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Background: Mycoplasma genitalium is a common infection of the genitourinary tract, but its pathogenic effects have not been well described, especially in women. The increasing evidence that M. genitalium is associated with HIV infection calls for an urgent consensus on how best to control this infection. The aim of this study was to describe symptoms and signs associated with M. genitalium infection among high-risk women in Uganda.Methods: A cohort of 1027 female sex workers was recruited in Kampala in 2008. At enrollment, HIV testing was performed, genital specimens were tested for other sexually transmitted infection, and urogenital symptoms and signs were recorded. Endocervical swabs were tested for M. genitalium using a commercial Real-TM PCR assay (Sacace Biotechnologies, Como, Italy). The associations of clinical signs and symptoms with prevalent M. genitalium were investigated using multivariable logistic regression models.Results: Reported dysuria and presence of mucopurulent vaginal discharge were significantly associated with M. genitalium infection (OR: 1.85, 95% confidence interval: 1.13-3.03 and OR: 1.55, 95% confidence interval: 1.06-2.29, respectively). There was little evidence for an association with cervicitis or with pelvic inflammatory disease.Conclusions: In this specific population, we found evidence that symptoms of urethritis and mucopurulent vaginal discharge were associated with M. genitalium infection. This supports earlier studies showing that M. genitalium may lead to clinically relevant genitourinary disorders and should be treated. In the absence of sensitive screening tests, further work is needed to validate clinical findings as possible indicators of M. genitalium infection to guide a possible syndromic approach for its control. [ABSTRACT FROM AUTHOR]

The African Union and the Africa Centers for Disease Control and Prevention issued a Call to Action in 2022 for Africa's New Public Health Order that underscored the need for increased capacity in the public health workforce. Additional domestic and global investments in public health workforce development are central to achieving the aspirations of Agenda 2063 of the African Union, which aims to build and accelerate the implementation of continental frameworks for equitable, people-centred growth and development. Recognising the crucial role of higher education and research, we assessed the capabilities of public health doctoral training in schools and programmes of public health in Africa across three conceptual components: instructional, institutional, and external. Six inter-related and actionable recommendations were derived to advance doctoral training, research, and practice capacity within and between universities. These can be achieved through equitable partnerships between universities, research centres, and national, regional, and global public health institutions., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Despite lifelong and detrimental effects, the co-occurrence of health risk behaviors (HRBs) during adolescence remains understudied in low- and middle-income countries. This study examines the co-occurrence of HRBs and its correlates among adolescents in sub-Saharan Africa, China, and India., Methods: A multi-country cross-sectional study was conducted in 2021-2022, involving 9697 adolescents (aged 10-19 years) from eight countries, namely Burkina Faso, China, Ethiopia, India, Ghana, Nigeria, Tanzania, and Uganda. A standardized questionnaire was administered to examine five types of HRBs - physical inactivity, poor dietary habits, smoking, alcohol consumption, and risky sexual behavior. Latent class analysis was employed to identify clustering patterns among the behaviors, and logistic regression was used to identify the correlates of these patterns., Findings: Three clusters of HRBs were identified, with Cluster 1 (27.73%) characterized by the absence of any specific risky behavior, Cluster 2 (68.16%) characterized by co-occurrence of physical inactivity and poor dietary habits, and Cluster 3 (4.11%) characterized by engagement in smoking, alcohol consumption, and risky sexual behavior. Relative to Cluster 1, being in Cluster 2 was associated with being female (aOR 1.20, 95% CI 1.09-1.32), not enrolled in education (aOR 0.84, 95% CI 0.71-0.99), and not engaged in paid work (aOR 1.23, 95% CI 1.08-1.41). Compared with those Cluster 1, adolescents in Cluster 3 were less likely to be female (aOR 0.41, 95% CI 0.32-0.54), be engaged in paid work (aOR 0.54, 95% CI 0.41-0.71), more likely to be older (aOR 7.56, 95% CI 5.18-11.03), not be enrolled in educational institution (aOR 1.74, 95% CI 1.27-2.38), and more likely to live with guardians other than parents (aOR 1.56, 95% CI 1.19-2.05)., Interpretation: The significant clustering patterns of HRBs among adolescents in sub-Saharan Africa, China, and India highlights the urgent need for convergent approaches to improve adolescent health behaviors. Early life and school-based programs aimed at promoting healthy behaviors and preventing risky and unhealthy behaviors should be prioritized to equip adolescents with the tools and skills for lifelong well-being., Funding: Fondation Botnar (Grant #INV-037672) and Harvard T.H. Chan School of Public Health, partially funded this study., Competing Interests: We declare no conflicts of interest., (© 2024 The Author(s).)

