI 2.1-7.6; p < 0.0001] and an increased age of 1 year (aOR: 1.3, 95 % CI 2.0-7.6; p < 0.0001) were significantly associated with having previously had sex. The likelihood to have a lower (<18) age at sexual debut was increased by male gender (aOR: 2.5, 95 % CI 1.7-5; p < 0.001), and urban origin (aOR: 2.9, 95 % CI 1.5-5.7; p < 0.01). The probability to have a high number (#3) of lifetime sexual partners was increased by age (aOR: 1.1, 95 % CI 1.0-1.2; p < 0.001), pornography viewing (aOR: 4.3, 95 % CI 1.9-9.5; p < 0.001), an early sexual debut (aOR: 2.8, 95 % CI 1.6-5.0; p < 0.001), having had occasional sexual partners (aOR: 7.0, 95 % CI 3.7-13.1; p < 0.0001), and was decreased by Muslim religious affiliation (aOR: 0.2, 95 % CI 0.1-0.9; p < 0.05). Having had casual sexual partners was associated with less inconsistent condom use (aOR: 0.5, 95 % CI 0.2-0.9; p < 0.05).

CONCLUSIONS

Our findings indicate that there is an alarming level of risky sexual behaviors among the study population. Strong and efficient measures should be undertaken to handle such harmful behaviors, this for the prevention and control of HIV/AIDS and other STIs in this vulnerable population.

Our bodies are our own: resistance to ABC-based HIV-prevention programmes in northern Tanzanian conservation organisations

ABC-based HIV-prevention programmes have been widely employed in northern Tanzanian wildlife conservation settings in an attempt to (re)shape the sexual behaviours of conservation actors. Utilising findings from 66 semi-structured interviews conducted in 2009-2010, this paper examines ABC prevention as a form of Foucauldian governmentality--circulating technologies of power that mobilise disciplinary technologies and attempt to transform such efforts into technologies of the self--and explores how individuals understand and respond to attempts to govern their behaviour. ABC regimes attempt to rework subjectivity, positioning HIV-related behaviours within a risk-based neoliberal rationality. However, efforts to use ABC as a technology to govern populations and individual bodies are largely incommensurate with existing Tanzanian sociocultural formations, including economic and gendered inequalities, and local understandings of sexuality. The language research participants used to talk about ABC and the justifications they offered for non-compliance illuminate this discrepancy. Data reveal that the recipients of ABC campaigns are active producers of understandings that work for them in their lives, but may not produce the behavioural shifts envisioned by programme goals. These findings corroborate previous research, which questions the continued plausibility of ABC as a stand-alone HIV- prevention framework.

Individual and contextual socioeconomic determinants of knowledge of the ABC approach of preventing the sexual transmission of HIV in Nigeria: a multilevel analysis

BACKGROUND

Nigeria has the highest number of people living with HIV/AIDS in the world after India and South Africa. HIV/AIDS places a considerable burden on society's resources, and its prevention is a cost-beneficial solution to address these consequences. To the best of our knowledge, there has been no multilevel study performed to date that examined the separate and independent associations of individual and community socioeconomic status (SES) with HIV prevention knowledge in Nigeria.

METHODS

Multilevel linear regression models were applied to the 2008 Nigeria Demographic and Health Survey on 48871 respondents (Level 1) nested within 886 communities (Level 2) from 37 districts (Level 3).

RESULTS

Approximately one-fifth (20%) of respondents were not aware of any of the Abstinence, Being faithful and Condom use (ABC) approach of preventing the sexual transmission of HIV. However, the likelihood of being aware of the ABC approach of preventing the sexual transmission of HIV increased with older age, male gender, greater education attainment, a higher wealth index, living in an urban area and being from least socioeconomically disadvantaged communities. There were significant community and district variations in respondents' knowledge of the ABC approach of preventing the sexual transmission of HIV.

