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Background: Alcohol use is a major contributor to mortality and morbidity worldwide. Uganda has a high level of alcohol use per capita. Compared to men, women are less likely to consume alcohol globally; however, women who drink have increased risks for co-occurring conditions, including depression, intimate partner violence, and HIV. This study assessed the prevalence of alcohol use and correlates of harmful alcohol use by gender and HIV status in rural Uganda., Methods: We used cross-sectional data from a study among women and men aged 15-59 residing in rural, central Uganda and accepting home-based HIV testing (Nov 2017 to Dec 2020). We estimated the prevalence of levels of alcohol use (categorized as no alcohol use (score 0), low (score 1-3 for men; 1-2 for women), medium (score 4-5 for men; 3-5 for women), high (score 6-7), and very-high (score 8-12) use with the AUDIT-C), stratified by gender and HIV status. We assessed correlates of harmful alcohol use using multivariable logistic regression models for women and men., Results: Among 18,460 participants, 67% (95% CI: 66-67%) reported no alcohol use, 16% (95% CI: 16-17%) reported low, 5% (95% CI: 4.8-5%) reported medium, 5% (95% CI: 4-5%) reported high, and 3% (95% CI: 2.8-3) reported very high alcohol use. Compared to women, men were more likely to report alcohol use (Chi-squared p-value<0.0001). People diagnosed with HIV (both newly diagnosed and previously aware of their status prior to home-based HIV testing) were more likely to report low, medium, high, and very high alcohol use compared to those who were HIV negative (Chi-squared p-value<0.0001). Among women, those who were newly diagnosed were more likely report alcohol use, compared to those who were HIV negative. In multivariable models, being newly diagnosed with HIV (compared to HIV negative) increased the odds of harmful alcohol use among women, but not men., Conclusion: While alcohol use was higher among men and people living with HIV, being newly diagnosed with HIV had a stronger relationship with harmful alcohol use among women than men. More research is needed to understand how alcohol use may increase the risks of HIV acquisition among women and to identify gender-responsive services to address harmful alcohol use and increase access to HIV testing and linkage to care for women who use harmful levels of alcohol., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Wynn et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Alcohol use among people living with HIV (PWH) is common and may negatively affect engagement in HIV care. We evaluated the relationships between alcohol use, ART use, and viral suppression among PWH in Uganda. PATH/Ekkubo was a trial evaluating a linkage to HIV care intervention in four Ugandan districts, Nov 2015-Sept 2021. Our analytical sample included: (1) baseline data from individuals not enrolled in the intervention trial (previously diagnosed HIV+); and 12-month follow-up data from the control group (newly diagnosed or previously diagnosed, but not in care). Level of alcohol use was categorized using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C): none (AUDIT-C = 0), low (women = 1-2, men = 1-3), medium (women = 3-5, men = 4-5), high/very high (6-12). Multivariable logistic regression models evaluated associations between alcohol use, ART use and viral suppression (a viral load of < 20); we also stratified by gender. Among 931 PWH, medium (OR: 0.43 [95% CI 0.25-0.72]) and high/very high (OR: 0.22 [95% CI 0.11-0.42]) levels of alcohol use were associated with lower odds of being on ART. In a sub-sample of 664, medium use (OR: 0.63 [95% CI 0.41-0.97]) was associated with lower odds of viral suppression. However, this association was not statistically significant when restricting to those on ART, suggesting the relationship between alcohol use and viral suppression is explained by ART use. Among men, high/very high, and among women, medium alcohol use levels were associated with lower odds of being on ART and being virally suppressed. Interventions for PWH who use higher levels of alcohol may be needed to optimize the benefits of Uganda's Universal Test and Treat strategy., (© 2024. The Author(s).)

Background: East Africa's fishing communities experience a high burden of two interrelated and frequently co-occurring health issues: HIV and hazardous alcohol use. Nearly two-thirds of Ugandan fisherfolk men meet the criteria for harmful alcohol use. We developed a multilevel intervention to reduce hazardous alcohol use and improve HIV care engagement among fisherfolk men living with HIV (LWHIV) in Wakiso district, Uganda., Methods: This is a qualitative study of stakeholder perspectives on the appropriateness, acceptability, and feasibility of a multilevel intervention for fisherfolk men LWHIV. The proposed intervention, Kisoboka ("It is possible!"), combines a structural component [changing the mode of work payments from cash to mobile money] with a behavioral component [motivational interviewing-based counseling combined with content using behavioral economic principles to promote behavior change]. We conducted one focus group (n=7) and eight in-depth interviews with fisherfolk men LWHIV and 19 key informant (KI) interviews with health workers, employers, and community leaders. These explored the appropriateness, acceptability, and feasibility of specific key intervention components., Results: Overall, stakeholders' perspectives supported high intervention acceptability and perceived appropriateness of the proposed intervention. It was perceived to be feasible with some caveats of recommendations for overcoming potential implementation challenges identified (e.g., having a friend assist with documenting savings and alcohol use if an individual was unable to write themselves) which are discussed., Conclusion: This work highlights the potential of the Kisoboka intervention and the importance of early engagement of key stakeholders in the intervention development process to ensure appropriateness, acceptability, feasibility, and socio-cultural fit., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