Changing realities in low- and middle-income countries (LMICs) in terms of inequalities, urbanization, globalization, migration, and economic adversity shape adolescent development and health, as well as successful transitions between adolescence and young adulthood. It is estimated that 90% of adolescents live in LMICs in 2019, but inadequate data exist to inform evidence-based and concerted policies and programs tailored to address the distinctive developmental and health needs of adolescents. Population-based data surveillance such as Health and Demographic Surveillance Systems (HDSS) and school-based surveys provide access to a well-defined population and provide cost-effective opportunities to fill in data gaps about adolescent health and well-being by collecting population-representative longitudinal data. The Africa Research Implementation Science and Education (ARISE) Network, therefore, systematically developed adolescent health and well-being indicators and a questionnaire for measuring these indicators that can be used in population-based LMIC settings. We conducted a multistage collaborative and iterative process led by network members alongside consultation with health-domain and adolescent health experts globally. Seven key domains emerged from this process: socio-demographics, health awareness and behaviors; nutrition; mental health; sexual and reproductive health; substance use; and healthcare utilization. For each domain, we generated a clear definition; rationale for inclusion; sub-domain descriptions, and a set of questions for measurement. The ARISE Network will implement the questionnaire longitudinally (i.e., at two time-points one year apart) at ten sites in seven countries in sub-Saharan Africa and two countries in Asia. Integrating the questionnaire within established population-based data collection platforms such as HDSS and school settings can provide measured experiences of young people to inform policy and program planning and evaluation in LMICs and improve adolescent health and well-being., Competing Interests: We declare no conflict of interest., (© 2023 The Authors.)

Menstrual health has received increasing recognition as an essential issue for public health and gender equality. A growing body of research has elucidated adolescent girls' menstrual needs and informed policy and practice responses. However, the experiences of adult women have received little attention, particularly in the workplace where many spend a significant proportion of their lives. To address this gap, we took a grounded theory approach to generate a nuanced understanding of working women's menstrual experiences, and the impact of menstruation on their work and health in Mukono District, Uganda. In-depth interviews were undertaken with 35 women aged 18-49. This included 21 women working in markets, 7 teachers and 7 healthcare facility workers. Frequent collaborative analysis sessions throughout data collection, coding of interview transcripts, and generation of participant, workplace, and category memos facilitated analysis. Our core category and underlying theory, ' being a responsible woman', underpinned women's experiences. ' Being responsible' meant keeping menstruation secret, and the body clean, at all times. These gendered expectations meant that any difficulty managing menses represented a failure of womanhood, met with disgust and shame. Difficulties with menstrual pain and heavy bleeding were excepted from these expectations and perceived as requiring compassion. Commercial menstrual products were expensive for most women, and many expressed concerns about the quality of cheaper brands. Workplace infrastructure, particularly unreliable water supply and cleanliness, was problematic for many women who resorted to travelling home or to other facilities to meet their needs. Menstruation presented a burden at work, causing some women to miss work and income, and many others to endure pain, discomfort and anxiety throughout their day. Our findings can inform norm and resource-focused responses to improve experiences and should provoke critical reflection on the discourse used in menstrual health advocacy in Uganda., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We analysed mutually comparable surveys on adolescent attitudes and behaviours from nine sites in seven sub-Saharan African countries, to determine the relationship between school enrolment and adolescent health outcomes., Methods: Data from the Africa Research, Implementation Science, and Education Network cross-sectional adolescent health surveys were used to examine the associations of current school enrolment, self-reported general health and four major adolescent health domains: (i) sexual and reproductive health; (ii) nutrition and non-communicable diseases; (iii) mental health, violence and injury; and (iv) healthcare utilisation. We used multivariable Poisson regression models to calculate relative risk ratios with 95% confidence intervals (CI), controlling for demographic and socio-economic characteristics. We assessed heterogeneity by gender and study site., Results: Across 7829 adolescents aged 10-19, 70.5% were in school at the time of interview. In-school adolescents were 14.3% more likely (95% CI: 6-22) to report that their life is going well; 51.2% less likely (95% CI: 45-67) to report ever having had sexual intercourse; 32.6% more likely (95% CI: 9-61) to report unmet need for health care; and 30.1% less likely (95% CI: 15-43) to report having visited a traditional healer. School enrolment was not significantly associated with malnutrition, low mood, violence or injury. Substantial heterogeneity was identified between genders for sexual and reproductive health, and in-school adolescents were particularly less likely to report adverse health outcomes in settings with high average school enrolment., Conclusions: School enrolment is strongly associated with sexual and reproductive health and healthcare utilisation outcomes across nine sites in sub-Saharan Africa. Keeping adolescents in school may improve key health outcomes, something that can be explored through future longitudinal, mixed-methods, and (quasi-)experimental studies., (© 2019 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Objective: To examine knowledge of menstruation, HIV and STIs other than HIV across eight sites in SSA to develop effective programmatic interventions enabling adolescents to achieve positive SRH as their transition to adulthood., Methods: We combine data from eight Health and Demographic Surveillance Sites across sub-Saharan Africa, from an adolescent-specific survey that included 7116 males and females age 10-19 years old. We provide pooled and site-specific estimates from multiple analytic models examining the how year-specific age, school attendance and work correlate with knowledge of menstruation, HIV knowledge and knowledge of sexually transmitted infections (STIs) other than HIV., Results: Many adolescents lack knowledge of menstruation (37.3%, 95% CI 31.8, 43.1 do not know of menstruation) and STIs other than HIV (55.9%, 95% CI 50.4, 61.3 do not know of other STIs). In multivariate analysis, older age, being in school and wealth are significant positive correlates of STI knowledge. Older adolescent age, female sex and being in school are significant positive correlates of knowledge of menstruation. Knowledge of HIV is high (89.7%, 95% CI 8.3, 12.7 know of HIV) and relatively similar across adolescent age, sex, wealth and school and work attendance., Conclusion: Knowledge of HIV is widespread across adolescents in these communities in sub-Saharan Africa, but knowledge of other dimensions of sexual and reproductive health - menstruation and other STIs in this study - is lacking especially for early adolescents (10- to 14-year olds). The dissemination of more comprehensive sexual and reproductive health information is needed within these and similar communities in SSA to help adolescents gain insight on how to make their own decisions towards positive adolescent sexual and reproductive health and protect them from risks., (© 2019 John Wiley & Sons Ltd.)

