Characteristics of Received HIV Prevention Advocacy from Persons Living with HIV in Uganda, and Associations with HIV Testing and Condom Use Among Social Network Members.

Receiving peer advocacy has been shown to result in increased HIV protective behaviors, but little research has gone beyond assessment of the mere presence of advocacy to examine aspects of advocacy driving these effects. With baseline data from a controlled trial of an advocacy training intervention, we studied characteristics of HIV prevention advocacy received among 599 social network members of persons living with HIV in Uganda and the association of these characteristics with the social network members' recent HIV testing (past six months) and consistent condom use, as well as perceived influence of advocacy on these behaviors. Participants reported on receipt of advocacy specific to HIV testing and condom use, as well as on measures of advocacy content, tone of delivery, support for autonomous regulation, and perceived influence on behavior. Receiving HIV testing advocacy and condom use advocacy were associated with recent HIV testing [65.2% vs. 51.4%; OR (95% CI) = 1.77 (1.11-2.84)], and consistent condom use with main sex partner [19.3% vs. 10.0%; OR (95% CI) = 2.16 (1.12-4.13)], respectively, compared to not receiving advocacy. Among those who received condom advocacy, perceived influence of the advocacy was positively correlated with consistent condom use, regardless of type of sex partner; support of autonomous regulation was a correlate of consistent condom use with casual sex partners, while judgmental advocacy was a correlate of consistent condom use with serodiscordant main partners. Among those who received testing advocacy, HIV testing in the past 6 months was positively correlated with receipt of direct support for getting tested. In multiple regression analysis, perceived influence of both HIV testing and condom use advocacy were positively correlated with advocacy that included access information and support of autonomous regulation; confrontational advocacy and judgmental advocacy were independent positive correlates of perceived influence of testing and condom use advocacy, respectively. These findings support associations that suggest potential benefits of peer advocacy from PLWH on HIV testing and condom use among their social network members, and indicate that advocacy content, tone of delivery, and support of autonomous regulation advocacy may play an important role in the success of advocacy.

Concordance of HIV Prevention Advocacy Reports and its Associations with HIV Protective Behaviors.

Peer advocacy can promote HIV protective behaviors, but little is known about the concordance on prevention advocacy(PA) reports between people living with HIV(PLWH) and their social network members. We examined prevalence and correlates of such concordance, and its association with the targeted HIV protective behavior of the social network member. Data were analyzed from 193 PLWH(index participants) and their 599 social network members(alters). Kappa statistics measured concordance between index and alter reports of PA in the past 3 months. Logistic and multinomial regressions evaluated the relationship between advocacy concordance and alter condom use and HIV testing behavior and correlates of PA concordance. Advocacy concordance was observed in 0.3% of index-alter dyads for PrEP discussion, 9% for condom use, 18% for HIV testing, 26% for care engagement, and 49% for antiretroviral use discussions. Fewer indexes reported condom use(23.5% vs. 28.1%;[Formula: see text]=3.7, p=0.05) and HIV testing(30.5% vs. 50.5%; [Formula: see text]=25.3, p<0.001) PA occurring. Condom advocacy concordance was higher if the index and alter were romantic partners(OR=3.50; p=0.02), and lower if the index was 10 years younger than the alter(OR=0.23; p = 0.02). Alters had higher odds of using condoms with their main partner when both reported condom advocacy compared to dyads where neither reported advocacy(OR=3.90; p<0.001) and compared to dyads where only the index reported such advocacy(OR = 3.71; p=0.01). Age difference and relationship status impact advocacy agreement, and concordant perceptions of advocacy are linked to increased HIV protective behaviors. Alters' perceptions may be crucial for behavior change, informing strategies for improving advocacy.

Equity in family planning policies and programs in Uganda: conceptualization, dimensions and implementation constraints.