The co-occurrence of and synergistic interactions between substance abuse, violence, and HIV, known as the "SAVA syndemic," is thought to be a driver of women's elevated risk for HIV in sub-Saharan Africa. This study uses data from the 2016 South African Demographic and Health Survey (DHS) and the 2016 South African Census to examine geospatial associations between alcohol use, intimate partner violence (IPV), unprotected sex, and HIV status among a population-based sample of 8528 South African women (age 15-49). Results support the geographic clustering of alcohol use, unprotected sex, and IPV, but not HIV, and geospatial clustering of HIV alone. This study highlights the need for geographically-tailored interventions to address syndemics through integrated interventions, such as those simultaneously focused on alcohol, IPV, and sexual risk reduction, and points to the need for more targeted research to link these factors to HIV from a place-based risk perspective., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

HIV stigma in health care disrupts the care continuum and negatively affects health outcomes among people living with HIV. Few studies explore HIV stigma from the perspective of health care providers, which was the aim of this mixed-methods, community-based participatory research study. Guided by the Health Stigma Discrimination Framework, we conducted an online survey and focus group interviews with 88 and 18 participants. Data were mixed during interpretation and reporting results. Stigma was low overall and participants reported more stigma among their colleagues. The main drivers of stigma included lack of knowledge and fear. Workplace policies and culture were key stigma facilitators. Stigma manifested highest through the endorsement of stereotypes and in the use of unnecessary precautions when treating people with HIV. This study adds to our understanding of HIV stigma within health care settings, with implications for the development of multi-level interventions to reduce HIV stigma among health care professionals.

Men's engagement in the HIV care continuum may be negatively affected by adherence to inequitable gender norms, which may be exacerbated by HIV stigma. This cross-sectional study with 300 male fisherfolk in Uganda examined the independent and interacting effects of inequitable gender norm endorsement and HIV stigma on men's missed HIV care appointments and missed antiretroviral (ARV) doses. Greater gender inequitable norm endorsement was associated with increased odds of missed HIV clinic visits (adjusted odds ratio [AOR)] 1.44, 95% CI 1.16-1.78) and a statistically significant interaction between internalized HIV stigma and inequitable gender norms on missed ARV doses was identified (AOR 5.32, 95% CI 2.60-10.86). Adherence to traditional gender norms reduces men's HIV appointment attendance, and among men with high internalized stigma, increases the likelihood of poor treatment adherence. These findings point to the need for HIV interventions that reconfigure harmful gender norms with a focus on stigma reduction., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

The adverse impact of exposure to war-related traumatic events on mental health is well documented. Few studies, however, have focused on the impact of exposure to war-related traumatic events on HIV sexual risk behavior in post-conflict countries such as Liberia. We investigated whether exposure to war-related traumatic events was linked to HIV sexual risk behavior, and identified potential mediators of this relationship, including stressful life events, problematic alcohol use, and intimate partner violence (IPV) among women and men in Liberia. Data were collected from a sample of 395 participants in Monrovia, Liberia. Results from the serial multiple mediator model did not support direct or indirect effects between war-related traumatic events and HIV sexual risk behavior among women. For men, we found both direct and indirect effects between war-related traumatic events and HIV sexual risk behavior. Findings from this research highlight the need for trauma-informed HIV prevention strategies in Liberia.

HIV fatalism, or the belief that HIV acquisition and mortality is out of one's control, is thought to contribute to HIV risk in fishing populations in East Africa. The objective of this cross-sectional study was to investigate the association between fatalism and sexual risk behaviours (unprotected sex, engagement in transactional sex), beyond the influence of other known HIV risk factors (e.g. food insecurity, mobility), and identify demographic, psychosocial, and structural correlates of HIV fatalism. Ninety-one men and women living in fishing villages on two islands in Lake Victoria, Uganda completed an interviewer-administered questionnaire after testing HIV-positive during home or community-based HIV testing between May and July 2015. Multivariate logistic regression was used to test the association between HIV fatalism and transactional sex and multivariate linear regression was used to identify demographic, psychosocial, and structural correlates of HIV fatalism. HIV fatalism was significantly associated with a greater likelihood of transactional sex (AOR = 3.07, 95% CI = 1.02-9.23, p = 0.04), and structural barriers to HIV care (e.g. distance to clinic) were significantly associated with HIV fatalism (β = 0.26, SE = 0.12, p = 0.04). Our findings highlight HIV fatalism as a contributor to transactional sex in Ugandan fishing communities, and as a product of broader social and contextual factors, suggesting the potential need for structural HIV interventions in this setting.