Background: Women remain disproportionally affected by the HIV/ AIDS epidemic because of sociocultural factors including violence perpetrated by intimate partners. Among HIVpositive (HIV+) women, intimate partner violence (IPV) affects engagement in care and reproductive health outcomes. We analyzed data from a national survey to estimate the prevalence of IPV among HIV+ women in care and associated factors., Methods: The study was conducted among 5198 HIV+ women in care. Data were collected on socio-demographic characteristics, self-reported couple HIV status, mutual HIV status disclosure and IPV. IPV was assessed by asking participants whether their current husband or partner ever hit, slapped, kicked or did anything to hurt them physically, and whether their current husband or partner ever physically forced them to have intercourse or perform any sexual acts against their will. Women who responded "yes" were classified as having ever experienced IPV. Modified Poisson regression was used to identify factors associated with experiencing IPV., Results: Of 5198 HIV+ women, 1664 (32.1%) had ever experienced physical violence, 1466 (28.3%) had ever experienced sexual violence and 2290 (44.2%) had ever experienced any IPV. Compared with women in relationships where the woman and their male partner were of the same age, women in relationships where the partner was ≥1 year younger were more likely to ever experience IPV (Prevalence risk ratio [PRR] = 1.43, 95% Confidence Interval [95%CI]: 1.10-1.71), as were women in relationships where the partner was < 10 years older (PRR = 1.20, 95%CI: 1.00-1.43) or ≥ 10 years older (PRR = 1.31, 95%CI: 1.05-1.64). Compared with women who did not have biological children, women with 3-4 biological children were more likely to have ever experienced IPV (PRR = 1.27 95%CI: 1.00-1.59) as were those with ≥5 biological children (PRR = 1.34, 95%CI: 1.06-1.71). Compared with women in sero-concordant relationships, women in sero-discordant relationships were less likely to ever experience IPV (PRR = 0.87 95%CI: 0.78-0.98)., Conclusions: In Uganda, a high proportion of HIV+ women have ever experienced IPV. Experiencing IPV was associated with circumstances related to the intimate relationship between the woman and her male partner. Health care workers should screen HIV+ women in care for IPV and offer appropriate psychosocial assistance.

Background: Many people living with HIV would like to have children but family planning (FP) services often focus on only contraception. Availability of safer conception services is still very low in most low income countries. In this study we assessed the knowledge and use of safer conception methods (SCM) among HIV infected women in HIV care in Uganda to inform integration of safer conception in existing FP services., Methods: Data were accrued from a nationally representative cross-sectional survey of 5198 HIV+ women aged 15-49 years from 245 HIV clinics in Uganda. Knowledge and use of safer conception methods and associated factors were determined. The measure of association was prevalence ratio (PR) with corresponding 95% confidence intervals, obtained using a modified Poisson regression via generalized linear models. All the analyses were conducted using STATA version 12.0., Results: Overall knowledge of any safer conception method was 74.1% (3852/5198). However only 13.2% knew 3 to 4 methods, 18.9% knew only 2 methods and 42% knew only one method. Knowledge of specific SCM was highest for timed unprotected intercourse (TUI) at 39% (n = 2027) followed by manual self-insemination (MSI) at 34.8% (n = 1809), and pre-exposure prophylaxis (PrEP) at 24.8% (n = 1289). Knowledge of SCM was higher in the Eastern region (84.8%, P < 0.001), among women in HIV-discordant relationships (76.7%, p < 0.017), and those on ART (74.5%, p < 0.034). Overall, 1796 (34.6%) women were pregnant or reported a birth in the past 2 years-overall use of SCM in this group was 11.6% (209/1796). The odds of use of SCM were significantly lower in Kampala [adj. PR = 0.489(0.314, 0.764)] or Eastern region [adj.PR = 0.244; (0.147, 0.405)] compared to Northern region. Higher odds of SCM use were associated with HIV status disclosure to partner [adj.PR = 2.613(1.308, 5.221)] and sero-discordant compared to HIV+ concordant relationship [adj.PR = 1.637(1.236, 2.168)]. Pre-existing knowledge of any one SCM did not influence SCM use., Conclusions: Knowledge and use of SCM among HIV+ women in care is low. Efforts to improve HIV status disclosure, integration of safer conception into FP and HIV services and regional efforts to promote sensitization and access to safer conception can help to increase uptake of safer conception methods.

