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The ABC strategy is credited for bringing the HIV/AIDS epidemic under control in Uganda. By promoting abstinence, being faithful, and condom use, safe(r) behaviours have been identified that are applicable to people in different circumstances. However, scaling-up of antiretroviral therapy in the country raised concerns that HIV prevention messages targeting the uninfected population are not taking sufficient account of inherent complexities. Furthermore, there is debate in the country over relative importance of abstinence in reduction of HIV incidence as well as over the morality and effectiveness of condoms. The purpose of this paper is to examine each component of ABC in light of current developments. It is argued that there is still a strong justification for condom use to complement abstinence and being faithful. There is an urgent need to update and relaunch Uganda's ABC strategy-its three elements are complementary, synergistic, and inseparable in the national HIV prevention programme. [ABSTRACT FROM AUTHOR]

This paper describes the implementation of a large community-based HIV/AIDS behavioural intervention in rural Uganda and presents 4 years' worth of quantitative process data. The intervention involved 560 field-based workers (57% male, 76% subsistence farmers, mean age 35 years), supervised by six central staff. Intervention channels included drama and video shows, Community Educators (CEs), as well as leaflet and condom distribution. Activities focused on one or more of 16 key topics. In total, 392 000 attendances (51% female) were recorded—a mean of over 6 for each of the 64 000 target adults—at 81 000 activities, with CEs attracting 71% of the total attendance; 164 000 leaflets and 242 000 condoms were also distributed. The annual cost of the intervention per target individual was approximately US$1.76. Our voluntary workforce experienced an annual attrition rate of 11%, with 'stable' workers more likely to be older, married or opinion leaders in their community than those who dropped out. We calculate that even a significant increase in the proportion of female field workers would have made little difference either to the sex ratio of attendees or to overall attendance. In spite of some initial resistance to the intervention, particularly in relation to condoms, we have demonstrated that people in rural Africa can accept and actively participate in the dissemination of HIV/AIDS prevention messages throughout their own communities. [ABSTRACT FROM AUTHOR]

A cross-sectional questionnaire survey examining knowledge, attitudes and intended use of condoms was conducted among 1,821 pupils (mean age = 14.2 years, range = 9-24) from 27 primary and secondary schools in rural south western Uganda. Condom education is not provided in Ugandan schools, but both boys and girls had relatively high overall levels of knowledge, even though boys demonstrated a higher level than girls. This suggests that respondents had successfully obtained reliable information from other sources. Boys and girls had similar and fairly positive attitudes towards condoms, although considerable shyness was expressed, both about discussing condoms with a partner and buying them. Fifty-eight per cent said that they themselves would use a condom if one were available, but girls were far less likely than boys to say so. Roman Catholics (46% of the sample) were less knowledgeable and less positive about condoms than non-Catholics, and the boys in this group, but not the girls, were also much less likely to say they would use one. Possible interventions based on these findings are discussed, and a research agenda for the delivery of assertiveness training to girls is proposed. [ABSTRACT FROM AUTHOR]

A 19 activity extracurricular school-based AIDS education programme lasting 1 year was conducted in rural southwestern Uganda using specially trained teachers, and was evaluated using mutually supportive quantitative and qualitative methods. In total, 1274 students from 20 intervention schools and 803 students from 11 control schools completed questionnaires at baseline, and their classes were followed up. In addition, 93 students from five of the intervention schools participated in 12 focus group discussions. The programme had very little effect--seven of the nine key questionnaire variables showed no significant increase in score after the intervention. Data from the focus group discussions suggest that the programme was incompletely implemented, and that key activities such as condoms and the role-play exercises were covered only very superficially. The main reasons for this were a shortage of classroom time, as well as teachers' fear of controversy and the unfamiliar. We conclude that large-scale comprehensive school-based AIDS education programmes in sub-Saharan Africa may be more completely implemented if they are fully incorporated into national curricula and examined as part of life-skills education. This would require teachers to be trained in participatory teaching methods while still at training college. [ABSTRACT FROM AUTHOR]

