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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.

Objectives: This study tested the theoretically grounded conceptual model of a multi‐level intervention, Family Health = Family Wealth (FH = FW), by examining FH = FW's effect on intermediate outcomes among couples in rural Uganda. FH = FW is grounded in the social‐ecological model and the social psychological theory of transformative communication. Design: A pilot quasi‐experimental controlled trial. Methods: Two matched clusters (communities) were randomly allocated to receive the FH = FW intervention or an attention/time‐matched water, sanitation and hygiene intervention (N = 140, 35 couples per arm). Quantitative outcomes were collected through interviewer‐administered questionnaires at baseline, 7‐months and 10‐months follow‐up. Focus group discussions (n = 39) and semi‐structured interviews (n = 27) were conducted with subsets of FH = FW participants after data collection. Generalized estimated equations tested intervention effects on quantitative outcomes, and qualitative data were analysed through thematic analysis—these data were mixed and are presented by level of the social‐ecological model. Results: The findings demonstrated an intervention effect on family planning determinants across social‐ecological levels. Improved individual‐level family planning knowledge, attitudes and intentions, and reduced inequitable gender attitudes, were observed in intervention versus comparator, corroborated by the qualitative findings. Interpersonal‐level changes included improved communication, shared decision‐making and equitable relationship dynamics. At the community level, FH = FW increased perceived acceptance of family planning among others (norms), and the qualitative findings highlighted how FH = FW's transformative communication approach reshaped definitions of a successful family to better align with family planning. Conclusions: This mixed methods pilot evaluation supports FH = FW's theoretically grounded conceptual model and ability to affect multi‐level drivers of a high unmet need for family planning. [ABSTRACT FROM AUTHOR]

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.

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. [ABSTRACT FROM AUTHOR]

Background: Fisherfolk are a most-at-risk population for HIV being prioritized for the scale up of HIV treatment in Uganda. Heavy alcohol use and potential drug use may be a major barrier to treatment adherence for men in this setting. Objective: This study examines the prevalence of substance use, and its influence on antiretroviral treatment (ART) adherence, among male fisherfolk on ART in Wakiso District, Uganda. Methods: This cross-sectional study included structured questionnaires (N = 300) with men attending HIV clinics near Lake Victoria. Using generalized logistic modeling analyses with a binomial distribution and logit link, we conducted multivariate models to test the association between each alcohol variable (quantity and frequency index, hazardous drinking) and missed pills, adjusting for covariates, and tested for interactions between number of pills prescribed and alcohol variables. Results: Thirty-one percent of men reported sub-optimal adherence. Half (46.7%) reported drinking, of which 64.8% met criteria for hazardous drinking. Illicit drug use was low (6%). In the multivariate model, men with greater scores on the alcohol frequency and quantity index were more likely to report missed pills compared to those reporting no drinking (AOR: 1.60, 95% CI: 1.29–1.97). Hazardous drinking had a greater effect on missed ARV doses among men taking twice daily regimens compared to once daily (AOR: 4.91, 95% CI: 1.68–14.37). Conclusions: Our findings highlight the need for targeted alcohol-reduction interventions for male fisherfolk on ART who drink at high quantities to improve ART adherence and to prevent the known negative health effects of alcohol for HIV-infected individuals. [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]

Effective interventions to reduce the unmet need for family planning in low-income settings are limited. This study aimed to establish the feasibility, acceptability, and preliminary effects of Family Health=Family Wealth (FH=FW), a multilevel intervention aimed to increase high-efficacy contraceptive uptake among couples wanting to delay pregnancy. A pilot quasi-experimental controlled trial was conducted in rural Uganda, with 70 couples wanting to delay pregnancy but not using contraceptives (n = 140). Two matched clusters (communities) were randomly allocated to receive FH=FW or a comparator intervention via coin toss. FH=FW included health system strengthening elements and four facilitated group sessions. Interviewer-administered questionnaires were conducted at baseline and at ∼7-month and ∼10-month follow-up, and process data gathered feasibility/acceptability outcomes. Of 121 households visited in the intervention community, 63 couples were screened, and 35 enrolled. In the comparator, 61 households were visited, 45 couples screened, and 35 enrolled. Intervention attendance was 99%, fidelity was 96%, and 100% of participants reported being satisfied with the intervention. From no use at baseline, there was 31% more high efficacy contraceptive uptake at 7 months and 40% more at 10 months in intervention versus comparator couples (adjusted odds ratio = 1.68, 95% confidence interval = 0.78–3.62, p = 0.19). A decline in fertility desires was observed in intervention versus comparator participants from baseline (Wald χ 2 = 9.87, p = 0.007; Cohen's d : 7 months, 0.06; 10 months, 0.49). FH=FW is a feasible and acceptable intervention with strong promise in its effect on contraceptive uptake to be established in a future trial. The FH=FW intervention addresses multilevel family planning barriers through four group dialogs with couples paired with efforts to reduce health system barriers. A quasi-experimental controlled trial provides preliminary support for its feasibility, acceptability, contraceptive uptake and fertility desire effects, and success in engaging both women and men. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) may increase risk for HIV/AIDS among women engaging in transactional sex in Ugandan fishing communities. In this cross-sectional study, 115 women reporting engaging in transactional sex in Lake Victoria fishing communities completed a computerized interview. We tested associations between IPV and other HIV risk factors, with unprotected sex and HIV status, and tested moderators of the IPV-HIV risk relationship. Women reporting recent sexual IPV reported 3.36 times more unprotected sex acts (AdjExp[B] = 3.36, 95% CI = 1.29–8.69,p = 0.07). The effect of sexual IPV on sexual risk was significantly greater among alcohol and fish sellers compared to sex workers (interaction: Exp[B] = 12.29, 95% CI = 5.06–29.85,p < 0.001). Women reporting any sexual IPV were nearly four times more likely to report being HIV positive than women reporting no sexual IPV (AOR = 3.94, 95% CI = 1.22–12.66,p = 0.02). Integrated IPV and HIV interventions are needed in this context, especially among alcohol and fish sellers engaging in transactional sex. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. • Heavy alcohol use is prevalent among fisherfolk men living with HIV. • Culturally and contextually relevant interventions are urgently needed. • Key stakeholders provided feedback on the Kisoboka intervention to guide refinement. • Behavioral and structural intervention aspects were seen as acceptable and feasible. [ABSTRACT FROM AUTHOR]