Objectives: To provide the first estimate of adolescents' abortion incidence in Uganda and to assess differences in the abortion experiences and morbidities of adolescent and nonadolescent postabortion care (PAC) patients., Study Design: We used the age-specific Abortion Incidence Complications Method, drawing from three surveys conducted in Uganda in 2013: a nationally representative Health Facilities Survey (n=418), a Health Professionals Survey (n=147) and a Prospective Morbidity Survey of PAC patients (n=2169). Multivariable logistic and Cox proportional hazard models were used to compare adolescent and nonadolescent PAC patients on dimensions including pregnancy intention, gestational age, abortion safety, delays to care, severity of complications and receipt of postabortion family planning. We included an interaction term between adolescents and marital status to assess heterogeneity among adolescents., Results: Adolescent women have the lowest abortion rate among women less than 35 years of age (28.4 abortions per 1000 women 15-19) but the highest rate among recently sexually active women (76.1 abortions per 1000 women 15-19). We do not find that adolescents face greater disadvantages in their abortion care experiences as compared to older women. However, unmarried PAC patients, both adolescent and nonadolescent, have higher odds of experiencing severe complications than nonadolescent married women., Conclusions: The high abortion rate among sexually active adolescents highlights the critical need to improve adolescent family planning in Uganda. Interventions to prevent unintended pregnancy and to reduce unsafe abortion may be particularly important for unmarried adolescents. Rather than treating adolescents as a homogenous group, we need to understand how marriage and other social factors shape reproductive health outcomes., Implications: This paper provides the first estimate of the adolescent abortion rate in Uganda. Studies of adolescent abortion and reproductive health must account for sexual activity and marital status. Further, interventions to address unintended pregnancy and unsafe abortion among unmarried women of all ages in Africa should be a priority., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by facility-based health workers in Burkina Faso and Village Health Teams (VHTs) in Uganda., Study Design: Participants were family planning clients of health centers (Burkina Faso) or VHTs (Uganda) who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12 months of pregnancy protection) to determine contraceptive continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection and if they discontinued either product., Results: Twelve-month continuation in Burkina Faso was 50% for DMPA-SC and 47.4% for DMPA-IM (p=.41, N=990, 492 DMPA-SC and 498 DMPA-IM). Twelve-month continuation in Uganda was 77.8% for DMPA-SC and 77.4% for DMPA-IM (p=.85, N=1224, 609 DMPA-SC and 615 DMPA-IM). Reasons for discontinuation of DMPA across groups in Burkina Faso included side effects (90/492, 18.3%), being late for injection (68/492, 13.8%) and refusal of spouse (51/492, 10.4%). Reasons for discontinuation in Uganda included being late for injection (65/229, 28.4%), received from non-VHT (50/229, 21.8%) and side effects (34/229, 14.8%). Increased age (adjusted hazard ratio=0.98, p=.01) and partner acceptance of family planning (adjusted hazard ratio=0.48, p<.001) had protective effects against discontinuation in Burkina Faso; we did not find statistically significant variables in Uganda., Conclusions: There is no difference in 12-month continuation (through four injections) between DMPA-SC and DMPA-IM whether from facility-based health workers in Burkina Faso or VHTs in Uganda. Continuation was higher through community-based distribution in Uganda than health facilities in Burkina Faso., Implications: The subcutaneous formulation of depot medroxyprogesterone acetate (DMPA-SC) is increasingly available in Family Planning 2020 countries. Use of DMPA-SC does not appear to change continuation relative to traditional intramuscular DMPA. Growing evidence of DMPA-SC's suitability for community-based distribution and self-injection may yield indirect benefits for contraceptive continuation and help reach new users., (Copyright © 2018. Published by Elsevier Inc.)