Abstract As part of a large IEC (Information, Education and Communication)/STD intervention trial, a 19-lesson, comprehensive school-based AIDS education programme was implemented and evaluated in 50 primary and 16 secondary schools in 12 parishes of Masaka District, Uganda. A series of three teacher-training and evaluation workshops spread over a year was held in each parish, between which teachers implemented the programme in the classroom. One hundred and forty-eight teachers were trained and about 3,500 students were subsequently exposed to the programme. Both teachers and students responded positively, which suggests that this type of programme has much to offer young people who attend school However, some problems were encountered: language, programme content, community resistance to teaching about condoms, and several practical issues. Proposed solutions include flexibility with the English language policy, alternative approaches to role play activities, targeting influential individuals with information about the need for young people to learn about safer sex, and a parallel community-based IEC programme to facilitate community acceptance of the need for the programme. In addition, implementation may be incomplete unless comprehensive AIDS education is fully incorporated into the curriculum, and properly examined. These findings are placed in the context of other life skills/AIDS education programmes being introduced both in Uganda and elsewhere in Africa. [ABSTRACT FROM AUTHOR]

A response by B. Harvey, J. Stuart, and T. Swan to a letter to the editor about the article AIDS education in the previous issue is presented.

Summary: Background: Treatment of sexually-transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. We aimed to assess the effect of these interventions on incidence of HIV-1 and other sexually-transmitted infections. Methods: We randomly allocated all adults living in 18 communities in rural Uganda to receive behavioural interventions alone (group A), behavioural and STI interventions (group B), or routine government health services and community development activities (group C). The primary outcome was HIV-1 incidence. Secondary outcomes were incidence of herpes simplex virus type 2 (HSV2) and active syphilis and prevalence of gonorrhoea, chlamydia, reported genital ulcers, reported genital discharge, and markers of behavioural change. Analysis was per protocol. Findings: Compared with group C, the incidence rate ratio of HIV-1 was 0.94 (0.60-1.45, p=0.72) in group A and 1.00 (0.63-1.58, p=0.98) in group B, and the prevalence ratio of use of condoms with last casual partner was 1.12 (95% CI 0.99-1.25) in group A and 1.27 (1.02-1.56) in group B. Incidence of HSV2 was lower in group A than in group C (incidence rate ratio 0.65, 0.53-0.80) and incidence of active syphilis for high rapid plasma reagent test titre and prevalence of gonorrhoea were both lower in group B than in group C (active syphilis incidence rate ratio, 0.52, 0.27-0.98; gonorrhoea prevalence ratio, 0.25, 0.10-0.64). Interpretation: The interventions we used were insufficient to reduce HIV-1 incidence in rural Uganda, where secular changes are occurring. More effective STI and behavioural interventions need to be developed for HIV control in mature epidemics. [ABSTRACT FROM AUTHOR]

Background: Provider-initiated HIV testing and counselling (PITC) is based on information-giving while voluntary counselling and testing (VCT) includes individualised client-centered counseling. It is not known if the provider-client experiences, perceptions and client satisfaction with the information provided differs in the two approaches., Methods: In 2008, we conducted structured interviews with 627 individuals in Uganda; 301 tested through PITC and 326 through voluntary counselling and testing (VCT). We compared client experiences and perceptions based on the essential elements of consent, confidentiality, counseling, and referral for follow-up care. We conducted multivariate analysis for predictors of reporting information or counselling as sufficient., Results: In VCT, 96.6% (282) said they were asked for consent compared to 91.3% (198) in PITC (P = 0.01). About the information provided, 92.0% (286) in VCT found it sufficient compared to 78.7% (221) in PITC (P = <0.01). In VCT 79.9% (246) thought their results were kept confidential compared to 71.7% (200) in PITC (P = 0.02). Eighty percent (64) of HIV infected VCT clients said they were referred for follow-up care versus 87.3% (48) in PITC (p = 0.2). Predictors of perceived adequacy of information in PITC included an opportunity to ask questions (adj.RR 1.76, CI 1.41, 2.18) and expecting the test results received (adj.RR 1.18, CI 1.06, 1.33). For VCT significant factors included being given an opportunity to ask questions (adj.RR 1.62, CI 1.00, 2.60) and 3+ prior times tested, (adj.RR 1.05, CI 1.00, 1.09)., Conclusions: This study demonstrates good practices in the essential elements of HIV testing for both VCT and PITC. However, further quality enhancement is required in both testing approaches in relation to referral to HIV care post-test, client confidence in relation to confidentiality, and providing an opportunity to ask questions to address client-specific information needs.

