Correction: Mobile Phone Technology for Preventing HIV and Related Youth Health Problems, Sexual Health, Mental Health, and Substance Use Problems in Southwest Uganda (Youth Health SMS)- Protocol for a Pilot Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/49352.].

Mobile Phone Technology for Preventing HIV and Related Youth Health Problems, Sexual Health, Mental Health, and Substance Use Problems in Southwest Uganda (Youth Health SMS): Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: East and Southern Africa have the highest HIV incidence and prevalence in the world, with adolescents and young adults being at the greatest risk. Despite effective combination prevention tools, including the recently available pre-exposure prophylaxis (PrEP), HIV incidence among adolescents and young adults in Uganda remains high, and PrEP use remains low. Mental health and substance use (behavioral health) play a role in sexual behavior and decision-making, contributing to an increase in the risk for acquiring HIV. Interventions that target multiple HIV risk factors, including sexual and mental health and problematic substance use, are crucial to ending the HIV epidemic. Yet few interventions addressing HIV related health disparities and comorbidities among adolescents and young adults in East and Southern Africa currently exist. OBJECTIVE: This study aims to evaluate the acceptability and feasibility of Kirabo, an SMS text message intervention informed by the information, motivation, and behavior model and to be disseminated through secondary schools. The study will gather preliminary estimates of Kirabo's effectiveness in increasing HIV testing and linking users to mental health counselors. METHODS: We identified Mobile 4 Reproductive Health for adaptation using the assessment, decision, administration, production, topical experts, integration, training, testing (ADAPT-ITT) framework. Mobile 4 Reproductive Health is an evidence-based automated 2-way SMS text messaging and interactive voice response platform that offers sexual and reproductive health information and links users to HIV clinics in East Africa. Through ADAPT-ITT we refined our approach and created Kirabo, an SMS text message-based intervention for linking adolescents and young adults to health services, including HIV testing and mental health counseling. We will conduct a 2-arm randomized controlled trial in Masaka, Uganda. Adolescents (N=200) will be recruited from local schools. Baseline sociodemographic characteristics, HIV test history, and behavioral health symptoms will be assessed. We will evaluate acceptability and feasibility using surveys, interviews, and mobile phone data. The preliminary efficacy of Kirabo in increasing HIV testing and linking users to mental health counselors will be evaluated immediately after the intervention and at the 3-month follow-up. We will also assess the intervention's impact on self-efficacy in testing for HIV, adopting PrEP, and contacting a mental health counselor. RESULTS: Intervention adaptation began in 2019. A pretest was conducted in 2021. The randomized controlled trial, including usability and feasibility assessments and effectiveness measurements, commenced in August 2023. CONCLUSIONS: Kirabo is a tool that assists in the efforts to end the HIV epidemic by targeting the health disparities and comorbidities among adolescents in Uganda. The intervention includes local HIV clinic information, PrEP information, and behavioral health screening, with referrals as needed. Increasing access to prevention strategies and mitigating factors that make adolescents and young adults susceptible to HIV acquisition can contribute to global efforts to end the HIV epidemic. TRIAL REGISTRATION: ClinicalTrials.gov NCT05130151; https://clinicaltrials.gov/study/NCT05130151. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49352.

Implications of rapid population growth on survey design and HIV estimates in the Rakai Community Cohort Study (RCCS), Uganda.

