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Drawing on an international literature review, two international workshops and primary qualitative research in Uganda this paper reviews experiences of mainstreaming HIV/AIDS in development sectors (such as education, health and agriculture) in developing countries. The extent to which HIV/AIDS mainstreaming strategies and associated challenges are similar to or different from those of mainstreaming gender in the health sector is also explored. The paper details the rationale for HIV/AIDS mainstreaming through illustrating the wide reaching effects of the pandemic. Despite the increasing interest in mainstreaming HIV/AIDS there is little clarity on what it actually means in theory or practice. This paper presents a working definition of HIV/AIDS mainstreaming. It is argued that all too often processes of ‘mainstreaming’ emerge as too narrow and reductionist to be effective. The paper then considers four key challenges for mainstreaming HIV/AIDS and explores how and to what extent they have also been faced in gender mainstreaming and what can be learnt from these experiences. These are: (1) the limited evidence base upon which to build mainstreaming strategies in different country contexts; (2) the role of donors in mainstreaming and implications for sustainability; (3) who should take responsibility for mainstreaming; and (4) how to develop capacity for mainstreaming. The conclusion argues for more joined up thinking and sustainable approaches to mainstreaming both HIV/AIDS and gender. [ABSTRACT FROM AUTHOR]

This paper considers the effects of antiretroviral treatment on the households of person with AIDS in western Uganda. Interviews were carried out with 110 co-resident “treatment partners” of people receiving treatment. We discuss these family members' accounts of the impact of sickness, followed by treatment, on their household's livelihood, defined as the activities needed to obtain and process the resources required to sustain the households. The household's ability to muster labour for subsistence agriculture was of paramount concern when family members considered what treatment meant for the households. While they were very happy with the treatment, they said that households have not yet recovered from the shock of AIDS sicknesses. [ABSTRACT FROM AUTHOR]

Women living with HIV are at increased risk for psychosocial distress, especially among social and economically disadvantaged women living in rural areas. Little is known about how social support and wealth impacts the mental health of women caring for young children in low- and middle-income countries. The purpose of this paper was to assess demographic, socio-economic, and social support correlates of depression and anxiety in HIV-infected+ female caregivers living in rural Uganda. Depression and anxiety were assessed using the Hopkins Symptom Checklist (HSCL-25), two-domains of social support (family and community) were measured with the adapted Multidimensional Scale for Perceived Social Support, and wealth was measured using a checklist of material possessions and housing quality among 288 women. Multivariable linear regression models assessed the association of depression and anxiety with demographic and social predictors. Sixty-one percent of women reported clinically significant symptoms of depression or anxiety using the standard HSCL-25 cut-off of >1.75. Lower wealth (p = .01) and family support (p = .01) were significantly associated with more depressive symptoms, with greater family support being more protective of depression in the highest wealth group (top 20%) compared to the lowest. More anxiety symptoms were associated with lower wealth (p = .001), lower family support (p = .02), and higher community support (p = .003). Economic and social support factors are important predictors of caregiver mental health in the face of HIV disease in rural Uganda. Findings suggest that interventions should consider ways to increase economic opportunities and strengthen family support for HIV+ caregivers. [ABSTRACT FROM PUBLISHER]

Major depressive disorder (MDD) is projected to become the second most common cause of disability by 2020 calling for a better understanding its antecedents across the lifespan and in diverse socio-cultural settings. In this paper we describe the risk factors of MDD among older people (50 years +) living in HIV-endemic central and southwestern Uganda. A cross-sectional study was undertaken among 471 respondents (50 years +) participating in the Wellbeing of Older People’s Study cohort of the MRC/UVRI Uganda research Unit on AIDS in Uganda. Participants were from five strata: HIV negative, HIV positive on ART, HIV positive not on ART, having an adult child on ART, and having an adult child who died of HIV. Overall MDD prevalence was 9.2% (95% CI 6.7–12.2%) with a prevalence among males of 7.4% (95% CI 4.0–12.3%) and females of 10.3% (95% CI 7.0–14.3%). Factors significantly associated with MDD included: declining socio-economic status, increasing disability scores, decreasing mean grip strength, reported back pain, and not having hypertension. Marginally associated with MDD was being HIV infected and not on ART. [ABSTRACT FROM PUBLISHER]

Psychological distress is common among adolescents living with HIV (ALHIV) worldwide, and has been associated with non-adherence to anti-retroviral therapy (ART), leading to poor virologic suppression, drug resistance, and increased risk for AIDS morbidity and mortality. However, only a few studies have explored the relationship between psychological distress and ART adherence among adolescents in sub-Saharan Africa. The paper examines the relationship between psychological distress and ART adherence, and effect of psychosocial resources on ART adherence. We conducted a cross-sectional survey of 464 ALHIV (aged 12–19; 53% female) seeking HIV care at a large HIV treatment center in Kampala, Uganda. ALHIV were recruited during routine clinic visits. Three self-reported binary adherence measures were utilized: missed pills in the past three days, non-adherence to the prescribed medical regimen, and self-rated adherence assessed using a visual analog scale. Psychological distress was measured as a continuous variable, and computed as the mean score on a locally developed and validated 25-item symptom checklist for Ugandan ALHIV. Psychosocial resources included spirituality, religiosity, optimism, social support, and coping strategies. After adjusting for respondents’ socio-demographic characteristics and psychosocial resources, a unit increase in psychological distress was associated with increased odds of missing pills in past 3 days (Odds Ratio(OR) = 1.75; Confidence Interval (CI): 1.04–2.95), not following the prescribed regimen (OR = 1.63; CI: 1.08–2.46), and lower self-rated adherence (OR = 1.79; CI: 1.19–2.69). Psychosocial resources were associated with lower odds for non-adherence on all three self-report measures. There is a need to strengthen the psychosocial aspects of adolescent HIV care by developing interventions to identify and prevent psychological distress among Ugandan ALHIV. [ABSTRACT FROM AUTHOR]

Consistent condom use can prevent HIV infection, yet levels of condom use are low in many settings. This paper examines determinants of inconsistent condom use among 905 women enrolled in a high-risk cohort in Kampala, Uganda, who reported sexual intercourse with paying clients in the last month. Among these, 40% participants reported using condoms inconsistently with paying clients in the past month. The most common reason for inconsistent condom use was client preference. Factors independently associated with inconsistent condom use included: sex work not being the sole source of income [adjusted odds ratio (aOR) = 1.54; 95% confidence interval (CI): 1.13-2.09], sexual debut before 14 years (aOR = 1.46; 95% CI: 1.09-1.96), daily consumption of alcohol (aOR = 1.90; 95% CI: 1.26-2.88) and being currently pregnant (aOR = 2.11; 95% CI: 1.25-3.57). Being currently married (aOR =0.36; 95% CI: 0.18-0.73) and a higher number of sexual partners per month (p-trend = 0.001) were associated with a lower risk of inconsistent condom use. Targeted programmes should be developed to promote consistent condom use in high-risk women, alongside interventions to reduce alcohol use. [ABSTRACT FROM AUTHOR]