While disclosure of HIV sero-status is encouraged in the management of the HIV and AIDS epidemic, it remains a challenge, especially among family members. This article examines the moral dilemmas and pragmatic incentives surrounding disclosure of HIV status in contemporary Uganda. Our findings are based on 12 in-depth interviews, 2 focus-group discussions, 6 key informant interviews with AIDS activists, and open-ended responses derived from 148 HIV-positive persons in a quantitative survey. The study was conducted in 2008-2009 in Kampala, Mpigi, and Soroti districts in Uganda. We found both parents and adult children facing dilemmas in disclosure, whether it was parents revealing their own HIV status to their children or the status of their perinatally infected children, or young people infected through sexual intercourse telling their parents. For both groups, there is fear of blame, stigma, discrimination, and shame and guilt related to unsafe sex, while young people also fear loss of privileges. On the other hand, there are practical imperatives for disclosure in terms of gaining access to care, treatment, and material resources. Faced with these dilemmas, HIV-positive people and their families require professional counselling to help them work through the emotional challenges encountered and identify mechanisms of support and coping.

Background: Recent efforts to curtail the HIV epidemic in Africa have emphasised preventing sexual transmission to partners through antiretroviral therapy. A component of current strategies is disclosure to partners, thus understanding its motivations will help maximise results. This study examines the rates, dynamics and consequences of partner disclosure in Burkina Faso, Kenya, Malawi and Uganda, with special attention to the role of support groups and stigma in disclosure., Methods: The study employs mixed methods, including a cross-sectional client survey of counselling and testing services, focus groups, and in-depth interviews with HIV-positive individuals in stable partnerships in Burkina Faso, Kenya, Malawi and Uganda, recruited at healthcare facilities offering HIV testing., Results: Rates of disclosure to partners varied between countries (32.7% - 92.7%). The lowest rate was reported in Malawi. Reasons for disclosure included preventing the transmission of HIV, the need for care, and upholding the integrity of the relationship. Fear of stigma was an important reason for non-disclosure. Women reported experiencing more negative reactions when disclosing to partners. Disclosure was positively associated with living in urban areas, higher education levels, and being male, while being negatively associated with membership to support groups., Conclusions: Understanding of reasons for disclosure and recognition of the role of support groups in the process can help improve current prevention efforts, that increasingly focus on treatment as prevention as a way to halt new infections. Support groups can help spread secondary prevention messages, by explaining to their members that antiretroviral treatment has benefits for HIV positive individuals and their partners. Home-based testing can further facilitate partner disclosure, as couples can test together and be counselled jointly.

Background: Though prevention and treatment depend on individuals knowing their HIV status, the uptake of testing remains low in Sub-Saharan Africa. One initiative to encourage HIV testing involves delivering services at home. However, doubts have been cast about the ability of Home-Based HIV Counseling and Testing (HBHCT) to adhere to ethical practices including consent, confidentiality, and access to HIV care post-test. This study explored client experiences in relation these ethical issues., Methods: We conducted 395 individual interviews in Kumi district, Uganda, where teams providing HBHCT had visited 6-12 months prior to the interviews. Semi-structured questionnaires elicited information on clients' experiences, from initial community mobilization up to receipt of results and access to HIV services post-test., Results: We found that 95% of our respondents had ever tested (average for Uganda was 38%). Among those who were approached by HBHCT providers, 98% were informed of their right to decline HIV testing. Most respondents were counseled individually, but 69% of the married/cohabiting were counseled as couples. The majority of respondents (94%) were satisfied with the information given to them and the interaction with the HBHCT providers. Most respondents considered their own homes as more private than health facilities. Twelve respondents reported that they tested positive, 11 were referred for follow-up care, seven actually went for care, and only 5 knew their CD4 counts. All HIV infected individuals who were married or cohabiting had disclosed their status to their partners., Conclusion: These findings show a very high uptake of HIV testing and satisfaction with HBHCT, a large proportion of married respondents tested as couples, and high disclosure rates. HBHCT can play a major role in expanding access to testing and overcoming disclosure challenges. However, access to HIV services post-test may require attention.