Background: Human immunodeficiency virus (HIV)-infected women are at high risk of cervical cancer., Objective: This study assessed uptake and correlates of cervical screening among HIV-infected women in care in Uganda., Methods: A nationally representative cross-sectional survey of HIV-infected women in care was conducted from August to November 2016. Structured interviews were conducted with 5198 women aged 15-49 years, from 245 HIV clinics. Knowledge and uptake of cervical screening and human papillomavirus (HPV) vaccination were determined. Correlates of cervical screening were assessed with modified Poisson regression to obtain prevalence ratios (PRs) using Stata version 12.0., Results: Overall, 94.0% (n = 4858) had ever heard of cervical screening and 66% (n = 3732) knew a screening site. However, 47.4% (n = 2302) did not know the schedule for screening and 50% (n = 2409) did not know the symptoms of cervical cancer. One-third (33.7%; n = 1719) rated their risk of cervical cancer as low. Uptake of screening was 30.3% (n = 1561). Women who had never been screened cited lack of information (29.6%; n = 1059) and no time (25.5%; n = 913) as the main reasons. Increased likelihood of screening was associated with receipt of HIV care at a level II health center [adj. PR 1.89, 95% confidence interval (CI) 1.29-2.76] and private facilities (adj. PR 1.68, 95% CI 1.16-3.21), knowledge of cervical screening (adj. PR 2.19, 95% CI 1.78-2.70), where to go for screening (adj. PR 6.47, 95% CI 3.69-11.36), and low perception of risk (adj. PR 1.52, 95% CI 1.14-2.03). HPV vaccination was 2%., Conclusions: Cervical screening and HPV vaccination uptake were very low among HIV-infected women in care in Uganda. Improved knowledge of cervical screening schedules and sites, and addressing fears and risk perception may increase uptake of cervical screening in this vulnerable population.

Objectives: Bacterial vaginosis (BV) is associated with increased risk for sexually transmitted infections (STIs) and HIV acquisition. This study describes the epidemiology of BV in a cohort of women at high risk for STI/HIV in Uganda over 2 years of follow-up between 2008-2011., Methods: 1027 sex workers or bar workers were enrolled and asked to attend 3-monthly follow-up visits. Factors associated with prevalent BV were analysed using multivariate random-effects logistic regression. The effect of treatment on subsequent episodes of BV was evaluated with survival analysis., Results: Prevalences of BV and HIV at enrolment were 56% (573/1027) and 37% (382/1027), respectively. Overall, 905 (88%) women tested positive for BV at least once in the study, over a median of four visits. Younger age, a higher number of previous sexual partners and current alcohol use were independently associated with prevalent BV. BV was associated with STIs, including HIV. Hormonal contraception and condom use were protective against BV. Among 853 treated BV cases, 72% tested positive again within 3 months. There was no difference in time to subsequent BV diagnosis between treated and untreated women., Conclusions: BV was highly prevalent and persistent in this cohort despite treatment. More effective treatment strategies are urgently needed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Introduction: Globally, most postpartum pregnancies are unplanned, mainly as a result of low level of knowledge and fear of contraceptive use especially in low-income settings. The aim of this study was to evaluate the effect of prenatal contraceptive counselling on postpartum contraceptive use and pregnancy outcomes after one year., Methods: Sixteen health centres were equally and randomly allocated to control and intervention arms. Mothers were consecutively recruited during their first antenatal clinic consultations. In the intervention arm Village Health Team members made home visits and provided prenatal contraceptive advice and made telephone consultations with health workers for advice while in the control arm mothers received routine antenatal care offered in the health centres. Data were collected in 2014 in the two districts of Kiryandongo and Masindi. This data was collected 12-14 months postpartum. Mothers were asked about their family planning intentions, contraceptive use and screened for pregnancy using human Chorionic Gonadotropin (hCG) levels. Socio-demographic and obstetric indices were recorded. Our primary outcomes of interests were current use of modern contraceptive, decision to use a modern contraceptive method and pregnancy status. Multilevel analysis using the xtmelogit stata command was used to determine differences between intervention and control groups., Results: A total of 1,385 women, 748 (control) and 627 (intervention) were recruited. About 80% initiated breastfeeding within six hours of delivery 78.4% (control) and 80.4% (intervention). About half of the mothers in each arm had considered to delay the next pregnancy 47.1% (control) and 49% (intervention). Of these 71.4% in the control and 87% in the intervention had considered to use a modern contraceptive method, only 28.2% of the control and 31.6% in the intervention were current modern contraceptive users signifying unmet contraceptive needs among immediate postpartum mothers. Regarding pregnancy, 3.3% and 5.7% of the women were found to be pregnant in the control and intervention arms respectively. There were no statistical differences between the control and intervention arms for all primary outcomes of interests., Conclusion: Prenatal contraceptive counseling did not affect postpartum contraceptive use among immediate postpartum mothers in Masindi and Kiryandongo districts. Interventions aiming at improving postpartum contraceptive use should focus on addressing unmet contraceptive needs.