OBJECTIVE: Since rapid population growth challenges longitudinal population-based HIV cohorts in Africa to maintain coverage of their target populations, this study evaluated whether the exclusion of some residents due to growing population size biases key HIV metrics like prevalence and population-level viremia. DESIGN, SETTING AND PARTICIPANTS: Data were obtained from the Rakai Community Cohort Study (RCCS) in south central Uganda, an open population-based cohort which began excluding some residents of newly constructed household structures within its surveillance boundaries in 2008. The study includes adults aged 15-49 years who were censused from 2019 to 2020. MEASURES: We fit ensemble machine learning models to RCCS census and survey data to predict HIV seroprevalence and viremia (prevalence of those with viral load >1000 copies/mL) in the excluded population and evaluated whether their inclusion would change overall estimates. RESULTS: Of the 24 729 census-eligible residents, 2920 (12%) residents were excluded from the RCCS because they were living in new households. The predicted seroprevalence for these excluded residents was 10.8% (95% CI: 9.6% to 11.8%)-somewhat lower than 11.7% (95% CI: 11.2% to 12.3%) in the observed sample. Predicted seroprevalence for younger excluded residents aged 15-24 years was 4.9% (95% CI: 3.6% to 6.1%)-significantly higher than that in the observed sample for the same age group (2.6% (95% CI: 2.2% to 3.1%)), while predicted seroprevalence for older excluded residents aged 25-49 years was 15.0% (95% CI: 13.3% to 16.4%)-significantly lower than their counterparts in the observed sample (17.2% (95% CI: 16.4% to 18.1%)). Over all ages, the predicted prevalence of viremia in excluded residents (3.7% (95% CI: 3.0% to 4.5%)) was significantly higher than that in the observed sample (1.7% (95% CI: 1.5% to 1.9%)), resulting in a higher overall population-level viremia estimate of 2.1% (95% CI: 1.8% to 2.4%). CONCLUSIONS: Exclusion of residents in new households may modestly bias HIV viremia estimates and some age-specific seroprevalence estimates in the RCCS. Overall, HIV seroprevalence estimates were not significantly affected.

The negative health spillover effects of universal primary education policy: Ethnographic evidence from Uganda.

Scholars of global health have embraced universal education as a structural intervention to prevent HIV. Yet the costs of school, including fees and other ancillary costs, create an economic burden for students and their families, indicating both the challenge of realising the potential of education for preventing HIV and the ways in which the desire for education may produce vulnerabilities to HIV for those struggling to afford it. To explore this paradox, this article draws from collaborative, team-based ethnographic research conducted from June to August 2019 in the Rakai district of Uganda. Respondents reported that education is the most significant cost burden faced by Ugandan families, sometimes amounting to as much as 66% of yearly household budgets per student. Respondents further understood paying for children's schooling as both a legal requirement and a valued social goal, and they pointed to men's labour migrations to high HIV-prevalence communities and women's participation in sex work as strategies to achieve that. Building from regional evidence showing young East African women participate in transactional, intergenerational sex to secure school fees for themselves, our findings point to the negative health spillover effects of Uganda's universal schooling policies for the whole family.

Psychosocial outcomes and peer influences among multiracial adolescents in the United States.

Objective: To examine racial and ethnic self-identification among adolescents and explore psychosocial outcomes and peer treatment for multiracial adolescents in the United States. Methods: Data are from the 2014 Child Development Supplement, a subsample of the Panel Study of Income Dynamics. Data were weighted to be nationally representative. Descriptive statistics were used to describe the population and to explore family and parent demographics. Multivariable regressions tested for differences in psychosocial outcomes and peer treatment and group behaviors for multiracial youth in comparison to their single race peers. Results: Black multiracial youth had significantly lower scores on the children's depression index compared to single race Black youth, and White multiracial youth reported significantly higher rates of peer mistreatment in comparison to White single race youth. Black multiracial and White multiracial adolescents reported similar positive and negative peer group behaviors. Conclusions: Complex patterns emerge when examining the psychosocial and peer treatment variables presented in this analysis for multiracial adolescents and their single-race peers. The findings regarding depressive symptoms and peer bullying point to signs of different relationships between multiracial groups. White multiracial adolescents report worse outcomes than their White single-race peers, but Black multiracial adolescents reporting better outcomes than their Black single-race peers.

Gendered access to digital capital and mobile phone ownership among young people in Rakai, Uganda.