Background: This paper documents and analyses some of the responses to the largest Ebola outbreak on record, which took place in Uganda between September 2000 and February 2001. Four hundred and twenty five people developed clinical symptoms in three geographically distinct parts of the country (Gulu, Masindi, and Mbarara), of whom 224 (53%) died. Given the focus of previous social scientific Ebola research on experiences in communities that have been directly affected, this article expands the lens to include responses to the outbreak in local, national, and international contexts over the course of the outbreak., Methods: Responses to the outbreak were gauged through the articles, editorials, cartoons, and letters that were published in the country's two main English language daily national newspapers: the New Vision and the Monitor (now the Daily Monitor). All the relevant pieces from these two sources over the course of the epidemic were cut out, entered onto a computer, and the originals filed. The three a priori codes, based on the local, national, and international levels, were expanded into six, to include issues that emerged inductively during analysis. The data within each code were subsequently worked into coherent, chronological narratives., Results: A total of 639 cuttings were included in the analysis. Strong and varied responses to the outbreak were identified from across the globe. These included, among others: confusion, anger, and serious stigma in affected communities; medical staff working themselves to exhaustion, with some quitting their posts; patients fleeing from hospitals; calls on spiritual forces for protection against infection; a well-coordinated national control strategy; and the imposition of some international travel restrictions. Responses varied both quantitatively and qualitatively according to the level (i.e. local, national, or international) at which they were manifested., Conclusions: The Ugandan experience of 2000/2001 demonstrates that responses to an Ebola outbreak can be very dramatic, but perhaps disproportionate to the actual danger presented. An important objective for any future outbreak control strategy must be to prevent excessive fear, which, it is expected, would reduce stigma and other negative outcomes. To this end, the value of openness in the provision of public information, and critically, of being seen to be open, cannot be overstated.

In the 1990s, African AIDS programs followed a voluntary counseling and testing (VCT) approach to HIV testing. In the wake of large scale AIDS treatment programs, policymakers opted for routine provider-initiated testing (PITC) with less emphasis on counseling, which led to concerns about the ethical conduct of HIV testing. Inspired by Annemarie Mol, we ask if PITC can be framed as good care, rather than as medical domination that threatens to violate patients' rights. Based on fieldwork in Ugandan and Kenyan health facilities, we reveal that situations of choice vary: patients in hospital wards, are given time to decide whether they want a test, while in antenatal care testing women find it very hard to opt-out. We argue that the medical context inherent in PITC provides an attractive moral space for people to undergo HIV tests., (Copyright © 2011 Taylor & Francis Group, LLC)

Objective: The objective of this study is to estimate the annual costs of information, education, and communication (IEC), both community- and school-based; strengthened public and private sexually transmitted infections treatment; condom social marketing (CSM); and voluntary counseling and testing (VCT) implemented in Masaka, Uganda, over 4 years, and to explore how unit costs change with varying population use/uptake., Study: Total economic provider's costs and intervention outputs were collected annually to estimate annual unit costs between 1996 and 1999., Results: In early intervention years, uptake of all activities grew dramatically and continued to grow for public STI treatment, CSM, and VCT. Attendance at IEC performances started to drop in year 4. Unit costs dropped rapidly with increasing uptake of and participation in interventions., Conclusions: When implementing long-term community-based interventions, it is important to take into account that it takes time for communities to scale up their participation, since this can lead to large variations in unit costs.