Introduction: Adolescents are frequently reluctant to seek sexual and reproductive health services (SRH). In Uganda, adolescent health and development is constrained by translation of the relevant policies to practice. Recent studies done in central Uganda have shown that there is need for a critical assessment of adolescent friendly services (AFS) to gain insights on current practice and inform future interventions. This study aimed to assess the sexual reproductive health needs of the adolescents and explored their attitudes towards current services available., Methods: A qualitative study was conducted in Wakiso district, central Uganda in September 2013.Twenty focus group discussions (FGDs) stratified by gender (10 out-of-school, and 10 in-school), were purposefully sampled. We used trained research assistants (moderator and note taker) who used a pretested FGD guide translated into the local language to collect data. All discussions were audio taped, and were transcribed verbatim before analysis. Thematic areas on; adolescent health problems, adolescent SRH needs, health seeking behaviour and attitudes towards services, and preferred services were explored. Data was analysed using atlas ti version 7 software., Results: Our results clearly show that adolescents have real SRH issues that need to be addressed. In and out-of-school adolescents had sexuality problems such as unwanted pregnancies, sexually transmitted infections (STIs), defilement, rape, substance abuse. Unique to the females was the issue of sexual advances by older men and adolescents. We further highlight RH needs which would be solved by establishing adolescent friendly clinics with standard recommended characteristics (sexuality information, friendly health providers, a range of good clinical services such as post abortion care etc.). With regard to health seeking behaviour, most adolescents do not take any action at first until disease severity increase., Conclusions: Adolescents in Uganda have multiple sexual and reproductive health needs that require special focus through adolescent friendly services. This calls for resource support in terms of health provider training, information education and communication materials as well as involvement of key stakeholders that include parents, teachers and legislators.

Objectives: Cross-sectional studies have shown a strong association between Mycoplasma genitalium and HIV infections. We previously reported that in a cohort of female sex workers in Uganda, M genitalium infection at baseline was associated with HIV seroconversion. Here we examine the temporal association between the M genitalium infection status shortly before HIV seroconversion and HIV acquisition., Methods: A nested case-control study was conducted within a cohort of women at high risk for HIV in Kampala. Cases were those of women acquiring HIV within 2 years of enrolment. For each of the 42 cases, 3 controls were selected from women HIV negative at the visit when the corresponding case first tested HIV seropositive. The association between HIV acquisition and M genitalium infection immediately prior to HIV testing was analysed using conditional logistic regression., Results: There was weak evidence of an association between M genitalium infection and HIV acquisition overall (crude OR=1.57; 95% CI 0.67 to 3.72, aOR=2.28: 95% CI 0.81 to 6.47). However, time of M genitalium testing affected the association (p value for effect-modification=0.004). For 29 case-control sets with endocervical samples tested 3 months prior to the first HIV-positive result, M genitalium infection increased the risk of HIV acquisition (crude OR=3.09; 95% CI 1.06 to 9.05, aOR=7.19; 95% CI 1.68 to 30.77), whereas there was little evidence of an association among the 13 case-control sets with samples tested at an earlier visit (crude OR=0.30: 95% CI 0.04 to 2.51; aOR=0.34; 95% CI 0.02 to 5.94)., Conclusions: Our study showed evidence of a temporal relationship between M genitalium infection and HIV acquisition that suggests that M genitalium infection may be a co-factor in the acquisition of HIV infection., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To determine and compare the rates of HIV superinfection and primary HIV infection in high-risk female sex workers (FSWs) in Kampala, Uganda., Design: A retrospective analysis of individuals who participated in a clinical cohort study among high-risk FSWs in Kampala, Uganda., Methods: Plasma samples from HIV-infected FSWs in Kampala, Uganda were examined with next-generation sequencing of the p24 and gp41 HIV genomic regions for the occurrence of superinfection. Primary HIV incidence was determined from initially HIV-uninfected FSWs from the same cohort, and incidence rate ratios were compared., Results: The rate of superinfection in these women (7/85; 3.4/100 person-years) was not significantly different from the rate of primary infection in the same population (3.7/100 person-years; incidence rate ratio = 0.91, P = 0.42). Seven women also entered the study dual-infected (16.5% either dual or superinfected). The women with any presence of dual infection were more likely to report sex work as their only source of income (P = 0.05), and trended to be older and more likely to be widowed (P = 0.07)., Conclusions: In this cohort of FSWs, HIV superinfection occurred at a high rate and was similar to that of primary HIV infection. These results differ from a similar study of high-risk female bar workers in Kenya that found the rate of superinfection to be significantly lower than the rate of primary HIV infection.