This article examines how gendered access to digital capital-in the form of the social and economic resources needed to own and use a mobile phone-is connected to key adult milestones, such as securing employment and engaging in romantic relationships. Descriptive statistical analysis of 11,030 young people aged 15-24 in Rakai, Uganda indicated that men were more likely to own mobile phones than women. Analysis of qualitative interviews with young people (N = 31) and ethnographic participant observations among young people (N = 24) add nuance and depth to the observed gender difference. We go beyond a 'categorical' approach to gender (i.e. comparing rates between men and women) to examine how access to digital capital is gendered both for men and for women. Mobile phone ownership both reproduces and destabilises gendered social organisation in ways that have implications for economic opportunities, social connections, HIV risk and overall health and well-being. Young men had greater access to the benefits of mobile phone ownership, whereas young women's access to those benefits was impeded by covert and overt gendered mechanisms of control that limited access to digital capital. Findings suggest that mhealth initiatives, increasingly deployed to reach under-resourced populations, must take into account gendered access to digital capital.

Opportunities to Improve Adolescent Sexual and Reproductive Health Services in Primary Care Clinics.

Primary care providers are well positioned to address the sexual and reproductive health (SRH) needs of adolescents; however, gaps often exist in the delivery of quality SRH services in primary care. Our objective was to identify specific opportunities to improve the delivery of adolescent SRH services in primary care. We conducted in-depth interviews with 25 primary care providers from various disciplines across rural and urban areas of Minnesota and conducted thematic analysis of transcribed data. Participants identified salient opportunities in three areas: (1) training and resources for providers (e.g., related to minor consent laws or addressing sensitive subjects), (2) practices and procedures (e.g., time-alone procedures and policies for confidential screening and sharing test results), and (3) education for adolescents (e.g., knowing their rights and accessing confidential SRH services). Study findings provide actionable opportunities to improve delivery of adolescent SRH services in primary care.

Factors influencing the conduction of confidential conversations with adolescents in the emergency department: A multicenter, qualitative analysis.

BACKGROUND: Health care providers (HCPs) in the emergency department (ED) frequently must decide whether to conduct or forego confidential conversations with adolescent patients about sensitive topics, such as those related to mental health, substance use, and sexual and reproductive health. The objective of this multicenter qualitative analysis was to identify factors that influence the conduct of confidential conversations with adolescent patients in the ED. METHODS: In this qualitative study, we conducted semistructured interviews of ED HCPs from five academic, pediatric EDs in distinct geographic regions. We purposively sampled HCPs across gender, professional title, and professional experience. We used the Theoretical Domains Framework (TDF) to develop an interview guide to assess individual and system-level factors affecting HCP behavior regarding the conduct of confidential conversations with adolescents. Enrollment continued until we reached saturation. Interviews were recorded, transcribed, and coded by three investigators based on thematic analysis. We used the coded transcripts to collaboratively generate belief statements, which are first-person statements that reflect shared perspectives. RESULTS: We conducted 38 interviews (18 physicians, 11 registered nurses, five nurse practitioners, and four physician assistants). We generated 17 belief statements across nine TDF domains. Predominant influences on having confidential conversations included self-efficacy in speaking with adolescents alone, wanting to address sexual health complaints, maintaining patient flow, experiencing parental resistance and limited space, and having inadequate resources to address patient concerns and personal preconceptions about patients. Perspectives divided between wanting to provide focused medical care related only to their chief complaint versus self-identifying as a holistic medical HCP. CONCLUSIONS: The factors influencing the conduct of confidential conversations included multiple TDF domains, elucidating how numerous intersecting factors influence whether ED HCPs address sensitive adolescent health needs. These data suggest methods to enhance and facilitate confidential conversations when deemed appropriate in the care of adolescents in the ED.

Capacity to Consent to Research Among Adolescent-Parent Dyads in Rakai, Uganda.