Men living with HIV/AIDS in sub-Saharan Africa are less likely than women to be engaged at each stage of the HIV care continuum. We conducted a scoping review in May of 2016 to identify how masculine norms influence men's HIV care engagement in sub-Saharan Africa. Our review yielded a total of 17 qualitative studies from 8 countries. Six major themes emerged that demonstrated how norms of masculinity create both barriers and facilitators to care engagement. Barriers included the exacerbating effects of masculinity on HIV stigma, the notion that HIV threatened men's physical strength, ability to provide, self-reliance, and risk behavior, and the belief that clinics are spaces for women. However, some men transformed their masculine identity and were motivated to engage in care if they recognized that antiretroviral therapy could restore their masculinity by rebuilding their strength. These findings demonstrate masculinity plays an important role in men's decision to pursue and remain in HIV care across sub-Saharan Africa. We discuss implications for tailoring HIV messaging and counseling to better engage men and an agenda for future research in this area.

This study explored the intersection of masculinity and HIV care engagement among fishermen and other male fisherfolk on antiretroviral therapy (ART) in Wakiso District, Uganda. We conducted 30 in-depth interviews with men on ART recruited from HIV treatment sites and used a thematic analysis approach. Since HIV diagnosis and ART initiation, men had adopted masculine identities more conducive to HIV care engagement. The masculine roles of worker and provider, husband and sexual partner and the appearance of physical strength were compromised by HIV, but restored by ART's positive effects on health. Peers also emerged as facilitators to HIV care, with men supporting each other to seek testing and treatment. However, structural and occupational barriers to HIV care associated with the masculine role of worker remained a barrier to care engagement. Findings suggest that emphasising the benefits of ART in bolstering men's ability to fulfil the roles important to them may improve the effectiveness of HIV testing and treatment messaging for men. Differentiated care models that address structural-level barriers to care, and community-level gender-transformative programming to help fishermen engage in HIV care, may be beneficial.

This cross-sectional study assessed determinants of HIV clinic appointment attendance and antiretroviral treatment (ART) adherence among 300 male fisherfolk on ART in Wakiso District, Uganda. Multi-level factors associated with missed HIV clinic visits included those at the individual (age, AOR = 0.98, 95% CI 0.97-0.99), interpersonal (being single/separated from partner, AOR: 1.25, 95% CI 1.01-1.54), normative (anticipated HIV stigma, AOR: 1.55, 95% CI 1.05-2.29) and physical/built environment-level (travel time to the HIV clinic, AOR: 1.11, 95% CI 1.02-1.20; structural-barriers to ART adherence, AOR: 1.27, 95% CI 1.04-1.56; accessing care on a landing site vs. an island, AOR: 1.35, 95% CI 1.08-1.67). Factors associated with ART non-adherence included those at the individual (age, β: - 0.01, η 2  = 0.03; monthly income, β: - 0.01, η 2  = 0.02) and normative levels (anticipated HIV stigma, β: 0.10, η 2  = 0.02; enacted HIV stigma, β: 0.11, η 2  = 0.02). Differentiated models of HIV care that integrate stigma reduction and social support, and reduce the number of clinic visits needed, should be explored in this setting to reduce multi-level barriers to accessing HIV care and ART adherence.

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.

Men living with HIV/AIDS in sub-Saharan Africa are less likely to test for HIV than women. We conducted a scoping review in May of 2016 to identify how masculine norms influence men's HIV testing in sub-Saharan Africa. Our review yielded a total of 13 qualitative studies from 8 countries. Masculine norms create both barriers and facilitators to HIV testing. Barriers included emotional inexpression, gendered communication, social pressures to be strong and self-reliant, and the fear that an HIV positive result would threaten traditional social roles (i.e., husband, father, provider, worker) and reduce sexual success with women. Facilitators included perceptions that HIV testing could restore masculinity through regained physical strength and the ability to re-assume the provider role after accessing treatment. Across sub-Saharan Africa, masculinity appears to play an important role in men's decision to test for HIV and further research and interventions are needed to address this link.