Background: Recent antimicrobial resistance data for Neisseria gonorrhoeae are lacking in Uganda, where, until 2010, ciprofloxacin was the nationally recommended first-line treatment of presumptive gonorrhea. This study assessed the antimicrobial susceptibility patterns of N. gonorrhoeae isolates cultured from female sex workers (FSWs) in Kampala., Methods: Gonococci were isolated from endocervical specimens collected from women enrolled in a FSW cohort for 18 months (2008-2009). Minimum inhibitory concentrations for 7 antibiotics (ciprofloxacin, cefixime, ceftriaxone, azithromycin, spectinomycin, penicillin, and tetracycline) were determined for 148 isolates using Etest strips. The European Committee on Antimicrobial Susceptibility Testing version 1.3 clinical breakpoints were used to assign susceptibility categories. The 2008 World Health Organization N. gonorrhoeae panel was used for quality assurance purposes., Results: For ciprofloxacin, 123 (83.1%) gonococcal isolates were resistant, 2 (1.4%) had intermediate susceptibility, and 23 (15.6%) were fully susceptible. All isolates were susceptible to ceftriaxone and spectinomycin, whereas 1 isolate (0.7%) was resistant to cefixime. For azithromycin, 124 isolates (83.8%) were susceptible, 20 (13.5%) had decreased susceptibility, and 4 (2.7%) were resistant. Most isolates were resistant to penicillin (101; 68.2%) and tetracycline (144; 97.3%). The minimum inhibitory concentration ranges for each antibiotic were as follows: ciprofloxacin (0.002-32 mg/L), ceftriaxone (≤0.002-0.064 mg/L), cefixime (≤0.016-0.38 mg/L), spectinomycin (2-24 mg/L), azithromycin (0.023-1 mg/L), penicillin (0.094-32 mg/L), and tetracycline (0.019-256 mg/L)., Conclusions: The high prevalence of ciprofloxacin-resistant gonorrhea observed in Kampala-based FSW emphasizes the need for sustainable gonococcal antimicrobial resistance surveillance programs in Uganda and, in general, Africa.

Background: In 2008, the first clinic for women involved in high-risk sexual behavior was established in Kampala, offering targeted HIV prevention. This article describes rates, determinants, and trends of HIV incidence over 3 years., Methods: A total of 1027 women at high risk were enrolled into a closed cohort. At 3-monthly visits, data were collected on sociodemographic variables and risk behavior; biological samples were tested for HIV and other reproductive tract infections/sexually transmitted infections (RTI/STIs). Hazard ratios for HIV incidence were estimated using Cox proportional hazards regression among the 646 women HIV negative at enrolment., Results: HIV incidence was 3.66/100 person-years (pyr) and declined from 6.80/100 pyr in the first calendar year to 2.24/100 pyr and 2.53/100 pyr in the following years (P trend = 0.003). Sociodemographic and behavioral factors independently associated with HIV incidence were younger age, younger age at first sex, alcohol use (including frequency of use and binge drinking), number of paying clients in the past month, inconsistent condom use with clients, and not being pregnant. HIV incidence was also independently associated with Mycoplasma genitalium infection at enrolment [adjusted hazard ratio (aHR) = 2.28, 95% confidence interval (CI): 1.15 to 4.52] and with Neisseria gonorrhoeae (aHR = 5.91, 95% CI: 3.04 to 11.49) and Trichomonas vaginalis infections at the most recent visit (aHR = 2.72, 95% CI: 1.27 to 5.84). The population attributable fractions of HIV incidence for alcohol use was 63.5% (95% CI: 6.5 to 85.8) and for treatable RTI/STIs was 70.0% (95% CI: 18.8 to 87.5)., Conclusions: Alcohol use and STIs remain important risk factors for HIV acquisition, which call for more intensive control measures in women at high risk. Further longitudinal studies are needed to confirm the association between M. genitalium and HIV acquisition.

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.

During 2006-2007, transmitted human immunodeficiency virus (HIV) drug resistance (TDR) among drug-naive women with newly diagnosed HIV infection and likely to be recently infected when attending antenatal clinics in Entebbe was found to be <5% with use of the World Health Organization (WHO) survey method. Using the same method, we attempted to classify TDR among women who seroconverted during 2008-2010 and who were identified from a cohort of recently infected sex workers in Kampala, Uganda. TDR mutations were identified using the 2009 WHO TDR mutations list. The WHO survey method could not be used to classify TDR because the necessary sample size was not reached during the survey period. However, a point prevalence estimate of 2.6% (95% confidence interval, 0.07%-13.8%) nonnucleoside reverse-transcriptase inhibitor TDR was determined.