OBJECTIVES: To assess the cognitive capacity of early, middle, and late adolescents and their parents or guardians to provide informed consent to a population-based cohort study. STUDY DESIGN: Adolescent-parent/guardian dyads including 40 early (n = 80; 10-14 years), 20 middle (15-17 years), and 20 late (18-19 years) adolescents were recruited from the Rakai Community Cohort Study, an open demographic cohort in Uganda. Participants were administered the MacArthur Competence Assessment Tool for Clinical Research, a structured open-ended assessment; interviews were recorded and transcribed. Twenty transcripts were scored independently by two coders; the intraclass correlation coefficient was 0.89. The remaining interviews were scored individually. We compared mean scores for early and middle/late adolescents using a one-sided t test and score differences between parent/guardian and adolescent dyads using two-sided paired t tests. RESULTS: Early adolescents (mean score, 28.8; 95% CI, 27.1-30.5) scored significantly lower (P < .01) than middle/late adolescents (32.4; 31.6-33.1). In paired dyad comparisons, we observed no statistically significant difference in scores between parents/guardians and middle/late adolescents (difference, -0.2; 95% CI, -1.0-0.6). We found a statistically significant difference in scores between parents/guardians and early adolescents (difference, 3.0; 95% CI, 1.2-4.8). CONCLUSIONS: The capacity of adolescents-of different ages and in diverse settings-to comprehend risks, benefits, and other elements of informed consent is a critical but understudied area in research ethics. Our findings support the practice of having middle and late adolescents provide independent informed consent for sexual and reproductive health studies. Early adolescents may benefit from supported decision-making approaches.

Debating Sex and Sovereignty: Uganda's New National Sexuality Education Policy.

Introduction: This article examines recent moral panics over sex education in Uganda from historical perspectives. Public outcry over comprehensive sexuality education erupted in 2016 over claims that children were being taught "homosexuality" by international NGOs. Subsequent debates over sex education revolved around defending what public figures claimed were national, religious, and cultural values from foreign infiltration. Methods: This paper is grounded in a survey of Uganda's two English-print national newspapers (2016-2018), archival research of newspapers held at Uganda's Vision Group media company (1985-2005), analyses of public rhetoric as reported in nationally circulating media, textual analysis of Uganda's National Sexuality Education Framework (2018), formal interviews with Ugandan NGO officers (3), and semi-structured interviews with Ugandan educators (3). Results: Uganda's current panic over sex education reignited longstanding anxieties over foreign interventions into the sexual health and rights of Ugandans. We argue that in the wake of a 35-year battle with HIV/AIDS and more recent controversies over LGBT rights, both of which brought international donor resources and governance, the issue of where and how to teach young people about sex became a new battleground over the state's authority to govern the health and economic prosperity of its citizens. Conclusions: Ethno- and religio-nationalist rhetoric used to oppose the state's new sexuality education policy was also used to justify sex education as a tool for economic development. Policy Implications: Analyzing rhetoric mobilized by both supporters and detractors of sex education reveals the contested political terrain policy advocates must navigate in Uganda and other postcolonial contexts.

Incident HIV Infection Among Young Men Associated With Female Sexual Partner Types Identified Through Latent Class Analysis, Rakai, Uganda.

BACKGROUND: Sexual partner characteristics are important determinants of HIV acquisition, but little is known about partner types of young men in sub-Saharan Africa. METHODS: Sexually active men aged 15-24 years from 5 rounds (2005-2013) of the Rakai Community Cohort Study in Uganda reported characteristics of up to 4 past-year female partners. Partner types were identified using latent class analysis. HIV incidence rates (IRs) were calculated by partner-type combinations, and individual-level risk adjusted IR ratios (aIRRs) relative to the lowest incidence type were estimated using the Poisson regression with generalized estimating equations. RESULTS: Young men (N = 1771) reported 4539 past-year female sexual partners. Three partner types were identified: type A: noncohabiting, student, medium duration partnerships; type B: cohabiting, nonstudent, longer duration partnerships; and type C: noncohabiting, nonstudent shorter duration partnerships. Type C partners engaged in the most HIV-related risk behaviors. Many men (29%) had more than 1 partner type/round. IR overall was 9.8/1000 person-years [95% confidence interval (CI): 4.7 to 20.6]. IR was 4.0 (95% CI: 1.2 to 12.7) for men with type A partners alone (41% of men). Relative to them, IR for those with type B partners alone (25%) was not significantly different. Men with type C partners alone (5%) had higher risk (aIRR = 3.2; 95% CI: 1.0 to 9.9), as did men with >1 partner type, including men with both type A and type B partners (12%; aIRR = 6.3; 95% CI: 2.5 to 15.9) and men with type C and other partner types (17%; aIRR = 4.3; 95% CI: 1.7 to 10.8). CONCLUSIONS: Partner-type combination was strongly associated with HIV incidence; type C partners and having more than 1 partner type were the riskiest patterns.