In a sample of outpatients (152 females, 152 males) receiving individual provider-initiated HIV testing and counselling (PITC) we aimed to identify factors associated with subsequent uptake of partner HIV testing. Purposively sampled outpatients receiving PITC at a Ugandan hospital completed a questionnaire immediately prior to testing for HIV, and then at 3 and 6 months post-test. By 6-month follow-up 96% of participants reported disclosing their HIV test results to their partner and 96.4% reported asking their partner to test. 38.8% of women and 78.9% of men reported that their partner tested and they knew their results. Recent (men AOR 5.84, 95.0% CI 1.90-17.99; women AOR 6.19, 95.0% CI 2.74-13.59) or any previous testing by the partner (women AOR 4.01, 95% CI 1.06-15.10) predicted uptake of partner testing by the 6-month follow-up. Among women, perceiving greater social support from their partner, which perhaps reflects better relationship quality, was predictive of their male partner testing for HIV (AOR 2.37, 95% CI 1.22-4.58). Notably intimate partner violence showed no negative association with partner testing. Our findings demonstrate that women are at a disadvantage compared to men in their ability to influence their partner to test for HIV, and that improving social support in intimate relationships should be a focus of HIV partner testing interventions. However, more research on interventions to improve partner testing is needed, particularly in identifying effective ways to support women in engaging their partners to test.

Background: Though home-based human immunodeficiency virus (HIV) counseling and testing (HBHCT) is implemented in many sub-Saharan African countries as part of their HIV programs, linkage to HIV care remains a challenge. The purpose of this study is to test an intervention to enhance linkage to HIV care and improve HIV viral suppression among individuals testing HIV positive during HBHCT in rural Uganda., Methods: The PATH (Providing Access To HIV Care)/Ekkubo Study is a cluster-randomized controlled trial which compares the efficacy of an enhanced linkage to HIV care intervention vs. standard-of-care (paper-based referrals) at achieving individual and population-level HIV viral suppression, and intermediate outcomes of linkage to care, receipt of opportunistic infection prophylaxis, and antiretroviral therapy initiation following HBHCT. Approximately 600 men and women aged 18-59 who test HIV positive during district-wide HBHCT in rural Uganda will be enrolled in this study. Villages (clusters) are pair matched by population size and then randomly assigned to the intervention or standard-of-care arm. Study teams visit households and participants complete a baseline questionnaire, receive HIV counseling and testing, and have blood drawn for HIV viral load and CD4 testing. At baseline, standard-of-care arm participants receive referrals to HIV care including a paper-based referral and then receive their CD4 results via home visit 2 weeks later. Intervention arm participants receive an intervention counseling session at baseline, up to three follow-up counseling sessions at home, and a booster session at the HIV clinic if they present for care. These sessions each last approximately 30 min and consist of counseling to help clients: identify and reduce barriers to HIV care engagement, disclose their HIV status, identify a treatment supporter, and overcome HIV-related stigma through links to social support resources in the community. Participants in both arms complete interviewer-administered questionnaires at six and 12 months follow-up, HIV viral load and CD4 testing at 12 months follow-up, and allow access to their medical records., Discussion: The findings of this study can inform the integration of a potentially cost-effective approach to improving rates of linkage to care and HIV viral suppression in HBHCT. If effective, this intervention can improve treatment outcomes, reduce mortality, and through its effect on individual and population-level HIV viral load, and decrease HIV incidence., Trial Registration: NCT02545673.

Background: Intimate partner violence (IPV), alcohol use, and depression are key vulnerabilities for HIV in Uganda, and taken together may have a synergistic effect on risk. Our objective was to investigate the associations between depression, IPV, and alcohol use and HIV-risk indicators among a sample of outpatients in rural Uganda, and the effect of co-occurrence of these factors on HIV-risk indicators., Methods: In a structured interview we collected data on high-risk sexual behavior, depression symptoms, emotional and physical IPV, and alcohol use, as well as a blood sample for HIV and syphilis tests and a urine sample for chlamydia and gonorrhea tests from 325 male and female outpatients receiving provider-initiated HIV testing and counseling (PITC) at a public hospital outpatient clinic in rural Uganda. We used logistic regression and generalized linear modeling to test independent associations between depression, IPV, and alcohol use and HIV-risk indicators, as well as the effect of co-occurrence on HIV-risk indicators., Results: Twelve percent of men and 15% of women had two or more of the following conditions: depression, IPV, and alcohol use; another 29% of men and 33% of women had 1 condition. Each condition was independently associated with HIV risk behavior for men and women, and for women, depression was associated with testing positive for HIV or a sexually transmitted infection (STI). Men with one condition (AOR 2.32, 95% CI 1.95-2.77) and two or more conditions (AOR 12.77, 95% CI 7.97-20.47) reported more high risk sex acts compared to those with no potential co-occurring conditions. For men, experiencing two or more conditions increased risky sex more than one alone (χ 2 24.68, p < 0.001). Women experiencing one condition (AOR 3.33, 95% CI 137-8.08) and two co-occurring conditions (AOR 5.87, 95% CI 1.99-17.35) were more likely to test positive for HIV or an STI and women with two co-occurring conditions were also at increased risk for risky sex (AOR 2.18, 95% CI 1.64-2.91). We also found preliminary evidence suggesting synergistic effects between depression and emotional IPV and between alcohol use and depression., Conclusions: This study demonstrates the co-occurrence of depression, IPV, and alcohol use in men and women in an outpatient setting in rural Uganda. The co-occurrence of these factors was associated with greater HIV risk, highlighting the need for a more holistic approach to HIV prevention and care research and programming.