We investigated for the first time the subtype distribution, prevalence of multiple HIV-1 infections, sexual networks, and partnership histories in a cohort of women engaged in high-risk sexual behavior such as female sex workers (FSWs) and women employed in entertainment facilities. Viral RNA was extracted from blood samples collected from 324 HIV-1-positive women; the gp-41 and pol-IN genes were directly sequenced. Women found to have closely related viruses and those with recombinant viruses were further analyzed in the pol-IN gene by clonal sequencing to determine HIV-1 multiple infections. Individual partnership histories were used to provide information on when sex work was undertaken and where. Subtyping in both gp-41 and pol-IN was successfully done in 210/324 (64.8%) women. Subtype distribution in these two genes was 54.3% (n=114) A/A, 2.9% (n=6) C/C, 24.3% (n=51) D/D, 11.9% (n=25) A/D, 4.8% (n=10) D/A, 0.5% (n=1) C/A, 1.0% (n=2) B/A, and 0.5% (n=1) B/D. Sexual networks were identified in six pairs and one triplet of women with closely related subtype A viruses. Partnership histories showed that women having phylogenetically similar viruses had worked in the same localities. Five cases of multiple infections were confirmed: four dual infections and one triple infection. In this first molecular epidemiology study among FSWs in Kampala, subtype A was the predominant subtype. About 9% of a subgroup had multiple infections. Partnership histories and multiple infections observed in this population suggest sexual mixing of the FSWs and their clients confirming their high-risk characteristics.

Background: The importance of Mycoplasma genitalium in human immunodeficiency virus (HIV)-burdened sub-Saharan Africa is relatively unknown. We assessed the prevalence and explored determinants of this emerging sexually transmitted infection (STI) in high-risk women in Uganda., Methods: Endocervical swabs from 1025 female sex workers in Kampala were tested for Mycoplasma genitalium using a commercial Real-TM polymerase chain reaction assay. Factors associated with prevalent Mycoplasma genitalium, including sociodemographics, reproductive history, risk behavior, and HIV and other STIs, were examined using multivariable logistic regression., Results: The prevalence of Mycoplasma genitalium was 14% and higher in HIV-positive women than in HIV-negative women (adjusted odds ratio [OR], 1.64; 95% confidence interval [CI], 1.12-2.41). Mycoplasma genitalium infection was less prevalent in older women (adjusted OR, 0.61; 95% CI, .41-.90 for women ages 25-34 years vs <25 years; adjusted OR, 0.32; 95% CI, .15-.71 for women ≥ 35 years vs those <25 years) and in those who had been pregnant but never had a live birth (adjusted OR, 2.25; 95% CI, 1.04-4.88). Mycoplasma genitalium was associated with Neisseria gonorrhoeae (adjusted OR, 1.84; 95% CI, 1.13-2.98) and with Candida infection (adjusted OR, 0.41; 95% CI, .18-.91), and there was some evidence of association with Trichomonas vaginalis (adjusted OR, 1.56; 95% CI, 1.00-2.44)., Conclusions: The relatively high prevalence of Mycoplasma genitalium and its association with prevalent HIV urgently calls for further research to explore the potential role this emerging STI plays in the acquisition and transmission of HIV infection.

Background: Uganda has long been successful in controlling the HIV epidemic; however, there is evidence that HIV prevalence and incidence are increasing again. Data on the HIV/STI epidemic among sex workers are so far lacking from Uganda. This paper describes the baseline epidemiology of HIV/STI in a newly established cohort of women involved in high-risk sexual behavior in Kampala, Uganda., Methods: Women were recruited from red-light areas in Kampala. Between April 2008 and May 2009, 1027 eligible women were enrolled. Sociodemographic and behavioral information were collected; blood and genital samples were tested for HIV/STI. Risk factors for HIV infection were examined using multivariate logistic regression., Results: HIV seroprevalence was 37%. The prevalence of Neisseria gonorrhoeae was 13%, Chlamydia trachomatis, 9%; Trichomonas vaginalis, 17%; bacterial vaginosis, 56% and candida infection, 11%. Eighty percent had herpes simplex virus 2 antibodies (HSV-2), 21% were TPHA-positive and 10% had active syphilis (RPR+TPHA+). In 3% of the genital ulcers, Treponema pallidum (TP) was identified, Haemophilus ducreyi in 6%, and HSV-2 in 35%. Prevalent HIV was independently associated with older age, being widowed, lack of education, sex work as sole income, street-based sex work, not knowing HIV-status, using alcohol, and intravaginal cleansing with soap. HIV infection was associated with N. gonorrhoeae, T. vaginalis, bacterial vaginosis, HSV-2 seropositivity and active syphilis., Conclusions: Prevalence of HIV/STI is high among women involved in high-risk sexual behavior in Kampala. Targeted HIV prevention interventions including regular STI screening, voluntary HIV testing and counseling, condom promotion, and counseling for reducing alcohol use are urgently needed in this population.