"Sex is supposed to be naturally more pleasurable": Healers as providers of holistic sexual and reproductive healthcare in Uganda.

Global health researchers often approach Traditional, Complementary, and Alternative Medicine (TCAM) from a health efficacy perspective, asking whether the presence of plural medical systems helps or hinders the uptake of biomedicine. Medical anthropologists, by contrast, typically emphasize how plural medical systems encourage us to rethink health ontologies-that is, who and what comes to constitute the experience of health and illness, and through which practices. Building on both approaches, we explore the role of "healers," a term we use to encompass several different kinds of TCAM providers, in the sexual and reproductive healthcare (SRH) of young people from southcentral Uganda, a region well known as an HIV/AIDS epicenter. Drawing from ethnographic data, we describe three reasons that young people seek SRH from healers. First, they associate stigma, scarcity, and high costs with biomedical SRH. Second, healers work across biomedical and non-biomedical therapeutic divides, prescribing herbs for sexually transmitted infections while simultaneously referring clients to biomedical HIV clinics. Third, healers provide counseling focused on pleasurable and economically-motivated sex. Because these therapies diverge from international and national HIV prevention messaging that frames non-marital and transactional sex in terms of danger and disease, healers' holistic approach to SRH may help to reconstitute the meaning, practice, and experience of "sexual health" in contemporary Uganda. This has important implications for improving global SRH programs and for understanding the continued appeal of TCAM more generally.

Associations between Developmental Assets and Adolescent Health Status: Findings from the 2016 National Survey of Children's Health.

BACKGROUND: Developmental assets foster positive health outcomes among adolescents, but have not been studied in adolescents with chronic illness or depression, two conditions that impact behaviors in school. We examined parent-reported assets in a national sample of adolescents and compared the number and types of assets by health statuses. METHODS: Data were from the 2016 National Survey of Children's Health (N = 15,734 adolescents), which captured 15 of 40 assets in the Developmental Assets Framework. We categorized adolescents as healthy; chronic physical illness alone; depression alone; and chronic physical illness with co-morbid depression. Data were analyzed using analysis of variance and logistic regression. RESULTS: Healthy adolescents and those with chronic physical illness alone were comparable in number and types of assets. Adolescents with chronic physical illness and co-morbid depression had fewer assets compared to healthy adolescents and those with chronic physical illness alone. Similar associations were found in comparing healthy adolescents to those with depression without chronic physical illness. CONCLUSIONS: The presence of depression, among adolescents with and without chronic physical illness, was associated with fewer internal and external assets. The absence of assets may serve as a unique indicator of underlying depressive symptoms among adolescents in the school setting.

Receipt of Private Time Among Adolescents and Young Adults With and Without Special Healthcare Needs.