Objective: Using daily diary methods, we aimed to test the hypothesis that at the event-level consuming alcohol increases the likelihood that antiretrovirals (ARV) will be missed on a particular day., Methods: This prospective cohort study of 74 (52 female, 22 male) people living with HIV (PLHIV) in South Africa collected event-level data on ARV adherence and alcohol consumption using structured daily phone interviews over a period of 42days generating 2718 data points. We used generalized estimating equations (GEE) analyses to assess univariate and multivariate associations between alcohol and adherence, controlling for sociodemographics and testing for effect modification., Results: Controlling for sociodemographics, each alcohol measure was a statistically significant predictor of non-adherence on a particular day; any drinking compared to no drinking (daytime: AOR=3.18, 95% CI=2.25-4.49; evening: AOR=3.43, 95% CI=2.12-5.53), consuming more alcohol than one normally consumes (daytime: AOR=1.06, 95% CI=1.02-1.11; evening: AOR=1.10, 95% CI=1.05-1.15), and drinking at low to moderate risk level (daytime: 4.29, 95% CI=2.81-6.56; evening: AOR=4.24, 95% CI=2.38-7.54) and high to very high risk levels (daytime: AOR=2.31, 95% CI=1.56-3.42; evening: AOR=3.08, 95% CI=1.91-4.98) were all significantly related to missing ARVs in the daytime and evening., Conclusions: These data provide support for an event-level relationship between alcohol and non-adherence. Interventions that mitigate alcohol use among people on ARVs or provide strategies to maintain optimal adherence among those who drink are needed., Competing Interests: none, (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Many population-based demographic surveys assess local and national HIV prevalence in developing countries through home-based HIV testing and counselling (HBHTC), but results are rarely returned to participants. This review gathered evidence on the feasibility and best practices of providing HIV test results during such surveys by reviewing population-based surveys that provided test results., Study Design: Literature review., Methods: This review was conducted as part of a broader literature review related to HBHTC. We present results from population-based HIV seroprevalence surveys conducted between January 1984 and June 2013., Results: We identified eighteen population-based surveys describing uptake of results when testing or results were offered in the home, four of which compare home uptake to facility-based testing. All were from Sub-Saharan Africa. More people tested and received results in HBHTC compared to facility-based testing. Uptake of test results (72%) and the percentage of the population tested (59%) was highest when testing and the provision of results were provided in the home compared to the provision of results elsewhere (41% uptake; 37% population coverage), as well as mobile/facility-based testing and the provision of results (15% uptake; 13% population coverage). Providing results the same day as testing in HBHTC produces higher uptake (97% uptake; 74% population coverage) than delayed results., Conclusions: Inclusion of home testing and provision of HIV results to participants in national population-based surveys in Sub-Saharan Africa is possible and should be prioritized. The timing and location of testing and the provision of results during HBHTC as part of population-based surveys affects uptake of testing and population coverage., (Copyright © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

In Uganda, elevated HIV prevalence in fishing communities along Lake Victoria have been attributed in part to heavy alcohol use, but qualitative research is needed to understand the contextual factors influencing alcohol and sexual risk. Eight focus group discussions were conducted (n = 50; 23 male, 27 female) in Gerenge, Uganda with five occupational groups: fishermen, fishmongers, alcohol-sellers, commercial sex workers, and restaurant owners. Data was analyzed using content analysis. Alcohol use was prevalent and said to influence risky sex. Sex-related alcohol expectancies and occupational factors influenced individuals to drink during sex and structural factors related to the built environment, economy, and policy were identified as key contributors to both alcohol use and sexual risk in general. The findings highlight alcohol reduction as an important component of HIV/AIDS prevention and suggest structural interventions should be prioritized in this context.