CONCLUSION

The present study provides evidence that both individual- and community-level SES factors are important predictors of knowledge of the ABC approach of preventing the sexual transmission of HIV in Nigeria. The findings underscore the need to implement public health prevention strategies not only at the individual level, but also at the community level.

The need to reemphasize behavior change for HIV prevention in Uganda: a qualitative study

Uganda has long been considered an AIDS success story, although in recent years declines in prevalence and incidence appear to have stalled or even reversed. During the early stages of Uganda's AIDS prevention program, health messages emphasized behavior change, especially fidelity. Ugandans were made to fear AIDS and feel personally at risk of dying from a new, poorly understood disease. In this research, six focus group discussions with 64 participants in peri-urban and rural areas outside Kampala suggest that HIV prevention messages have shifted in the direction of risk reduction: condoms, testing, and drugs. Ugandans now seem less afraid of becoming infected with HIV, at least in part because antiretroviral therapy is available, and this diminished fear may be having a disinhibiting effect on sexual behavior. Participants believe that HIV rates are on the rise, that more individuals are engaged in multiple and concurrent sexual partnerships, and that sexual behavior is less restrained than a generation ago. These findings suggest that AIDS-prevention programs in Uganda would benefit from refocusing on the content that yielded success previously-sexual behavior change strategies.

Knowledge and misconceptions about HIV counseling and testing (HCT) among the post-conflict youths of Gulu, Northern Uganda. A prospective study design

BACKGROUND

Uganda has been reported as the most successful country in Africa in reducing the prevalence of HIV/AIDS from 18% to 6.4% over the last two decades. There is evidence to suggest that despite a significant decline between 1992 and 2002, HIV prevalence has stagnated over the last 5-9 years at between 6.1 and 6.5% and it is rising in some parts of the country such as Gulu. This rise are thought to be due to the high levels of stigma and superstition preventing HIV counseling and testing (HCT). WHO reports in 2009 showed that only 20% of Uganda's populations knew their HIV sero-status. This study was designed to find out the knowledge, misconceptions, attitude and practices of youths of Gulu about HCT.

METHODS

A cross-sectional study was conducted in Gulu, Pece among the youths 15 to 35 years. An in-depth interview using a questionnaire was administered to youths of Commercial Road Sub-ward. Informed consent and ethical approval was obtained and 86 respondents were interviewed.

RESULTS

Ninety three percent of respondents had knowledge about HCT and 97.7% were able to mention two or more of its benefits. Most (88.4%) agreed on public disclosure of their HIV status and 84.9% would encourage others to undertake it. Only 36.1% of respondents had undertaken HCT while the rest had not undertaken it due to fear of stigmatization.

CONCLUSION

There is adequate knowledge, good attitude but poor practice and misconceptions to HCT. The young adults in Gulu should be supported in a special program to enable them undertake HCT and access other services for HIV/AIDS prevention.

An exploratory study of HIV-prevention advocacy by persons in HIV care in Uganda

To explore how people living with HIV (PLHIV) and in care encourage others to adopt HIV-protective behaviours, we conducted in-depth interviews with a purposive sample of 40 HIV clinic patients in Kampala, Uganda. Content analysis was used to examine the message content, trigger events, and outcomes of HIV-prevention advocacy events initiated by the HIV clients with members of their social networks. The content themes included encouraging specific behaviours, such as HIV testing and treatment, condom use and non-promiscuity, as well as more general cautionary messages about protecting oneself from HIV infection. Common triggers for bringing up HIV-prevention advocacy information in a discussion or conversation included: wanting to prevent the targeted person from 'falling into the same problems,' wanting to benefit oneself with regard to avoiding re-infection, out of concern that the target would engage in higher-risk behaviour, due to observed changes in the target's health, and to convey information after receiving treatment at the clinic. The participants mostly reported positive or neutral responses to these advocacy events; negative responses were rare. Interventions to empower PLHIV to be agents of change could represent a new frontier for HIV prevention.