BACKGROUND: Equity is at the core and a fundamental principle of achieving the family planning (FP) 2030 Agenda. However, the conceptualization, definition, and measurement of equity remain inconsistent and unclear in many FP programs and policies. This paper aims to document the conceptualization, dimensions and implementation constraints of equity in FP policies and programs in Uganda. METHODS: A review of Ugandan literature and key informant interviews with 25 key stakeholders on equity in FP was undertaken between April and July 2020. We searched Google, Google Scholar and PubMed for published and grey literature from Uganda on equity in FP. A total of 112 documents were identified, 25 met the inclusion criteria and were reviewed. Data from the selected documents were extracted into a Google master matrix in MS Excel. Data analysis was done across the thematic areas by collating similar information. Data were analyzed using thematic content analysis approach. RESULTS: A limited number of documents had an explicit definition of equity, which varied across documents and stakeholders. The definitions revolved around universal access to FP information and services. There was a limited focus on equity in FP programs in Uganda. The dimensions most commonly used to assess equity were either geographical location, or socio-demographics, or wealth quintile. Almost all the key informants noted that equity is a very important element, which needs to be part of FP programming. However, implementation constraints (e.g. lack of quality comprehensive FP services, duplicated FP programs and a generic design of FP programs with limited targeting of the underserved populations) continue to hinder effective implementation of equitable FP programs in Uganda. Clients' constraints (e.g. limited contraceptive information) and policy constraints (inadequate focus on equity in policy documents) also remain key challenges. CONCLUSIONS: There is lack of a common understanding and definition of equity in FP programs in Uganda. There is need to build consensus on the definitions and measurements of equity with a multidimensional lens to inform clear policy and programming focus on equity in FP programs and outcomes. To improve equitable access to and use of FP services, attention must be paid to addressing implementation, client and policy constraints.

Correlates of HIV Prevention Advocacy by Persons Living with HIV in Kampala, Uganda: A Cross-sectional Evaluation of a Conceptual Model.

BACKGROUND: HIV prevention advocacy empowers persons living with HIV (PLWH) to act as advocates and encourage members of their social networks to engage in protective behaviors such as HIV testing, condom use, and antiretroviral therapy (ART) adherence. We examined correlates of HIV prevention advocacy among PLWH in Uganda. METHOD: A cross-sectional analysis was conducted with baseline data from 210 PLWH (70% female; mean age = 40 years) who enrolled in a trial of an HIV prevention advocacy training program in Kampala, Uganda. The baseline survey, which was completed prior to receipt of the intervention, included multiple measures of HIV prevention advocacy (general and specific to named social network members), as well as internalized HIV stigma, HIV disclosure, HIV knowledge, positive living (condom use; ART adherence), and self-efficacy for HIV prevention advocacy. RESULTS: Consistent with our hypotheses, HIV disclosure, HIV knowledge, consistent condom use, and HIV prevention advocacy self-efficacy were all positively correlated with at least one measure of HIV prevention advocacy, after controlling for the other constructs in multiple regression analysis. Internalized HIV stigma was positively correlated with advocacy in bivariate analysis only. CONCLUSION: These findings identify which characteristics of PLWH are associated with acting as change agents for others in their social network to engage in HIV protective behaviors.

Effects of a peer advocacy intervention on cervical cancer screening among social network members: results of a randomized controlled trial in Uganda.