PURPOSE: Private time is an opportunity for the adolescent patient to speak directly to a healthcare provider and a marker of quality preventive health care. Little is known about whether adolescents and young adults (AYAs) with special healthcare needs (SHCNs) are afforded private discussions with their primary care clinicians. METHODS: We surveyed a nationally representative sample of 1,209 adolescents (13-18 years) and 709 young adults (19-26 years) about whether they had SHCNs and whether they had ever had private, one-on-one time with their healthcare providers. RESULTS: SHCNs were reported by 20.3% of adolescents and 15.6% of young adults. Among adolescents, older age was associated with more SHCNs. Among young adults, women and blacks were more likely to report SHCNs than men and those reporting other race categories. For both AYAs, those with SHCNs more often received private time than those without SHCNs: 54.2% of adolescents and 88.1% of young adults with SHCNs reported ever having received private time, compared with 29.6% of adolescents and 62.1% of young adults without SHCNs. CONCLUSIONS: Lack of private time continues to impact quality primary care for AYAs; however, AYAs with SHCNs are more likely to have received private time than AYAs who do not have SHCNs. Further research is needed to understand whether increased number of clinical visits, clinician-related factors, or other factors lead to more opportunities for young people with SHCNs to receive private time from their clinicians.

HIV combination prevention and declining orphanhood among adolescents, Rakai, Uganda, 2001-18: an observational community cohort study.

BACKGROUND: Orphanhood increased markedly in the 1980s and 1990s in sub-Saharan Africa because of HIV-related mortality. Little is known about the contribution of HIV interventions, such as antiretroviral therapy (ART) and male medical circumcision, to more recent trends in orphanhood. In this study, we examined trends over time in maternal-only, paternal-only, and double orphanhood among adolescents before and after ART and male medical circumcision became widely available in the Rakai region of south-central Uganda. We sought to understand the association between adolescent orphanhood and HIV combination prevention (community-level ART use and prevalence of male medical circumcision). We hypothesised that increasing combination prevention, including greater use of ART and higher prevalence of male medical circumcision, would be associated with a lower probability of orphanhood. METHODS: We examined the prevalence of orphanhood among adolescents aged 15-19 years, before and after roll-out of ART in mid-2004 and male medical circumcision in 2007, using data from 28 continuously followed communities within the Rakai Community Cohort Study. We used multinomial logistic regression with clustered SEs to estimate adjusted relative risk ratios (RRs) for maternal-only, paternal-only, and double orphanhood compared with non-orphanhood over 11 survey rounds between 2001 and 2018. Controlling for community HIV prevalence, household socioeconomic status, and adolescent age, we examined the association between community prevalence of ART use among people living with HIV and prevalence of male circumcision, including traditional circumcision. The primary outcome was orphanhood among adolescents aged 15-19 years. FINDINGS: Orphanhood declined from 52% (920 of 1768 participants) in 2001-02 to 23% (592 of 2609 participants) by 2016-18 (p<0·0001), while double orphanhood declined from 20% (346 of 1768 participants) to 3% (86 of 2609 participants) (p<0·0001). Community prevalence of ART use among people living with HIV increased from 11% (105 of 945 participants) in 2005-06 to 78% (1163 of 1485 participants) in 2016-18. Male circumcision rates rose from 19% (147 of 790 participants) in 2005-06 to 65% (3535 of 5433 participants) in 2016-18. In the multinomial logistic regression model, a 10% increase in community prevalence of ART use was associated with a decrease in maternal orphanhood (adjusted relative RR 0·90, 95% CI 0·85-0·95) and double orphanhood (0·80, 0·75-0·85). In the post-ART era, a 10% increase in the community prevalence of male circumcision was associated with a decrease in paternal orphanhood (2005-18, adjusted relative RR 0·92, 0·87-0·97) and double orphanhood (0·91, 0·85-0·98). INTERPRETATION: Widespread availability and uptake of HIV combination prevention was associated with marked reductions in orphanhood among adolescents. Reductions in orphanhood promise improved health and social outcomes for young people. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases.

When Coffee Collapsed: An Economic History of HIV in Uganda.