This paper describes a study which explored the lives of young Ugandan women through their voices, and related the findings to HIV prevention paradigms. The research was conducted in the context of the continuing vulnerability of young Ugandan women to HIV; reflected in disproportionately high prevalence compared to young men. The participants of the study were 15 young women aged 15–19 years, from Busoga Region in Eastern Uganda. Given the focus on young women's voices within norms of gender inequality, a narrative methodology was used as a safe space for participants to speak about their lives, expanding on research experiences with young people. The methods used included drawing; written stories and drama; aspirational writing and diary keeping. Forty-eight narratives, in image and word form, represented everyday experiences in young women's lives, as well as difficult experiences of inequality and resistance. Young women portrayed considerable social barriers to empowerment, and a challenging environment of poverty and educational limitations. Young women's representations were analysed using a gender empowerment and positive sexuality framework. The resulting analysis was then critically applied to HIV prevention paradigms. Evidence from the study showed that prevailing HIV prevention paradigms reinforce the difficulties faced by young women in their sexual lives. This research adds to calls for alternative and wider approaches to HIV prevention, underpinned by gender empowerment. Alternative approaches need to build young African women's voices in the spaces of homes, schools and communities. It is vital, however, that such efforts are embedded in more radical change leading to social environments receptive to the needs of young women. [ABSTRACT FROM PUBLISHER]

This paper defines the range of sexual partners chosen by out-of-school adolescents from Masaka District in rural south-west Uganda, and implications for sexual and reproductive health discussed. Data are drawn from a sexual health needs assessment using applied anthropological techniques with 31 adolescents, their parents, guardians and community leaders. Data were analysed using inductive thematic methods. Out-of-school adolescents are exposed to risk both stable and casual sexual relationships. Young men and women want a stable relationship with one reliable partner. Young men seek a 'steady' relationship with younger schoolgirls; some also seek multiple 'casual' relationships with young women easily convinced with gifts. Young women accept 'permanent' partnerships with traders or transport workers one-three years older than themselves; some accept 'casual' relationship with age mates, others have 'casual' relationships with older men. All relationships involve the exchange of gifts and money. Older partners, or 'sugar daddies', are valued, despite the knowledge they are more likely to be HIV positive, because they offer greater financial rewards than age mates. Though far less common, some older women seek relationships with younger men, but are treated with suspicion by young men, who believe they are seeking to 'infect' them 'maliciously' with AIDS. The community sees these relationships as a source of AIDS in adolescents, and condemn older men, whom they believe to be 'killing' the younger generation. Both young men and women are exposure to sexual health risk in their primary partnerships; young men in partnerships with schoolgirls who have concurrent partnerships with older men, unlikely to use condoms and young women with partners who work, and have casual relationships in urban trading centres. Health promotion encouraging partnership with age mates, discouraging sex with older partners and 100% condom use before marriage are most appropriate for out-of-school adolescents in this context. [ABSTRACT FROM AUTHOR]

This paper examines how HIV diagnosis, illness and anti-retroviral therapy (ART) have an impact on the social dimensions of people's lives in rural Uganda, focusing on identity, relationships and membership of groups. Using concepts drawn from sociological research on experiences of illness and recovery, 'getting back to normal', 'rebirth' and 'turning point', we present findings from qualitative research that explored the social changes brought about by HIV and ART among 70 men and women taking ART since 2003. With a second chance at life, some people's narratives revealed a pursuit of getting 'back to normal', restoring and resuming their place in their families and communities. Others sought to change or transform their new lives, what we term a 'social rebirth', moving away from old social networks and lifestyles. Regaining health was associated with a desire to make the most of life by joining social groups and civil society organisations, establishing new relationships and advising and supporting others. However, earlier losses of family and friends due to AIDS-related deaths made 'social rebirth' hard for many people. Our findings also show that the process of responding to ART is not linear and the pursuit of change following diagnosis and treatment may be difficult to sustain, as the months and years on ART progress and the struggles of getting on with life take their toll. Sustaining social rebirth was challenging and complex due to the nature of HIV infection itself (for example, new intimate relationships pose challenges) and the harsh economic environment. Maintaining changed lives for those living with HIV and ART is important because this will contribute to better disease self-management and so demands an understanding by support organisations of the nature of these changes and challenges. [ABSTRACT FROM AUTHOR]

This paper explores HIV patients' adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Interviewees voiced their experiences of, and views on ART adherence both from an individual and a system level perspective. Two main themes emerged from the content analysis: “Patients' competing costs and systems' resource constraints” and “Patients' trust in ART and quality of the patient-provider encounters.” The first theme refers to how patients' adherence was challenged by difficulties in supporting themselves and their families, paying for transportation, for drug refill and follow-up as well as paying for registration fees, opportunistic infection treatment, and expensive referrals to other hospitals. The second theme describes factors that influenced patients' capacity to adhere: personal responsibility in treatment, trust in the effects of antiretroviral drugs, and trust in the quality of counseling. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling. [ABSTRACT FROM AUTHOR]

Although adolescent girls in Uganda are particularly vulnerable to HIV infection, providing relevant sexual health education to them is problematic. The senga (father's sister), is the traditional channel for socializing adolescent girls into sex and marriage among many ethnic groups in Uganda. This paper discusses the implementation and community acceptability of 'modern' sengas who were trained to provide HIV-related counselling to adolescent girls. Fourteen sengas were trained in two villages and, in the course of the 1-year study, 247 individuals made a total of 403 visits to them. By including both traditional services (such as advice on and assistance with labial elongation) and modern health and sex education, the sengas provided a 'middle road' between tradition and modernity. As a result, despite initial suspicion by the community, their activities were supported by the community generally and effective as intervention. [ABSTRACT FROM AUTHOR]

Although long distance truck drivers have been implicated in the spread of HIV in Africa, there is a paucity of studies of their sexual cultures. This paper reports on a study of the sexual culture of drivers, mediators and commercial sex workers (CSWs) in a roadside truck stop on the Trans-Africa highway in south west Uganda. Sixty-nine truck drivers, six middlemen and 12 CSWs were interviewed using semi-structured questionnaires. Interviewing truck drivers also entailed participating in the town's nightlife and spending much time in the bars. Truck drivers stop briefly at the truck stop for various reasons: to eat, sleep, have sex and sell goods they are carrying. Middlemen mediate the latter two activities. Middlemen buy goods from the drivers and introduce them to 'suitable' women with whom they can have casual sex. Most drivers have sex when they spend the night at the truck stop, and most make use of the services of the middlemen. The most important reasons why drivers use middlemen are that the latter speak the local languages and, in particular, know the trustworthy and 'safe' (HIV-negative) women. The CSWs use middlemen mainly because they are a guarantee that the driver will pay and they usually ensure that drivers pay well. The mediation system is becoming increasingly professionalized. Most drivers claimed to use condoms during casual sex, and this was confirmed by the CSWs. General use of condoms is encouraging, particularly given the context of a culture generally opposed to condoms. The idea that middlemen can recognize 'safe' women is worrying. However, given their key position, middlemen could form the hub of an opinion leader type intervention focused on drivers and the professional group of sex workers described here, providing condoms, advising about the importance of condom use in all casual sexual encounters, giving information about HIV and STDs, and possibly referring drivers and women to appropriate sources of HIV counselling and testing and STD treatment. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Depression is a common cause of morbidity globally and can impact adherence to medications, posing challenges to medication-based HIV prevention. The objectives of this work are to describe the frequency of depression symptoms in a cohort of 499 young women in Kampala, Uganda and to determine the association of depression symptoms with use of HIV pre-exposure prophylaxis (PrEP). Mild or greater depression, assessed by the patient health questionnaire (PHQ-9), was experienced by 34% of participants at enrollment. Participants with mild depression symptoms tended to uptake PrEP, request PrEP refills, and adhere to PrEP with similar frequency to women with no/minimal signs of depression. These findings highlight opportunities to leverage existing HIV prevention programs to identify women who may benefit from mental health services and may not otherwise be screened. Trial registration: ClinicalTrials.gov identifier: NCT03464266.. [ABSTRACT FROM AUTHOR]