Cervical cancer (CC) is the most common cancer among women in Uganda, yet lifetime CC screening is as low as 5%. Training women who have screened for CC to engage in peer advocacy could increase uptake of CC screening in social networks. We conducted a randomized controlled trial of a peer-facilitated, manualized, 7-session group intervention to train women to engage in CC prevention advocacy. Forty women recently screened for CC (index participants) enrolled and were assigned to receive the intervention (n = 20) or wait-list control (n = 20). Each index was asked to recruit up to three female social network members (alters) who had not been screened for CC (n = 103 enrolled alters). All index and alter participants were assessed at baseline and month-6 follow-up. All but one (n = 39; 98%) index and 98 (95%) alter participants completed the month 6 assessment. In multivariate regression models controlling for baseline outcome measures and demographic covariates, intervention alters were more likely to have been screened for CC at month 6 [67% vs. 16%; adjusted OR (95% CI) = 12.13 (4.07, 36.16)], compared to control alters. Data also revealed significant increased engagement in CC prevention advocacy, among both index and alter participants in the intervention group at month 6, compared to the control group. The intervention was highly effective in increasing CC screening uptake among social network members, and engagement in CC prevention advocacy among not only intervention recipients, but also targets of advocacy, suggesting the potential for wide dissemination of CC knowledge.Trial Registration. NIH Clinical Trial Registry NCT04960748 ( clinicaltrials.gov ).

Increased Knowledge Mediates the Effect of Game Changers for Cervical Cancer Prevention on Diffusion of Cervical Cancer Screening Advocacy Among Social Network Members in a Pilot Trial.

BACKGROUND: Game Changers for Cervical Cancer Prevention (GC-CCP), a peer-led, group advocacy training intervention, increased cervical cancer (CC) prevention advocacy not only among intervention recipients, but also their social network members (referred to as "alters") who were targeted with advocacy in a pilot randomized controlled trial. We examined mediators and moderators of this effect on alter advocacy, to understand how and for whom the intervention had such an effect. METHOD: Forty women (index participants) who had recently screened for CC enrolled and were randomly assigned to receive the GC-CCP intervention (n = 20) or the wait-list control (n = 20). Up to three alters from each participant (n = 103) were surveyed at baseline and month 6. Measures of CC-related cognitive constructs (knowledge, enacted stigma, and risk management self-efficacy), as well as extent of advocacy received from index participants, were assessed as mediators of the intervention effect on alter advocacy using multivariate regression analyses. Alter characteristics were examined as moderators. RESULTS: Increased CC-related knowledge partially mediated the intervention effect on increased alter engagement in CC prevention advocacy; those with greater gains in knowledge reported greater engagement in advocacy. No moderators of the intervention effect were identified. CONCLUSION: The effect of GC-CCP on alter CC prevention advocacy is enhanced by increased alter knowledge pertaining to CC prevention, causes, and treatment and suggests this may be key for diffusion of intervention effects on increased CC prevention advocacy throughout a social network. TRIAL REGISTRATION: NCT04960748 (registered on clinicaltrials.gov , 7/14/2021).

Piloting Gain and Loss-Framed PrEP and Childbearing Messaging to Promote HIV Testing in Uganda: Perspectives from Couples and Providers.

Fears of relationship dissolution and the inability to bear healthy children remain barriers to HIV testing in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) carries both clinical and symbolic benefits that counter these fears. We conducted a pilot messaging intervention through Uganda's assisted partner notification (APN) program, where providers assist HIV-positive index clients in notifying sexual partners and encourage testing. We randomized providers at three clinics to implement phone scripts over two months with (1) gain-framed or (2) loss-framed information about PrEP and childbearing; or (3) usual care. In 23 in-depth interviews with providers, index clients, and partners, five major themes emerged on intervention acceptability and feasibility: (1) value of PrEP and childbearing messaging in APN; (2) value of this messaging coming earlier in APN; (3) overall preference for gain-framed messages; (4) need to tailor timing of messaging; and (5) need for messaging outside of APN. Register data (109 index clients, 145 partners) indicated most index clients (95%) wanted their potential conception partners informed about PrEP. Preliminary trends suggest the intervention sites outperformed usual care in testing rates among potential conception partners. Messaging that highlights PrEP and safe childbearing may be a promising new communication strategy to promote HIV testing.

Effect of COVID-19 lock down on teenage pregnancies in Northern Uganda: an interrupted time series analysis.