In some Ugandan fishing communities, almost half the population lives with HIV. Researchers designate these communities "HIV hotspots" and attribute disproportionate disease burdens to "sex-for-fish" relationships endemic to the lakeshores. In this article, we trace the emergence of Uganda's HIV hotspots to structural adjustment. We show how global economic policies negotiated in the 1990s precipitated the collapse of Uganda's coffee sector, causing mass economic dislocation among women workers, who migrated to the lake. There, they entered overt forms of sex work or marriages they may have otherwise avoided, intimate economic arrangements that helped to "engineer the spread of HIV," as one respondent recounted.

Household wealth and HIV incidence over time, rural Uganda, 1994-2018.

OBJECTIVE: To examine the relationship between household wealth and HIV incidence in rural Uganda over time from 1994 to 2018. In research conducted early in the epidemic, greater wealth (i.e. higher socioeconomic status, SES) was associated with higher HIV prevalence in sub-Saharan Africa (SSA); this relationship reversed in some settings in later years. DESIGN: Analysis of associations over time in a population-based open cohort of persons 15-49 years from 17 survey-rounds in 28 continuously followed communities of the Rakai Community Cohort Study (RCCS). METHODS: The RCCS sample averaged 8622 individuals and 5387 households per round. Principal components analysis was used to create a nine-item asset-based measure of household wealth. Poisson regression with generalized estimating equation (GEE) and exchangeable correlation structure was used to estimate HIV incidence rate ratios (IRRs) by SES quartile, survey-round, sex, and age group. RESULTS: From 1994 to 2018, SES rose considerably, and HIV incidence declined from 1.45 to 0.40 per 100 person-years (IRR = 0.39, 95% CI = 0.32--0.47, P < 0.001). HIV incidence was similar by SES category in the initial survey intervals (1994-1997); however, higher SES groups showed greater declines in HIV incidence over time. Multivariable analyses showed significant associations between HIV incidence and SES (IRR = 0.55 for highest compared with lowest quartile, 95% CI = 0.45--0.66, P < 0.001) controlling for time, sex, and age group. CONCLUSION: Beyond the early years of the RCCS, higher SES was associated with lower HIV incidence and SES gradients widened over time. The poor, like other key populations, should be targeted for HIV prevention, including treatment as prevention.

The Promise and Peril of Mobile Phones for Youth in Rural Uganda: Multimethod Study of Implications for Health and HIV.

BACKGROUND: In East Africa, where landlines are used by 1% of the population and access to the internet is limited, owning a cell phone is rapidly becoming essential for acquiring information and resources. Our analysis illuminates the perils and potential promise of mobile phones with implications for future interventions to promote the health of adolescents and young adults (AYAs) and to prevent HIV infection. OBJECTIVE: The aim of this study is to describe the current state of AYAs' phone use in the region and trace out the implications for mobile health interventions. METHODS: We identified 2 trading centers that were representative of southern Uganda in terms of key demographics, proportion of cell phone ownership, and community HIV prevalence. We stratified the sample of potential informants by age group (15-19 years and 20-24 years), gender, and phone ownership and randomly sampled 31 key informant interview participants within these categories. In addition, we conducted 24 ethnographic participant observations among AYAs in the communities of study. RESULTS: AYA frequently reported barriers to using their phones, such as difficulty accessing electricity. Nearly all AYAs used mobile phones to participate in the local economy and communicate with sexual partners. Phone use was frequently a point of contention between sexual partners, with many AYAs reporting that their sexual partners associated phone use with infidelity. Few AYAs reported using their phones for health-related purposes, with most getting health information in person from health workers. However, most AYAs reported an instance when they used their phone in an emergency, with childbirth-related emergencies being the most common. Finally, most AYAs reported that they would like to use their phones for health purposes and specifically stated that they would like to use their mobile phones to access current HIV prevention information. CONCLUSIONS: This study demonstrates how mobile phones are related to income-generating practices in the region and communication with sexual partners but not access to health and HIV information. Our analysis offers some explanation for our previous study, which suggested an association between mobile phone ownership, having multiple sexual partners, and HIV risk. Mobile phones have untapped potential to serve as tools for health promotion and HIV prevention.