The uptake of HIV prevention services is lower among youth than adults in sub-Saharan Africa. Existing youth livelihood trainings offer a potential entry point to HIV prevention services. We determined feasibility and preliminary effectiveness of integrating HIV prevention into youth clubs implementing an empowerment and livelihood for adolescents (ELA) intervention in rural Uganda. Staff conducted community mobilization for youth (15–24 years) over one month. Clubs met (3×/week) over six months, with local peer mentors trained to teach life-skills and sexual/reproductive health education. We integrated mentor-led education on HIV prevention, including pre- and post-exposure prophylaxis (PrEP/PEP). Clubs offered on-site HIV testing, a field trip to a local clinic and PrEP referrals after one month and six months. Surveys were conducted at baseline and six months. Forty-two participants (24 adolescent girls/young women (AGYW) and 18 adolescent boys/young men (ABYM)) joined the clubs. At baseline, no participants accepted referral for PrEP, whereas 5/18 (28%) sexually active, HIV-negative AGYW requested PrEP referral at follow-up. One ABYM requested PEP referral. Integration of HIV prevention services into an established ELA curriculum at mentor-led youth clubs in rural Uganda was feasible. PrEP uptake increased among sexually active AGYW. Evaluation of this approach for HIV prevention among youth merits further study. [ABSTRACT FROM AUTHOR]

Youth living with HIV (YLWHIV) have an increased cancer risk. Our objective is to describe the prevalence of medical record (MR) reported suspected cancers in a contemporary cohort of YLWHIV in Uganda that was assembled through MR reviews of patients 10 to 24 years old across 35 Ugandan HIV care health facilities. Clinical data were abstracted to identify suspected cancer cases and information about HIV care. Among 3728 YLWHIV, we identified eight suspected cancer cases. The most common suspected types were Kaposi sarcoma (n=4) followed by lymphoma (n=3). Challenges encountered in data abstraction were missing data for several variables and confirmatory cancer diagnostic information. In follow-up of suspected cases referred for diagnosis at the Uganda Cancer Institute (UCI), none had diagnosis records in UCI files. In addition, ∼18% of patients (n=686) were lost-to-follow-up (LTF) defined as not having returned to the clinic in ≥183 days and three patients died from presumed Kaposi sarcoma. Although our results suggest that cancer is rare in YLWHIV, the possibility that the cancer burden is higher cannot be excluded due to incomplete information in MRs and high LTF rates. Further, our study raises concern that patients referred for diagnosis are not accessing potential life-saving care. [ABSTRACT FROM AUTHOR]

Achieving universal HIV test-and-treat will require targeted interventions for those with worse outcomes, including advanced HIV. We conducted qualitative, semi-structured interviews with healthcare workers (HCWs) and people living with HIV (PLWH) at 5 HIV clinics in Kampala, Uganda, to understand barriers to care. PLWH enrolled started/restarted on HIV treatment ≤3 months prior. PLWH were grouped as 1) "ART-experienced" or those restarted therapy after ≥12 months off, 2) ART naïve CD4 count <100 cells/uL "late presenters" or 3) ART naïve CD4 count >350 cells/uL "early presenters". In-depth interviews were conducted in Luganda, translated, and transcribed verbatim. Between May and August 2017, 58 PLWH and 20 HCWs were interviewed. High stigma and low social support emerged as themes among all as barriers to care. Alcohol abuse was a barrier for men. Fear of domestic violence and abandonment were barriers for women, limiting disclosure of their HIV status to their male partners. Clinic factors such as rapport with staff, distance, efficiency, and privacy impacted care. Future interventions to decrease delayed ART initiation should target stigma and social support. Assisted disclosure, contact tracing, and alcohol abuse treatment should be implemented. Strengthening client support, reducing wait times, and increasing privacy assurances would improve care-seeking behaviors. [ABSTRACT FROM AUTHOR]

HIV stigma is a major barrier to HIV care and treatment among people living with HIV (PLWH). Evidence suggests that expansion in antiretroviral therapy (ART) may reduce stigma. However, there are limited longitudinal studies examining temporal trends in HIV stigma in sub-Saharan Africa in the Undetectable = Untransmittable (U = U) era. We longitudinally assessed temporal trends in self-reported experienced stigma and the association of experienced stigma with ART adherence and viral suppression among PLWH enrolled in the African Cohort Study (AFRICOS). AFRICOS is an ongoing cohort study enrolling PLWH in Uganda, Kenya, Tanzania, and Nigeria. As of 1 March 2020, 2937 PLWH enrolled in AFRICOS and had available data. In 2013, 22% of participants reported stigma at the enrollment visit and by 2018 the prevalence decreased to 1% overall and was below 2% for all countries. However, there was not a statistically significant change in stigma prevalence in our longitudinal models. In adjusted models, experiencing stigma was associated with a 0.67 decreased odds of ART Adherence (95% confidence interval (CI): 0.56–0.80) and a 0.64 decreased odds of viral suppression (95% CI: 0.73–0.99). HIV-associated stigma was associated with poor self-reported ART adherence and unsuppressed viral load. [ABSTRACT FROM AUTHOR]

HIV disproportionately affect adolescent girls and young women in sub-Saharan Africa. In Uganda, the HIV prevalence is four times higher in adolescent girls compared to boys. This study examined gender, HIV general and clinical knowledge, and prevention attitudes among adolescents living with HIV in Uganda. Data from a cluster randomized clinical trial were analyzed. A total of 702 adolescents (average age of 12.4) were randomized to either a control arm receiving bolstered standard of care or the treatment arm receiving bolstered standard of care plus a family economic empowerment intervention to support medication adherence. Ordinary Least Squares models that adjust for clustering of adolescents within health clinics were conducted. No gender differences were observed in HIV knowledge and prevention attitudes at baseline. However, at 12-months follow-up, boys were more likely than girls to report correct HIV general knowledge (d = 0.21), clinical knowledge (d = 0.48), and favorable prevention attitudes (d = 0.27). The intervention was not associated with any of the outcomes. Given the high HIV prevalence among adolescents, specifically girls, there is need to develop and/or tailor existing programs and interventions that equip adolescent girls with comprehensive knowledge and prevention attitudes, that are culturally appropriate, to reduce HIV transmission and reinfection within this population. [ABSTRACT FROM AUTHOR]

Introduction: Discomfort with and reluctance to disclose HIV status can lead to depression, social isolation, and poor medication adherence; we examined relationships among these variables within a sample of adolescents living with HIV in Uganda. Methods: We used baseline data from the Suubi + Adherence study, which recruited a total of 702 adolescents (ages 10–16 years) living with HIV in southwestern Uganda. Structural equation models were conducted separately among in-school adolescents and out-of-school adolescents to assess associations between discomfort level with HIV status and depressive symptoms and if this association was mediated by hopelessness. Results: Out-of-school adolescents had significantly higher depression scores compared with those in-school youth (M = 6.24 vs. M = 5.03, p < 0.001). Although high discomfort level with HIV status was significantly associated with higher depression scores among both in-school adolescents and out-of-school adolescents, this association among out-of-school adolescents (B = 0.49, 95%CI: 0.19, 0.79), was more substantial than for in-school adolescents (B = 0.10, 95%CI: 0.03, 0.17). Discussion: One's discomfort with their HIV status and the extent to which they are hopeful about the future can contribute to the development of depressive symptoms and these factors need to be considered in the development of assessments and interventions for the treatment of depression among adolescents living with HIV. [ABSTRACT FROM AUTHOR]