The impact of socio-demographic and religious factors upon sexual behavior among Ugandan university students

INTRODUCTION

More knowledge is needed about structural factors in society that affect risky sexual behaviors. Educational institutions such as universities provide an opportune arena for interventions among young people. The aim of this study was to investigate the relationship between sociodemographic and religious factors and their impact on sexual behavior among university students in Uganda.

METHODS

In 2005, 980 university students (response rate 80%) were assessed by a self-administered questionnaire. Validated instruments were used to assess socio-demographic and religious factors and sexual behavior. Logistic regression analyses were applied.

RESULTS

Our findings indicated that 37% of the male and 49% of the female students had not previously had sex. Of those with sexual experience, 46% of the males and 23% of the females had had three or more sexual partners, and 32% of the males and 38% of the females did not consistently use condoms. For those who rated religion as less important in their family, the probability of early sexual activity and having had a high number of lifetime partners increased by a statistically significant amount (OR = 1.7; 95% CI: 1.2-2.4 and OR = 1.6; 95% CI: 1.1-2.3, respectively). However, the role of religion seemed to have no impact on condom use. Being of Protestant faith interacted with gender: among those who had debuted sexually, Protestant female students were more likely to have had three or more lifetime partners; the opposite was true for Protestant male students.

CONCLUSION

Religion emerged as an important determinant of sexual behavior among Ugandan university students. Our findings correlate with the increasing number of conservative religious injunctions against premarital sex directed at young people in many countries with a high burden. of HIV/AIDS. Such influence of religion must be taken into account in order to gain a deeper understanding of the forces that shape sexual behavior in Uganda.

Risk Factors and Seroprevalence of Hepatitis C among Patients Hospitalized at Mulago Hospital, Uganda

The emergence of hepatitis C virus (HCV) and its associated sequelae in Africa is a cause for significant concern. Human immunodeficiency virus (HIV) positive patients are at an increased risk of contracting HCV infection due to similar risk factors and modes of transmission. We investigated the seroprevalence of hepatitis C in hospitalized HIV-positive and HIV-negative patients in Mulago Hospital, an academic hospital in Uganda. Blood samples were first tested for HCV antibodies, and positive tests were confirmed with HCV RNA PCR. We enrolled five hundred patients, half HIV-positive and half HIV negative. Overall, 13/500 patients (2.6%) tested positive for HCV antibodies. There was no difference in HCV antibody detection among HIV-positive and HIV-negative patients. Out of all risk factors examined, only an age greater than 50 years was associated with HCV infection. Traditional risk factors for concurrent HIV and HCV transmission, such as intravenous drug use, were exceedingly rare in Uganda. Only 3 of 13 patients with detectable HCV antibodies were confirmed by HCV RNA detection. This result concurs with recent studies noting poor performance of HCV antibody testing when using African sera. These tests should be validated in the local population before implementation.

Prevention messages and AIDS risk behavior in Kampala, Uganda

Uganda was one of the first countries to substantially reduce HIV rates through behavior change, but these gains have not continued in recent years. Little is known about what messages Ugandans are currently hearing about AIDS prevention, what they themselves believe to be important prevention strategies, and how these beliefs are associated with behavior. We interviewed men and women aged between 20 and 39 in two poor peri-urban areas of Kampala, using a random sample, cross-sectional household survey design. Respondents provided detailed reports of sexual behavior over the past six months, the main prevention message they are currently hearing about AIDS, and their own ranking of the importance of prevention strategies. Condom use was the main AIDS prevention message that respondents reported hearing, followed by getting tested. These were also what respondents themselves considered most important, followed closely by faithfulness. Abstinence was the lowest ranked strategy, but a higher ranking for this prevention strategy was the only one consistently associated with less risky behavior. A higher ranking for condoms was associated with higher levels of risk behavior, while the ranking of testing made no difference in any behavior. These results present challenges for AIDS prevention strategies that rely primarily on promoting condoms and testing. HIV prevention programs need to assess their impact on behavior.