BACKGROUND: Pregnancy and childbirth complications are the leading cause of death among girls aged 15-19 years globally, with low- and middle-income countries (LMICs) accounting for 99% of global maternal deaths of women aged 15-49 years. Despite teenage pregnancies declining in many developing countries in recent years, the COVID-19 period intensified the problem and altered the trend for most countries. We determined the effect of the COVID-19 lockdown on the teenage pregnancy trend in Pakwach district, Uganda, to understand its magnitude in our study population. METHODS: Using interrupted time series analysis (ITS), sometimes known as quasi-experimental time series analysis. We constructed a time series of the first ANC service utilization records for girls aged 10-19 years in Pakwach district, Uganda, and conducted an interrupted series analysis. We compared the two periods of March 2019 to March 2020 and March 2020 to March 2021. We used Stata 15 to conduct our analysis, performed OLS, and plotted the results. RESULTS: The teenage pregnancy trend before the lockdown was decreasing by - 0.203 pregnancies per month, but in the first month after the institution of the lockdown (March 20, 2020), there was an increase in the teenage pregnancy rate of 13.9 pregnancies [95% CI: - 33.6 to 61.5], which corresponds to an increase in the monthly trend in teenage pregnancies (relative to the period before the COVID-19 lockdown trend) of 1.53 girls per month. CONCLUSION: Teenage pregnancies increased during the lockdown. This slight increase depicted the impact of the pandemic on the teenage pregnancy trend associated with the COVID-19 outbreak. The government needs to focus on intervention to reduce this trend and avoid any further increases.

Association of Condom Use Advocacy with Perceived Condom Use Among Social Network Members: The Mediating Role of Advocates' Internalized HIV Stigma and Own Condom Use.

We examined the association of HIV prevention advocacy with social network members (alters) on alter condom use behavior, and factors that may mediate and moderate this relationship, among people living with HIV (PLWH) in Uganda. Ninety PLWH completed all assessments (baseline and 5- and 8-month follow-ups). Internalized HIV stigma, HIV disclosure self-efficacy, positive living behavior (i.e., condom use), and advocacy self-efficacy were examined as mediators (at 5-month follow-up) of the association between condom use advocacy and perceived alter condom use. Individual socio-demographic and social network characteristics at baseline were examined as moderators. Among alters who received condom use advocacy in the months prior to both baseline and 5-month follow-up, 69.9% (51/73) were perceived to mostly/always use condoms at either the 5- or 8-month follow-up, which was significantly higher than the 36.4% (235/645) of alters who received none or less advocacy. Participants' internalized HIV stigma and consistent condom use mediated the association of advocacy and perceived consistent condom use among alters; the participant having any secondary education and the alter being male were associated with increased magnitude of the associations between advocacy and alter condom use. These findings highlight the importance of sustained advocacy to promote consistent condom use, and the value of anti-stigma and positive living interventions as mechanisms for enhancing effective advocacy.

Tobacco Smoking and Associated Factors Among People Living With HIV in Uganda.