This article sets out to investigate alcohol and substance use (ASU) among adolescents living with HIV (ALWH) in the sub-Saharan African setting of Uganda. A cross-sectional analysis of the records of 479 adolescents (aged between 12and 17 years) attending the study, "Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)" was undertaken. ASU was assessed through both youth self-report and caregiver report using the Diagnostic and Statistical Manual of Mental Disorders-5 referenced instruments, the Youth Inventory-4R and the Child and Adolescent Symptom Inventory-5 (CASI-5). Rates and association with potential risk and outcome factors were investigated using logistic regression models. The rate of ASU was 29/484 (5.9%) with the most frequently reported ASU being alcohol 22/484 (4.3%) and marijuana 10/484 (2.1%). Functional impairment secondary to ASU was reported by 10/484 (2.1%) of the youth. ASU was significantly associated with urban residence, caregiver psychological distress and the psychiatric diagnosis of post-traumatic stress disorder. On associations with negative outcomes, ASU was significantly associated with only "ever had sex". Health care for ALWH in sub-Saharan Africa should include ASU prevention and management strategies. [ABSTRACT FROM AUTHOR]

Depressive symptoms among HIV-positive (HIV+) women may negatively impact their health and possibly that of their young children through risk of compromised caregiving. We evaluated how depression symptoms in predominantly (97%) female caregivers relate to neurodevelopmental outcomes in their HIV affected children. Data come from the IMPAACT P1104s Study, an observational cohort across six sites in four countries: Zimbabwe, South Africa, Uganda and Malawi. Participants (n = 611) were 5–11-year-old children with HIV (HIV), HIV exposed uninfected (HEU), or HIV unexposed uninfected (HUU). Primary caregivers were assessed for depression with the Hopkins Symptom Checklist (HSCL) and children with Behavior Rating Inventory for Executive Function (BRIEF) parent-report, Kauffman Assessment Battery for Children II (KABC), Bruininks-Oseretsky Test of Motor Proficiency 2nd Ed. (BOT-2), Test of Variables of Attention (TOVA), Multiple Indicators Cluster Survey, Child Disability and Development scales (MICS-4). Caregivers with higher depression scores (>1.75 mean HSCL score) reported more executive function problems in their children, regardless of HIV status. All executive function scores were significantly (p < 0.001) associated with depressive symptomatology at baseline and across time. Caregiver depressive symptomatology was not associated with other assessed neurocognitive outcomes. These results highlight the potential impact of caregiver depression on child behavioral outcomes. [ABSTRACT FROM AUTHOR]

We investigated changes in cognitive function and physical health and behavioural outcomes (HIV disease progression, health-seeking behaviour, adherence to HIV medications and risky sexual behaviour) at baseline and 12 months later among 1126 Ugandan adults living with HIV. Overall, cognitive function improved from baseline to follow-up, except for gait speed, which was slower at follow-up compared to baseline. There were improvements in physical health and behavioural outcomes by follow-up, with greater improvements among individuals on ART compared to those not on ART. Change in gait speed over time significantly predicted risky sexual behaviours at follow-up. This is the first study to investigate the longitudinal relationships between cognitive function and health outcomes among Ugandan adults living with HIV and provide insights into the possible links between cognitive function and negative clinical and behavioural health outcomes in people living with HIV. [ABSTRACT FROM AUTHOR]

Novel monitoring technologies in HIV research, such as electronic adherence monitors (EAMs), have changed the nature of researcher-participant interactions. Yet little is known about how EAMs and the resulting interaction between researchers and participants affect research participation and the data gathered. We interviewed participants and research assistants (RAs) in an observational cohort study involving EAMs for HIV antiretroviral therapy (ART) in Uganda. We qualitatively explored interviewees' views about ethical issues surrounding EAMs and assessed data with conventional and directed content analysis. Participants valued their relationships with RAs and were preoccupied with RAs' perceptions of them. Participants were pleased when the EAM revealed regular adherence, and annoyed when it revealed non-adherence that contradicted self-reported pill-taking behavior. For many, the desire to maintain a good impression incentivized adherence. But some sought to creatively conceal non-adherence, or refused to use the EAM to avoid revealing non-adherence to RAs. These findings show that participants' perceptions of the study staff's perceptions of them affected the experience of being monitored, study participation, and ultimately the data gathered in the study. Investigators in monitoring-based research should be aware that social interactions between participants and study staff could affect both the practical and ethical conduct of that research. [ABSTRACT FROM AUTHOR]

Understanding the link between HIV knowledge, risky sexual behaviors, and social intolerance such as stigma and discrimination is important for HIV prevention and treatment program planning. We investigated whether intolerant attitudes and practices among Ugandan adults were associated with HIV-transmission knowledge. We analyzed data from a nationally representative population-based household survey, the 2011 Uganda AIDS Indicator Survey. A total of 15,526 participants who responded to questions on HIV knowledge, social intolerance and risky sexual behavior were included in this analysis. Results show that 34.8% of respondents reported having fear of casual contact with people living with HIV (PLWA), 21% blame PLWAs for their disease, 62% would not want HIV infection in their family disclosed, while 25% reported engaging in risky sexual behaviors. After adjusting for age, sex, residence, and level of education, people with low HIV-transmission knowledge had almost three-fold higher odds of fear of casual contact with a PLWA (aOR = 2.70, 95%CI = 2.33-3.13), and had 30% higher odds of HIV-related stigmatizing attitudes (aOR = 1.29, 95%CI = 1.07-1.54). Further, they had 47% higher odds of having sex under the influence of alcohol (aOR = 1.47, 95%CI = 1.25-1.73) and 40% higher odds of having unprotected sex with any of their last three sex partners (aOR = 1.39, 95%CI = 1.06-1.89). Our findings show that intolerant attitudes such as stigma still persist, particularly among people with low HIV-transmission knowledge. Improving knowledge about HIV/AIDS can foster positive attitudes and building safe practices among populations, and is critical for improving prevention and treatment programs. [ABSTRACT FROM AUTHOR]

Ugandan fishing communities are dually burdened with high rates of HIV and alcohol use. This qualitative study explores context and motivation of alcohol consumption, and alcohol's effect on antiretroviral treatment (ART) adherence, among male fisherfolk living with HIV in Wakiso District, Uganda. We conducted in-depth semi-structured interviews with 30 men in HIV care and on ART, and used a thematic analysis approach for analysis. Alcohol use was identified as a major barrier to ART adherence through cognitive impairment and the intentional skipping of doses when drinking. Men reportedly reduced their drinking since HIV diagnosis -- motivated by counseling received from providers and a newfound desire to live a healthy lifestyle. However, social, occupational, and stress-related influences that make alcohol reduction difficult were identified. Our findings suggest alcohol use may pose a challenge to ART adherence for fishermen living with HIV -- and has implications for the tailoring of screening and brief intervention for alcohol reduction in HIV care for this population. [ABSTRACT FROM AUTHOR]

We investigated uptake of home-based HIV counselling and testing (HBHCT) and HIV care services post-HBHCT in order to inform the design of future HBHCT programmes. We used data from an open-label cluster-randomised controlled trial which had demonstrated the effectiveness of a post-HBHCT counselling intervention in increasing linkage to HIV care. HBHCT was offered to adults (≥18 years) from 28 rural communities in Masaka, Uganda; consenting HIV-positive care naïve individuals were enrolled and referred for care. The trial's primary outcome was linkage to HIV care (clinic-verified registration for care) six months post-HBHCT. Random effects logistic regression was used to investigate factors associated with HBHCT uptake, linkage to care, CD4 count receipt, and antiretroviral therapy (ART) initiation; all analyses of uptake of post-HBHCT services were adjusted for trial arm allocation. Of 13,455 adults offered HBHCT, 12,100 (89.9%) accepted. HBHCT uptake was higher among men [adjusted odds ratio (aOR) 1.20, 95% confidence interval (CI) = 1.07-1.36] than women, and decreased with increasing age. Of 551 (4.6%) persons who tested HIV-positive, 205 (37.2%) were in care. Of those not in care, 302 (87.3%) were enrolled in the trial and of these, 42.1% linked to care, 35.4% received CD4 counts, and 29.8% initiated ART at 6 months post-HBHCT. None of the investigated factors was associated with linkage to care. CD4 count receipt was lower in individuals who lived ≥30 min from an HIV clinic (aOR 0.60, 95%CI = 0.34-1.06) versus those who lived closer. ART initiation was higher in older individuals (≥45 years versus <25 years, aOR 2.14, 95% CI = 0.98-4.65), and lower in single (aOR 0.60, 95% CI = 0.28-1.31) or divorced/separated/widowed (aOR 0.47, 95% CI = 0.23-0.93) individuals versus those married/cohabiting. HBHCT was highly acceptable but uptake of post-HBHCT care was low. Other than post-HBHCT counselling, this study did not identify specific issues that require addressing to further improve linkage to care. [ABSTRACT FROM AUTHOR]