Effect of a healthcare gender gap on progression of HIV/AIDS defined by clinical-biological criteria among adults from Cordoba City (Argentina) from 1995 to 2005

OBJECTIVE

To establish the influence of clinical status at diagnosis and of gender on progression of HIV/AIDS determined by clinical-biological factors in patients from Cordoba City (Argentina) from 1995 to 2005).

METHODS

Gender and clinical and laboratory data were evaluated by descriptive statistics, non-parametric survival analysis, and generalized linear models at the beginning of the study (diagnosis) and at the end (hospital records, n=209).

RESULTS

At diagnosis, women (n=28, 13.4%) had a higher probability of being asymptomatic than men (n=181, 86.6%). High viremia was associated with advanced clinical stages, but was inversely related to CD4 count. Truncated Kaplan-Meier curves were similar for both sexes. The probability of not having AIDS criteria at the end of the study was higher in patients without these criteria at diagnosis. Women had a higher probability of having AIDS at the end of the follow-up than men. In contrast, men had a higher prevalence of venereal diseases (n=38, 21%), dysmetabolic profile (n=14, 7.7%) and positive serology for opportunists (n=31, 17.1%). Marker diseases were mainly represented by internal mycosis and waste syndrome, although less specific findings (anemia, oral lesions) were also associated with progression.

CONCLUSIONS

Using an integrative approach, high viremia was critically linked to clinical and lymphocyte impairment. Early diagnosis was a major determinant of clinical course, with women having a worse prognosis. However, men were diagnosed in clinically advanced stages and with other non-HIV-related entities, which could affect progression. These findings should be integrated into the planning of preventive strategies.

Examining the actions of faith-based organizations and their influence on HIV/AIDS-related stigma: a case study of Uganda

BACKGROUND

Stigma and discrimination are widely recognized as factors that fuel the HIV/AIDS epidemic. Uganda's success in combating HIV/AIDS has been attributed to a number of factors, including political, religious and societal engagement and openness - actors that combat stigma and assist prevention efforts.

OBJECTIVES

Our study aimed to explore perceptions of Uganda-based key decision-makers about the past, present and optimal future roles of FBOs in HIV/AIDS work, including actions to promote or dissuade stigma and discrimination.

METHODS

We analyzed FBO contributions in relation to priorities established in the Global Strategy Framework on HIV/AIDS, a consensus-based strategy developed by United Nations Member States. Thirty expert key informants from 11 different sectors including faith-based organizations participated in a structured interview on their perceptions of the role that FBOs have played and could most usefully play in HIV/AIDS prevention, care and support.

RESULTS

Early on, FBOs were perceived by key informants to foster HIV/AIDS-related stigma and discrimination. Respondents attributed this to inadequate knowledge, moralistic perspectives, and fear relating to the sensitive issues surrounding sexuality and death. More recent FBO efforts are perceived to dissuade HIV/AIDS-related stigma and discrimination through increased openness about HIV status among both clergy and congregation members, and the leadership of persons living with HIV/AIDS.

CONCLUSIONS

Uganda's program continues to face challenges, including perceptions among the general population that HIV/AIDS is a cause for secrecy. By virtue of their networks and influence, respondents believe that FBOs are well-positioned to contribute to breaking the silence about HIV/AIDS which undermines prevention, care and treatment efforts.

Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence

OBJECTIVES

To identify the changes in sexual behaviour that led to the dramatic reduction in the prevalence of HIV in Uganda in the early 1990s.

METHODS

Seven different types of evidence were examined: (1) models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda; (2) reports of behaviour change in the primary newspaper in Uganda; (3) surveys with questions about perceptions of personal behaviour change; (4) large demographic and health surveys (DHS) collected in 1988/9 and 1995 and large Global Program on AIDS (GPA) surveys in 1989 and 1995 with questions about reported sexual behaviour; (5) smaller less representative surveys of reported sexual behaviour collected in other years; (6) reports of numbers of condoms shipped to Uganda; and (7) historical documents describing the implementation of HIV prevention programmes in Uganda.