INTRODUCTION: The prevalence of smoking among people living with HIV (PLWH) in Uganda is high. AIMS AND METHODS: We assessed the smoking patterns, behaviors, and associated factors among PLWH in Uganda through a cross-sectional survey. Descriptive statistics were used to describe smoking patterns and behaviors. Logistic regression was used to identify factors associated with current smoking status. RESULTS: We recruited 777 participants between October and November 2019: 387 (49.8%) current smokers and 390 (50.2%) nonsmokers. 60.9% were males, and the mean age was 40.5 (SD 10.7) years. In multivariate logistic regression, the following increased the odds of being a current smoker: being male (odds ratio [OR] 6.60 [95% confidence interval, CI = 4.34-10.04]), having at least two smokers among five closest friends (OR 3.97 [95% CI = 2.08-7.59]), living in smoking-permitted households (OR 5.83 [95% CI = 3.32-10.23]), alcohol use (OR 3.96 [95% CI = 2.34-6.71]), a higher perceived stress score (OR 2.23 [95% CI = 1.50-3.34]), and higher health-related quality of life (OR 5.25 [95% CI = 1.18-23.35]). Among smokers, the mean Fagerström Test for Nicotine Dependence score was 3.0 (SD 1.9), and 52.5% were making plans to quit. Self-efficacy to resist smoking and knowledge of the impact of smoking on PLWH's health were low. CONCLUSIONS: Being male, having at least two smokers among five closest friends, living in smoking-permitted households, alcohol use, higher perceived stress scores, and higher health-related quality of life were associated with being a current smoker. Smokers had low to moderate nicotine dependence, high willingness to quit, and low self-efficacy. IMPLICATIONS: Future behavioral smoking cessation interventions for PLWH should address co-consumption with alcohol and comorbid mental health conditions that are common among PLWH such as stress. In addition, they should take into account the lack of knowledge among this population of the impact of smoking on their health, and low self-efficacy. Given the relatively low levels of nicotine dependency and high levels of willingness to quit in our sample, smoking cessation interventions, if offered, are likely to support this population in achieving long-term smoking abstinence.

Peer-leaders' experiences and challenges in distributing HIV self-test kits in a rural fishing community, Rakai, Uganda.

BACKGROUND: Distribution of HIV self-test kits by trained lay people in the community has resulted in increased uptake of HIV testing services among the targeted populations. However, little data exists on the experiences and challenges faced by trained lay people while distributing the kits. METHODS: This qualitative study was conducted in Kasensero fishing community, Rakai, Uganda, in September 2019. We purposely selected 18 out of 34 peer-leaders that participated in a peer-led HIV self-testing intervention to participate in a post-intervention qualitative evaluation. The main intervention included identification and training of lay people in the community ('peer-leaders') to distribute HIV self-test kits to pre-selected members of their social network. Data for this study were collected at the end of the intervention. Data were collected on peer-leaders' experiences in distributing the kits, challenges experienced during distribution and suggestions on how to improve peer-led HIV self-testing in typical fishing communities in the future. Data were analyzed manually following a thematic framework approach. RESULTS: Of the 18 peer-leaders, eleven (61.1%) were aged 20-24 years while thirteen (72.2%) had secondary education. Most (n = 15) of the peer-leaders reported that they found it easier to distribute the kits to their social network members, with most of them distributing the kits at the social network members' homes or at their own homes. HIV self-test kits were distributed at varying times (e.g. in the afternoon) depending on the agreement reached between the peer-leader and their social network member. A few peer-leaders reported that some of their social network members initially hesitated to accept the kits while other peer-leaders reported that they spent a 'lot of time' explaining the HIV self-testing procedures to some of their illiterate members. Peer-leaders argued for supervised HIV self-testing for illiterate people and the need to continuously follow-up social network members to check if they tested for HIV. CONCLUSION: A majority of the peer-leaders successfully distributed the kits to their social network members save for a few who experienced challenges. These findings suggest that lay people can be trained as effective HIV self-test kits distributors to improve the distribution of kits in the community.

Men's comfort in distributing or receiving HIV self-test kits from close male social network members in Dar Es Salaam, Tanzania: baseline results from the STEP project.