While sex workers (SWs) bear the brunt of the epidemic in Uganda, there remains a dearth of empirical research on the structural drivers of HIV prevention among SWs. This study examined the drivers of inconsistent condom use by one-time and regular clients of young women SWs in Gulu, Northern Uganda. Data were drawn from the Gulu Sexual Health Study, a cross-sectional study of young SWs, aged 14 years and older (2011-2012). SWs were recruited using peer/SW-led outreach, in partnership with The AIDS Support Organization and other CBOs. Multivariable logistic regression was used to examine the correlates of inconsistent condom use by one-time and regular clients. In total, 84.5% of the 381 SWs servicing regular clients and 76.8% of the 393 SWs servicing one-time clients reported inconsistent client condom use. In multivariable analysis, physical/sexual violence by clients (AOR = 5.39; 95%CI 3.05-9.49), low sexual control by workers (measured by the validated Pulweritz scale) (AOR = 2.86; 95%CI 1.47-5.58), alcohol/drug use while working (AOR = 1.98; 95%CI 1.17-3.35) and migration to Gulu for sex work (AOR = 1.73; 95%CI 0.95-3.14) were positively correlated with inconsistent condom use by one-time clients. Correlates of inconsistent condom use by regular clients included: low sexual control by workers (AOR = 4.63; 95%CI 2.32-9.23); physical/sexual violence by clients (AOR = 3.48; 95%CI 1.85-6.53); police harassment (AOR = 2.57; 95%CI 1.17-5.65); and being a single mother (AOR = 2.07; 95%CI 1.09-3.93). Structural and interpersonal factors strongly influence inconsistent condom use by clients, with violence by clients and police, low sexual control by workers, migration and single-parenthood all linked to non-condom use. There is a need for peer-led structural interventions that improve access to occupational health and safety standards (e.g., violence prevention and alcohol/drug harm reduction policies/programming). Shifts away from the current punitive approaches towards SWs are integral to the success of such interventions, as they continue to undermine HIV prevention efforts. [ABSTRACT FROM AUTHOR]

Technology-based interventions for behavior change, such as adherence monitors and SMS text messages, can improve adherence to HIV antiretroviral therapy. It is unclear, however, how the effects of such interventions are maintained when interventions are withdrawn. We explored resiliency of people living with HIV in coping with adherence to antiretroviral therapy (ART) after withdrawing an adherence support intervention of real-time adherence monitors linked to SMS text messages at study closure. This is a qualitative study conducted with former participants of a pilot randomized controlled trial after study closure. Between April 2016 and November 2016, we used convenient sampling to interview 28 of the 62 participants from the pilot trial, which was conducted in rural Uganda. Interviews elicited information on experiences of taking ART in the absence of the intervention, coping strategies, and changes in social support interactions. Data were analyzed inductively using content analysis. Most participants demonstrated resilience through learning adherence from the intervention; and internalizing the habit of medication adherence. They seemed to have a sense of self-esteem, positive thinking, and access to supportive relationships. Other participants employed adaptive coping strategies, such as using alternative cues (e.g., alarms), accessing spiritual support, and adjusting their medication time to their routine. A few participants lacked resiliency, lost the habit and struggled with adherence. They were dependent on the intervention, appeared isolated and psychologically stressed, and were unable to overcome challenges associated with poor social support systems. Intervention-related benefits may or may not persist after the intervention is withdrawn. Contingent on individuals" underlying characteristics and relationships, participants manifested resiliency through learning and internalization, as well as using alternative coping strategies. Such resiliency could facilitate the use of short-term interventions, which are particularly important for resource-limited settings. Participants should be referred to available additional support at study closure when needed. [ABSTRACT FROM AUTHOR]

Patient costs are a critical barrier to the elimination of mother to child HIV transmission. Despite the Ugandan government providing free public HIV services, infant antiretroviral (ARV) prophylaxis coverage remains low (25%). To understand costs mothers incur in accessing ARV prophylaxis for their infants, we conducted a mixed methods study to quantify and identify their direct costs. We used cross-sectional survey data and focus group discussions from 49 HIV-positive mothers in Uganda. Means and standard deviations were calculated for the direct costs (e.g., transportation, caretaker, services/medications) involved in accessing infant HIV services. The direct cost of attending HIV clinic visits averaged $3.71 (SD = $3.52). Focus group discussions identified two costs hindering access to infant HIV services: transportation costs and informal service charges. All participants reported significant costs associated with accessing infant HIV services - the equivalent of 2-3 days' income. To address transportation costs, community and home care models should be explored. Additionally, stricter policies and oversight should be implemented to prevent informal HIV service charges. [ABSTRACT FROM AUTHOR]

Studies from sub-Saharan Africa indicate that children made vulnerable by poverty have been disproportionately affected by HIV with many exposed via mother-to-child transmission. For youth living with HIV, adherence to life-saving treatment regimens are likely to be affected by the complex set of economic and social circumstances that challenge their families and also exacerbate health problems. Using baseline data from the National Institute of Child and Human Development (NICHD) funded Suubi+Adherence study, we examined the extent to which individual and composite measures of equity predict self-reported adherence among Ugandan adolescents aged 10–16 (n = 702) living with HIV. Results showed that greater asset ownership, specifically familial possession of seven or more tangible assets, was associated with greater odds of self-reported adherence (OR 1.69, 95% CI: 1.00–2.85). Our analyses also indicated that distance to the nearest health clinic impacts youth’s adherence to an ARV regimen. Youth who reported living nearest to a clinic were significantly more likely to report optimal adherence (OR 1.49, 95% CI: 0.92–2.40). Moreover, applying the composite equity scores, we found that adolescents with greater economic advantage in ownership of household assets, financial savings, and caregiver employment had higher odds of adherence by a factor of 1.70 (95% CI: 1.07–2.70). These findings suggest that interventions addressing economic and social inequities may be beneficial to increase antiretroviral therapy (ART) uptake among economically vulnerable youth, especially in sub-Saharan Africa. This is one of the first studies to address the question of equity in adherence to ART among economically vulnerable youth with HIV. [ABSTRACT FROM PUBLISHER]