RESULTS

All seven types of data produced consistent evidence that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships, and then increased their use of condoms with non-marital and non-cohabiting partners.

CONCLUSIONS

Consistent with basic theories about transmission of sexually transmitted infections, first reducing the number of sexual partners and breaking up sexual networks and then reducing the chances of HIV transmission with remaining casual partners by using condoms can be achieved and can dramatically reduce the sexual transmission of HIV in generalised epidemics.

The effects of enhanced access to antiretroviral therapy: a qualitative study of community perceptions in Kampala city, Uganda

INTRODUCTION

Since 2001, Antiretroviral Therapy (ART) has been integrated as part of the Uganda National Program for Comprehensive HIV/AIDS Care and Support. If patients take Antiretroviral drugs (ARVs) as prescribed, quality of life is expected to improve and patients become healthier. It is, however, postulated that scale up of ARVs could erode the previous achievement in behaviour change interventions. This study examined community perceptions and beliefs on whether enhanced access to ARVs increases risk behaviour. It also examined people's fears regarding HIV/AIDS infection and the use of ARVs.

METHODS

This was a qualitative study that utilized Focus Group Discussions (FGDs) and Key Informant (KI) interviews. Participants were purposefully sampled. Twenty FGDs comprising of 190 participants and 12 KI interviews were conducted. FGDs were conducted with adult men and women (above 25 years), and youth (male and female) while KI interviews were held with Kampala City Council officials, Kawempe Division Local Council officials, health workers and religious leaders. All data was tape recorded with consent from participants and transcribed thereafter. Typed data was analyzed manually using qualitative latent content analysis technique.

RESULTS

Most participants felt that enhanced access to ART would increase risky sexual behaviour; namely promiscuity, lack of faithfulness among couples, multiple partners, prostitution, unprotected sexual practices, rape and lack of abstinence as the risky sexual behaviours. A few FGDs, however, indicated that increased ART access and counselling that HIV-positive people receive promoted positive health behaviour. Some of the participants expressed fears that the increased use of ARVs would promote HIV transmission because it would be difficult to differentiate between HIV-positive and HIV-negative persons since they all looked healthy. Furthermore, respondents expressed uncertainty about ARVs with regard to adherence, sustainable supply, and capacity to ensure quality of ARVs on the market.

CONCLUSIONS

There are fears and misconceptions that enhanced access to ART will increase risky sexual behaviour and HIV transmission. Information Education and Communication (IEC) on ART use and availability should be enhanced among all people. Prevention programs which are modified and specific to the needs of the people living with HIV should be developed and implemented, and should include information on the ability of individuals to transmit HIV even when they are on ART.

Focusing HIV prevention on those most likely to transmit the virus

Despite some success in reducing HIV incidence, the global epidemic continues to grow. For every person with AIDS in developing countries placed on treatment in 2005, many others were newly infected. We need more effective prevention programs that focus interventions on those most at risk for HIV transmission (MART), particularly those with 1) high behavioral risk and 2) high viral loads due to acute or recent infection, co-infections with other diseases, high viral set points, or untreated AIDS. This article provides examples of how prevention programs can incorporate emerging testing technologies and social/behavioral approaches to reach these individuals, their partners, and the social networks where active transmission is occurring.

Framing HIV prevention discourse to encompass the complexities of war in northern Uganda

In northern Uganda, physical and structural violence (political repression, economic inequality, and gender-based discrimination) increase vulnerability to HIV infection. In settings of war, traditional HIV prevention that solely promotes risk avoidance and risk reduction and assumes the existence of personal choice inadequately addresses the realities of HIV transmission. The design of HIV prevention strategies in northern Uganda must recognize how HIV transmission occurs and the factors that put people at risk for infection. A human rights approach provides a viable model for achieving this aim.