BACKGROUND: A variety of strategies have been used to reach men with HIV self-testing services, including social network-based HIV self-test kits distribution. However, few studies have assessed men's comfort to distribute to or receive HIV self-test kits from close male friends within the same social network. In this study, we assessed men's comfort to distribute to and/or receive HIV self-test kits from close male friends and associated factors among men who socialize in networks locally referred to as "camps" in Tanzania. METHODS: Data are from the baseline survey of a cluster-randomized controlled trial conducted in June 2019 with 18 social networks or "camps" in Dar es Salaam, Tanzania. Participants were 18-year-old or older male camp members who were HIV-negative at the time of enrolment. We used the Generalized Estimating Equations (GEE) to assess factors associated with being comfortable to distribute to and/or receive HIV self-test kits from close male members within one's social network. RESULTS: Of 505 participants, 67.9% (n = 342) reported being comfortable to distribute to while 68.2% (n = 344) were comfortable to receive HIV self-test kits from their close male friends. Ever having heard about HIV self-testing (Adjusted Prevalence Ratio (Adj. PR): 1.6; 95% Confidence Interval [CI]: 1.3, 1.9), willingness to self-test for HIV in front of a sexual partner (Adj. PR: 3.0; 95%CI: 1.5, 6.1) and exposure to peer-led HIV self-testing education and promotion (Adj. PR: 1.4; 95%CI: 1.2, 1.7) were significantly associated with being comfortable to distribute HIV self-test kits to close male members within one's social network. Similar results were observed for being comfortable to receive HIV self-test kits from a close male friend within one's social network. CONCLUSIONS: Overall, these findings suggest that distribution of HIV self-test kits through close male friends could improve the proportion of men reached with HIV self-testing services and improve HIV testing rates in this population where uptake remains low. However, additional promotional strategies such as peer-led HIV self-testing education are needed to raise awareness and increase the proportion of men who are comfortable to receive and/or distribute HIV self-testing kits.

Examination of Mediators and Moderators to Understand How and in What Context Game Changers Increases HIV Prevention Advocacy Among Persons Living With HIV in Uganda.

BACKGROUND: Our randomized controlled trial (RCT) of the group-based Game Changers intervention demonstrated effects on the primary goal of increased HIV-protective behaviors among social network members (alters), via the mechanism of increased participant engagement in HIV prevention advocacy with alters. We sought to understand how and in what context the intervention has its effects by examining specific mediators and moderators of the intervention's effect on increased prevention advocacy. METHODS: The RCT was conducted with 98 adult PLWH in Uganda. Intervention content targeted internalized HIV stigma, HIV disclosure, positive living behaviors, and self-efficacy for advocacy; these constructs were examined as intervention mediators (at the 5-month follow-up) of advocacy effects reported at the 8-month follow-up. Baseline sample characteristics were explored as moderators. RESULTS: Internalized HIV stigma and HIV disclosure mediated intervention effects on prevention advocacy, but not antiretroviral adherence or self-efficacy for advocacy. Moderators of the intervention effect included several network characteristics (trust in, support from, stigma from, and connectedness among network members), but not respondent socio-demographics or HIV disease characteristics. The intervention was associated with greater prevention advocacy when trust in, support from, and connectedness among alters were high, and stigma from alters was low. CONCLUSIONS: These findings highlight the importance of helping PLWH cope with self-stigma and gain comfort with disclosure, as well as the potential influence of network support, trustworthiness, connectedness, and stigmatization on engagement in prevention advocacy.

COVID-19 Awareness, Adoption of COVID-19 Preventive Measures, and Effects of COVID-19 Lockdown Among Adolescent Boys and Young Men in Kampala, Uganda.

There is growing evidence of the challenges with adherence to COVID-19 prevention measures and the effect of the prevention measures on the health of populations in various parts of the world but with limited documentation in sub-Saharan Africa. We assessed COVID-19 awareness, adoption of COVID-19 prevention measures, and the effects of COVID-19 lockdown on the mental health status, socio-economic disruptions and engagement in unhealthy behaviours among 2500 in- and out-of-school adolescent boys and young men (ABYM) aged 10-24 years in Kampala, Uganda. 74.8% (n = 1869) were in-school; nearly half (47.3%, n = 1182) were aged 15-19 years. Although > 80% were aware of at least two COVID-19 prevention measures, only 22.2% (n = 555) reported that they always wore a face mask while in a public place; 40.9% (n = 1023) always washed their hands with soap and running water while 17.6% (n = 440) always avoided gatherings of more than five people. COVID-19 lockdown led to: (a) increased mental health challenges (e.g. 1.2% [n = 31] contemplated committing suicide); (b) limited ability to meet basic needs (e.g. 62.0% [n = 1549] found it difficult to afford a diverse/balanced diet); (c) socio-economic disruptions (e.g. 30.3% [n = 756] experienced a reduction in income) and (d) engagement in unhealthy behaviours (e.g. 62% [n = 1554] reported a sedentary life style such as excessive watching of TV). These effects were more pronounced among older adolescent boys (15-19 years) and young men (20-24 years) and out-of-school compared to in-school ABYM. Our findings suggest a need for appropriate health promotion, mental health and socio-economic interventions targeting ABYM in Kampala, Uganda.