Improving economic resources of impoverished youth may alter intentions to engage in sexual risk behaviors by motivating positive future planning to avoid HIV risk and by altering economic contexts contributing to HIV risk. Yet, few studies have examined the effect of economic-strengthening on economic and sexual behaviors of orphaned youth, despite high poverty and high HIV infection in this population. Hierarchal longitudinal regressions were used to examine the effect of a savings-led economic empowerment intervention, the Suubi-Maka Project, on changes in orphaned adolescents’ cash savings and attitudes toward savings and HIV-preventive practices over time. We randomized 346 Ugandan adolescents, aged 10–17 years, to either the control group receiving usual orphan care plus mentoring (n = 167) or the intervention group receiving usual orphan care plus mentoring, financial education, and matched savings accounts (n = 179). Assessments were conducted at baseline, 12, and 24 months. Results indicated that intervention adolescents significantly increased their cash savings over time (b = $US12.32, ±1.12,p < .001) compared to adolescents in the control group. At 24 months post-baseline, 92% of intervention adolescents had accumulated savings compared to 43% in the control group (p < .001). The largest changes in savings goals were the proportion of intervention adolescents valuing saving for money to buy a home (ΔT1−T0 = +14.9,p < .001), pursue vocational training (ΔT1−T0 = +8.8,p < .01), and start a business (T1−T0 = +6.7,p < .01). Intervention adolescents also had a significant relative increase over time in HIV-preventive attitudinal scores (b = +0.19, ±0.09,p < .05), most commonly toward perceived risk of HIV (95.8%,n = 159), sexual abstinence or postponement (91.6%,n = 152), and consistent condom use (93.4%,n = 144). In addition, intervention adolescents had 2.017 significantly greater odds of a maximum HIV-prevention score (OR = 2.017, 95%CI: 1.43–2.84). To minimize HIV risk throughout the adolescent and young adult periods, long-term strategies are needed to integrate youth economic development, including savings and income generation, with age-appropriate combination prevention interventions. [ABSTRACT FROM PUBLISHER]

HIV disclosure is a gateway to HIV prevention – particularly among couples living in regions severely affected by the HIV epidemic. This cross-sectional study utilizes data collected from 862 people living with HIV across three countries (Ethiopia, Mozambique, and Uganda) in 2011 to determine the role of partner disclosure on self-reported health perceptions and changes in sexual risk behavior. The study's secondary aims are to understand whether or not internalized stigma mediates this relationship and if there is a different pattern of results by gender. The multivariate analysis reveals that the three key HIV-related independent variables, belonging to a support group, doing volunteer work, and disclosing to one's spouse or partner, were significantly associated with lower levels of internalized stigma. Internalized stigma was associated with self-perceptions of poorer health for both women and men, with women reporting higher levels of internalized stigma than men. Disclosure to spouse was positively associated with perceptions of better health for women but not for men. For men, doing HIV-related volunteer work and disclosing their status to their spouse were positively associated with self-reported changes in sexual risk behavior, although stigma was not found to mediate this relationship. Findings from this study suggest that disclosure and stigma have gender-specific effects on individual well-being and changes in sexual risk behaviors. As such, programs must address gender inequity in disclosure patterns and stigma to enhance prevention efforts. [ABSTRACT FROM AUTHOR]

Youth represent almost half of all new HIV infections globally. Although condom use is an effective method of HIV prevention among sexually active youth in sub-Saharan Africa (SSA), they face substantial barriers in obtaining condoms in environments where adults hold attitudes condemning premarital sex. More research is needed to better understand the multitude of factors that affect SSA youths' behaviors regarding safe sex practices, including factors that may influence their ability to obtain condoms, and decisions to be tested for HIV. In this study of Uganda youth (n= 1503) from five secondary schools, logistic regression models highlight factors that influence perceptions regarding respect and confidentiality at health centers, condom acquisition, and HIV testing. Family support appears to be an especially important factor that affects youth perceptions about how they will be treated when seeking condoms and HIV testing. Condom acquisition and HIV-testing behaviors are also associated with peer influence, self-esteem, and demographic characteristics, such as age. [ABSTRACT FROM AUTHOR]

The threat of tuberculosis (TB) in Uganda cannot be considered in isolation from the HIV/AIDS epidemic. Stigma contributes to delays in seeking treatment and poor adherence for both TB and HIV patients. This study aims to assess and describe stigma and predictors of stigma related to TB and HIV in the population of western Uganda. This was a cross-sectional mixed methods study. A survey was administered to 360 individuals, randomly selected from one district in western Uganda. Participants were classified as low/high stigma based on weighted scores built from survey questions. Logistic regression was used to determine significant predictors for high stigma. Six focus groups were conducted to inform survey findings; themes were developed using content analysis. Twenty-six per cent of respondents were found to have stigmatising attitudes towards HIV and 47% towards TB. Multivariate logistic regression models included age, sex, marital status, education, residence and having a friend with HIV/TB. Those who had an HIV-positive friend were less likely to have high HIV stigma (OR: 0.41, 95% CI: 0.23–0.72). Those with secondary education or more were half as likely to have high TB stigma (OR: 0.50, 95% CI: 0.27–0.91). Focus group participants felt that “normalisation” of HIV has contributed to reduced HIV stigma, but there is still a fear of being recognised at the HIV clinic. TB stigma causes patients to remain silent instead of seeking care. Fear of TB is driven by the assumption that “TB means HIV”. Declining HIV stigma is encouraging but more effort needs to be made to improve confidentiality. TB stigma is high and is likely affecting care seeking behaviour; TB awareness campaigns should be a priority and emphasise the treatability and curability of TB, regardless of HIV status. [ABSTRACT FROM PUBLISHER]

Capitalizing on emerging data suggesting that HIV-preventive behaviors can be positively affected by Internet-based programs, we developed and tested CyberSenga, an Internet-based, comprehensive sexuality education program for adolescents in Mbarara, Uganda. Three hundred and sixty-six secondary school students were randomly assigned to either the five-lesson program (+ booster) or a treatment-as-usual control. At three-month follow-up, intervention participants provided feedback on the program acceptability. Six focus groups with intervention participants were additionally conducted after the final follow-up at 6 months. Data support a hypothesis of feasibility: despite schedule interruptions, 95% of intervention participants completed all the five modules; only 17% deviated from the once-a-week intended delivery schedule. Internet service was uninterrupted during the field period and, in general, the technology performed to specifications. The intervention also appears to be acceptable: 94% of intervention youth somewhat or strongly agreed that they learned a lot and 93% said they were somewhat or very likely to recommend the program. Although more than two in three youth somewhat or strongly agreed that the program talked too much about sex (70%) and condoms (75%), 89% somewhat or strongly disagreed that “I do not think kids like me should do the CyberSenga program.” Feedback from focus group participants further suggested that the content was generally acceptable and did not contradict local norms in most cases. In fact, despite concerns from some local stakeholders to the contrary, information about condoms did not appear to be confusing or contradictory for youth who were abstinent. Nonetheless, some of the sexual topics seemed to be unfamiliar or uncomfortable for some participants – particularly brief references to oral and anal sex. Together, both qualitative and quantitative data suggest that the program is a feasible and acceptable way of delivering HIV preventive information to both sexually experienced and inexperienced adolescents in Mbarara, Uganda. [ABSTRACT FROM AUTHOR]

Our objective was to determine whether serial HIV testing during pregnancy and the postpartum period as well as male partner testing are acceptable and feasible in Tororo, Uganda. This was a prospective study of pregnant women at the Tororo District Hospital (TDH) Antenatal Clinic. Patients presenting for routine antenatal care were asked to participate in a serial HIV testing integrated into standard antenatal and postpartum/child immunization visits, and to invite their male partners for HIV testing. Serial testing was defined as ≥2 tests during pregnancy and ≥2 tests within 24 weeks postpartum. Of the 214 enrolled women, 80 (37%) completed serial testing, 176 (82%) had ≥2 tests, and 147 (69%) had ≥3 tests during the study period. One hundred eighty-two women (85%) accepted male partner testing, but only 19 men (10%) participated. One woman seroconverted during the study, for a cumulative HIV incidence of 0.5% (1/214). In multivariable logistic regression analysis, longer distance between home and clinic (aOR 0.87 [95% CI 0.79–0.97]) and not knowing household income (aOR 0.30 [95% CI 0.11–0.84]) were predictive of not completing serial testing. Higher level of education was associated with completing serial testing (linear trendpvalue = 0.05). In conclusion, partial serial HIV testing was highly acceptable and feasible, but completion of serial testing and male partner testing had poor uptake. [ABSTRACT FROM PUBLISHER]