Objective: Changing behaviour is an important method for preventing HIV infection. We examined why a community randomized trial of a behavioural intervention found no significant effect of this on HIV incidence in rural Uganda., Design: An individual-level analysis of a community randomized trial., Methods: All sexually active, initially HIV-seronegative individuals with data on sexual behaviour were included (1558 men and 1836 women). Uptake of the intervention was measured using self-reported attendance at meetings, videos, dramas, and interactions with community educators in the past year. Sexual behaviour was assessed using self-reported condom use and the number of sexual partners in the past year., Results: Overall, 81% of individuals in the intervention communities and 9% in the comparison communities reported attending at least one of the intervention activities in the past year. Attendance was lower in women, in those aged 55 years or older, and in the widowed. There was a lower HIV incidence in those who reported attending at least one intervention activity compared with those who attended none, and in women this effect was statistically significant (in women, adjusted rate ratio 0.41, 95% CI 0.19-0.89, P = 0.024; in men, adjusted rate ratio 0.66, 95% CI 0.25-1.79, P = 0.42). Reported behaviour change did not differ markedly between those who did and did not report attending any intervention activities., Conclusion: Although the intervention had no significant benefit in the communities as a whole, it resulted in a reduced risk of HIV acquisition in women who attended it. The methodological implications for future trials are discussed.

Objective: To describe study design, methods and baseline findings of a behavioural intervention alone and in combination with improved management of sexually transmitted diseases (STDs) aimed at reducing HIV incidence and other STDs., Design: A three-arm community randomized controlled trial (RCT) of 18 rural communities (approximately 96 000 adults) in SW Uganda. A standardized behavioural intervention was implemented in 12 communities (arms A and B) through community-based education, meetings and information leaflets. Six of these communities in addition received improved STD management through government and private health units (arm B). Arm C communities received routine government health services. Impact assessment was through three questionnaire and serological surveys of 750-1000 adults in each community at 18-24-month intervals. The primary outcome measure was HIV incidence and secondary measures were syphilis and herpes simplex virus type 2 incidence, prevalence of Neisseria gonorrhoea and Chlamydia trachomatis and sexual behaviour changes., Results: Approximately 15 000 adults (72% of eligible population) were enrolled at baseline. HIV baseline prevalence rates were 9-10% in all arms and demographic and behavioural characteristics and STD prevalence were also similar. In intervention communities, there were 391 995 attendance at 81 502 activities (6.1 per target adult), 164 063 leaflets distributed (2.6 per person) and 1 586 270 condoms (16.5 condoms per adult). In the STD communities a total of 12 239 STD cases (65% women) were seen over a 5-year period (7.7 per 100 adults/year)., Conclusion: This is the first community RCT of its type with a behavioural component. There is fair baseline comparability between study arms and process data suggest that interventions were adequately implemented.

Objective: To assess whether sexually transmitted infections (STIs) and sexual behavior are independently associated with HIV-1 among adult women, men, and teenagers in rural Uganda., Design: Cross-sectional survey., Methods: All adults (13 years and older) residing in 18 communities were invited to participate. HIV status was determined from serum samples and data collected during confidential interview. Independent effects of risk factors for HIV were estimated using adjusted odds ratios (ORs) with 95% confidence intervals (CIs) from logistic regression., Results: Women reporting genital ulcers in the last 12 months were over twice as likely to be HIV positive after adjustment for sociodemographic factors and number of lifetime sexual partners (OR, 2.5; 95% CI, 1.9-3.4). Equivalent associations were stronger for men (OR, 3.2; 95% CI, 2.2-4.7) but weaker for teenagers (OR, 2.0, 95% CI, 0.5-8.7). Number of lifetime sexual partners was associated ( p <.05) with HIV status for women, men, and teenagers independently of reported genital ulcers. Teenagers reporting casual partners were over four times ( p <.001), and men reporting condom use almost twice ( p <.001), as likely to be HIV positive. Neither history of genital discharge nor other measures of sexual behavior were independently related to HIV status., Conclusion: Reported STIs and sexual behavior are independently associated with HIV in rural Uganda. Community-based interventions to reduce HIV should target both and should include teenagers.