The purpose of this qualitative study was to explore the psychosocial changes revealed by persons living with HIV/AIDS (PLWHA) in western Uganda as a result of the introduction of highly active antiretroviral therapy (HAART). Fourteen participants were interviewed on two occasions. Two focus groups discussions were also conducted. Patients experienced important personal benefits as a result of HAART and the resulting clinical improvement. These benefits included a restoration of hope, self-esteem and personal agency. Patients were also relieved of the great fear which they had about the conditions of their death. The financial and social struggles introduced by AIDS illness continued after the introduction of HAART. The conclusion is that the HAART programs should provide more holistic care to patients to address the persistent family issues identified in this study. [ABSTRACT FROM AUTHOR]

Older caregivers have major caregiving responsibilities in countries severely affected by the HIV epidemic, but little is known about their own health and well-being. We conducted this study to assess the association of caregiving responsibilities and self-perceived burden with caregivers' health, HIV status, background characteristics and care-receiving among older people in South Western Uganda. Men and women aged 50 years and older were recruited from existing cohort studies and clinic registers and interviewed at home. Health was measured through a composite score of health in eight domains, anthropometry and handgrip strength. Summary measures of caregiving responsibilities and self-reported burden were used to analyse the main associations. There were 510 participants, including 198 living with HIV. Four fifths of women and 66% of men were caregivers. Older respondents with no care responsibility had poorer scores on all health indicators (self-reported health score, body mass index and grip strength). Having a caregiving responsibility was not associated with poorer health status or quality of life. Notably, HIV-infected people, whether on antiretroviral treatment (ART) or not, had similar caregiving responsibilities and health status as others. The self-reported burden associated with caregiving was significantly associated with a poorer health score. One third of female caregivers were the single adult in the household with larger caregiving responsibilities. Many of these women are in the poorest wealth quartile of the households in the study and are therefore more likely to need assistance. Physical and financial supports were received by 70% and 63%, respectively. Those with larger caregiving responsibilities more frequently received support. Caregiving responsibilities were associated with better health status, greater satisfaction and quality of life. Older HIV-infected people, whether on ART or not, had similar caregiving responsibilities and self-reported health status as other older people. [ABSTRACT FROM PUBLISHER]

Efforts to expand access to HIV care and treatment often stress the importance of disclosure of HIV status to aid adherence, social support, and continued resource mobilization. We argue that an examination of disclosure processes early in the process of seeking testing and treatment can illuminate individual decisions and motivations, offering insight into potentially improving engagement in care and adherence. We report on baseline data of early HIV disclosure and nondisclosure, including reasons for and responses to disclosure from a cohort of men and women (n=949) currently accessing antiretroviral treatment in two regions of Uganda. We found early disclosures at the time of suspicion or testing positive for HIV by men and women to be largely for the purposes of emotional support and friendship. Responses to these selected disclosures were overwhelmingly positive and supportive, including assistance in accessing treatment. Nonetheless, some negative responses of worry, fear, or social ostracism did occur. Individuals deliberately chose to not disclose their status to partners, relatives, and others in their network, for reasons of privacy or not wanting to cause worry from the other person. These data demonstrate the strategic choices that individuals make early in the course of suspicion, testing, and treatment for HIV to mobilize resources and gain emotional or material support, and similarly their decisions and ability to maintain privacy regarding their status. [ABSTRACT FROM PUBLISHER]

Mobile technologies for health (mHealth) represents a growing array of tools being applied in diverse health care settings. mHealth interventions for improving HIV/AIDS care is a promising strategy, but its evidence base is limited. We conducted a formative research evaluation to inform the development of novel mHealth HIV/AIDS care interventions to be used by community health workers (CHWs) in Kampala, Uganda. A mixed methods formative research approach was utilized. Qualitative methods included 20 in-depth interviews (IDIs) and six focus groups with CHWs, clinic staff, and patients. Thematic analysis was performed and selected quotations used to illustrate themes. Quantitative methods consisted of a survey administered to CHWs and clinic staff, using categorical and Likert scale questions regarding current mobile phone and internet access and perceptions on the potential use of smartphones by CHWs. Qualitative results included themes on significant current care challenges, multiple perceived mHealth benefits, and general intervention acceptability. Key mHealth features desired included tools to verify CHWs’ task completions, clinical decision support tools, and simple access to voice calling. Inhibiting factors identified included concerns about CHWs’ job security and unrealistic expectations of mHealth capabilities. Quantitative results from 27 staff participants found that 26 (96%) did not have internet access at home, yet only 2 (7.4%) did not own a mobile phone. Likert scale survey responses (1–5, 1 = Strongly Disagree, 5 = Strongly Agree) indicated general agreement that smartphones would improve efficiency (Mean = 4.35) and patient care (4.31) but might be harmful to patient confidentiality (3.88) and training was needed (4.63). Qualitative and quantitative results were generally consistent, and, overall, there was enthusiasm for mHealth technology. However, a number of potential inhibiting factors were also discovered. Findings from this study may help guide future design and implementation of mHealth interventions in this setting, optimizing their chances for success. [ABSTRACT FROM PUBLISHER]

Social support in addition to antiretroviral therapy (ART) has been indicated to be beneficial to person living with HIV/AIDS (PLWHA) and their families, but very few ART service providers go beyond ART. This study investigates whether receipt of social support in addition to ART for PLWHA makes the households that they reside in better off than households that have PLWHA but are without social support. The analysis uses data comprising of 450 households, which is a sub-sample from the 2010/2011 Centre for Health Economics Ugandan HIV Survey, a cross-sectional survey of 596 households that was undertaken in Uganda. Data were collected from households of clients that obtained ART from two major ART service providers in Central Uganda; The AIDS Support Organisation (TASO) and Ministry of Health (MOH), Uganda. Probit models and ordinary least squares regressions are employed to compare outcomes for individuals from households with a TASO or MOH client. Outcomes for individuals in households with a TASO PLWHA are hypothesised to be superior to those from households with an MOH PLWHA given that the benefits from social support accrue not only to the PLWHA but also to the household and communities they belong to. The results confirm that individuals from a household with a TASO PLWHA are better off in terms of physical health outcomes including better productivity as non-wage labour hours and having more cash in hand and having savings. The findings highlight the importance of additional support to HIV/AIDS clients and have implications for supplementation of ART service provision with other services to maximise the benefits from ART in resource constrained countries like Uganda. [ABSTRACT FROM AUTHOR]

A cost analysis study calculates resources needed to deliver an intervention and can provide useful information on affordability for service providers and policy-makers. We conducted cost analyses of both a peer health worker (PHW) and a mHealth (mobile phone) support intervention. Excluding supervisory staffing costs, total yearly costs for the PHW intervention was $8475, resulting in a yearly cost per patient of $8.74, per virologic failure averted cost of $189, and per patient lost to follow-up averted cost of $1025. Including supervisory staffing costs increased total yearly costs to $14,991. Yearly costs of the mHealth intervention were an additional $1046, resulting in a yearly cost per patient of $2.35. In a threshold analysis, the PHW intervention was found to be cost saving if it was able to avert 1.50 patients per year from switching to second-line antiretroviral therapy. Other AIDS care programs may find these intervention costs affordable. [ABSTRACT FROM AUTHOR]

In recent years, Uganda has experienced rapid growth in networked groups of people living with HIV (PLHIV) who provide support, engage in advocacy, treatment and care and raise the profile of HIV in the public domain. This qualitative study focused the benefits of joining a networked group, relationships between groups, impact of networked groups on the community and shaping private and public experience living with HIV. Data were collected from two Ugandan districts, using semi-structured interviews, focus group discussions (FGDs), observation and reviews of group records and archives. Respondents (n=46) were adults living with HIV, and members of rural and urban PLHIV groups. Narratives from PLHIV (n=27) were gathered, and records from PLHIV group service-registers (n=20) reviewed. Key Informants (n=15) were purposively selected for interview, based on participation in PLHIV groups, utilisation of network services and their positions as key stakeholders. FGDs were held with network support agents (NSAs), members of PLHIV groups, and their leaders. Following qualitative analysis, findings suggest that for respondents, PLHIV networks enhance the impact and effectiveness of individual groups: the whole is greater than the sum of the parts. For groups, being part of a wider network allows for diversity of service delivery, and well-defined roles for individuals to participate in community support and sensitisation, with a reduction in the experience of stigma. We conclude that networking PLHIV groups is an effective strategy for improving the quality and reach of community-based HIV services. Governments should be encouraged to support networks and include them in policy-making at the national level. Local and regional groups should explore further ways to collaborate and expand support to PLHIV in Uganda. [ABSTRACT FROM PUBLISHER]

HIV care and treatment providers across sub-Saharan Africa are integrating livelihood interventions to improve food security of their clientele. Many integrated HIV and livelihood programmes (IHLPs) require the formation and use of groups of HIV-infected/affected individuals as the operational target for programme interventions, indeed, virtually without exception the group is the focal point for material and intellectual inputs of IHLPs. We sought to critically examine the group approach to programming among IHLPs in Uganda, and to explore and problematise the assumptions underpinning this model. A case study approach to studying 16 IHLPs was adopted. Each IHLP was treated as a case comprising multiple in-depth interviews conducted with staff along the livelihood programme chain. Additionally, in-depth interviews were conducted with staff from The AIDS Support Organization (TASO), and with members of 71 HIV-infected TASO-registered client households. Our analysis reveals three important considerations in IHLP programming regarding the group-centred approach: (1) Group membership is widely held to confer benefits in the form of psycho-social and motivational support, particularly in empowering individuals to access HIV services and handle stigma. This is contrasted with the problem of stigma inherent in joining groups defined by HIV-status; (2) Membership in groups can bring economic benefits through the pooling of labour and resources. These benefits however need to be set against the costs of membership, when members are required to make contributions in the form of money, goods or labour; (3) Sharing of goods and labour in the context of group membership allow members to access benefits which would otherwise be inaccessible. In exchange, individual choice and control are diminished and problems of resources held in common can arise. While the group model can bring benefits to IHLP efficiency and by extension to food security, and other outcomes, its application needs to be carefully scrutinised at the individual programme level, in terms of whether it is an appropriate approach, and in terms of mitigating potentially adverse effects. [ABSTRACT FROM AUTHOR]

The aim of the study is to measure trends in condom use in marital and cohabiting relationships in South Africa and Uganda. The data for the study come from two cross sectional surveys conducted in 1998 and 2008 among adult men and women and their partners in KwaZulu-Natal, South Africa and the Jinja district, Uganda. The findings suggest that consistent condom use has risen substantially in both countries. The percentage reporting consistent condom use in the South African sample of husbands increased from 2.5% in 1998 to 12% in 2008 and from 5.5 to 12.5% among wives. In Uganda, the corresponding trends are 1.1–8.3% for husbands and 4–8.6% for wives. In both countries, condom use was considerably higher among the minority of couples where one or both partners were thought to be HIV positive. Increasingly, in both countries condoms are also used for contraceptive purposes. Condoms play a role in preventing HIV infection but the challenge is for prevention programs to broaden their focus toward meeting the needs of married and cohabiting couples. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM AUTHOR]

Disclosure of HIV sero-positive results among HIV-discordant couples in sub-Saharan Africa is generally low. We describe a facilitated couple counselling approach to enhance disclosure among HIV-discordant couples. Using unique identifiers, 293 HIV-discordant couples were identified through retrospective linkage of married or cohabiting consenting adults individually enrolled into a cohort study and into two randomised trials of male circumcision in Rakai, Uganda. HIV-discordant couples and a random sample of HIV-infected concordant and HIV-negative concordant couples (to mask HIV status) were invited to sensitisation meetings to discuss the benefits of disclosure and couple counselling. HIV-infected partners were subsequently contacted to encourage HIV disclosure to their HIV-uninfected partners. If the index positive partner agreed, the counsellor facilitated the disclosure of HIV results, and provided ongoing support. The proportion of disclosure was determined. Eighty-one per cent of HIV-positive partners in discordant relationships disclosed their status to their HIV-uninfected partners in the presence of the counsellor. The rates of disclosure were 81.3% in male HIV-positive and 80.2% in female HIV-positive discordant couples. Disclosure did not vary by age, education or occupation. In summary, disclosure of HIV-positive results in discordant couples using facilitated couple counselling approach is high, but requires a stepwise process of sensitisation and agreement by the infected partner. [ABSTRACT FROM AUTHOR]

Gender differences in treatment outcomes of 305 persons living with HIV receiving antiretroviral treatment (ART) in Kabarole district, western Uganda, were evaluated. The primary treatment outcome was virological suppression defined as HIV-1 RNA viral load (VL) <400 copies/ml and the secondary outcome measure was the increase in the CD4 cell count after six months on ART. Statistical analysis included descriptive, univariate, and multivariate methods. Proportionally, more females chose to seek treatment compared to males. After six months of treatment, females were more likely to have viral suppression (VL > 400 copies/ml) as compared to males (odds ratio 2.14, 95% confidence interval 0.99-4.63, p=0.05). While females had a significantly higher baseline CD4 cell count at initiation of treatment compared to males, the increase in CD4 cell count after six months on ART was similar in males and females. The reasons for better ART outcomes for females should be further investigated. Ideally, ART programs should work toward equitable treatment outcomes for men and women, if the cause of the gender differential lies in patient behavior and the way ART services are delivered. [ABSTRACT FROM AUTHOR]

Good adherence is critical for antiretroviral therapy (ART) in sub-Saharan Africa. We report on the characteristics of medicine companions (MCs) chosen by Ugandan patients enrolling on ART, and on how MCs were chosen, and what roles they played. Baseline data on MCs of 1453 participants in a randomized controlled trial comparing facility and home-based delivery of ART in Jinja, Uganda were analyzed. Textual data on experience with MCs were collected through in-depth interviews among a subsample of 40 trial participants equally divided by sex and trial arm. Significantly more women (71%) than men (29%) were recruited. The majority (75%) of women participants were either widowed (51%) or separated or divorced (24%), whereas most of the men (66%) were married. Women were most likely to choose a child as their MC while men were most likely to choose their spouse; 41% of women chose an MC under 21 compared with only 14% of men. Only 31% of married women chose their husband, compared with 66% of married men who chose their wife. Qualitative interviews suggested MCs proved useful for reminding and other supportive tasks in the first three months but were generally less essential by six months and beyond. Convenience, reliability, and trust were key considerations in choosing an MC. Children provided the only alternative for many unmarried women, but even some married women felt children made more reliable MCs than husbands. Participants who had disclosed their serostatus usually received drug-taking reminders from multiple household members. One participant in the qualitative sample with poor family relations delayed starting treatment due to unwillingness to identify an MC. MCs were generally welcome and useful in supporting early adherence. However, disclosure to an MC should not be a condition of obtaining treatment. [ABSTRACT FROM AUTHOR]