A Pilot Test of Game Changers, a Social Network Intervention to Empower People with HIV to be Prevention Advocates in Uganda.

We conducted a pilot randomized controlled trial of Game Changers, a 6-session group intervention that empowers people with HIV to be HIV prevention advocates in their social networks. Ninety-nine people with HIV (51 intervention, 48 wait-list control) and 58 of their social network members (alters) completed baseline and 5- and 8-month post-baseline assessments. Results indicated high acceptability, demonstrated by participants' and facilitators' positive attitudes qualitatively and favorable ratings of intervention sessions quantitatively, and high feasibility (76% attended all intervention sessions). Intention-to-treat analyses indicated significantly increased HIV prevention advocacy among HIV-positive participants and alters [b (SE) = 0.4 (0.2), p = .017; b (SE) = 0.4 (0.2), p = .035]; reduced internalized HIV stigma [b (SE) = - 0.3 (0.1), p = .012], increased HIV-serostatus disclosure [b (SE) = 0.1 (0.1), p = .051], and increased social network density among HIV-positive participants [b (SE) = 0.1 (0.03), p = .004]; and marginally reduced condomless sex among alters [OR (95% CI) = 0.3 (0.1-1.2), p = .08]. Positioning people with HIV as central to prevention has the potential to reduce stigma and improve prevention outcomes throughout social networks.

Risk factors for HIV infection among married couples in Rakai, Uganda: a cross-sectional study.

BACKGROUND: Although married couples can be at an elevated risk of HIV infection, few studies have explored the risk factors for HIV infection at the couple-level. We explored the risk factors for HIV infection among married couples in settings with differing HIV prevalence levels in Rakai, Uganda. METHODS: This was a cross-sectional study conducted among 664 heterosexual couples living in three HIV prevalence strata (low: 9-11.2%; medium: 11.4-20% or high HIV prevalence: 21-43%) in Rakai District, south-western Uganda, between November 2013 and February 2014. Data were collected on socio-demographic and behavioural characteristics from all consenting adults and aggregated to allow for couple-level analyses. We conducted bivariate and multivariable Logistic regression to assess the factors that were independently associated with HIV infection among married couples. Data were analysed using STATA statistical software (version 14.1). RESULTS: Of the 664 couples, 6.4% (n = 42) were in HIV-discordant relationships; 5.8% (n = 39) were in concordant HIV-positive relationships while 87.8% (n = 583) were in concordant HIV-negative relationships. At the bivariate analysis, we found that residing in a high HIV prevalence stratum, reporting extra-marital relations, age difference between partners and number of previous marriages were significantly associated with being part of an HIV infected couple. After adjusting for potential cofounders, living in a high HIV prevalence stratum (Adjusted OR [AOR] =2.31, 95% CI: 1.52, 3.52), being in a third or higher order relationship (AOR = 3.80, 95% CI: 2.30, 6.28), and engagement in extra-marital relations (AOR = 1.75; 95% CI: 1.19, 2.59) were associated with couple HIV infection. Individuals that had stayed together for six or more years had 28% odds of being part of an HIV infected couple (AOR = 0.28; 95%CI: 0.18, 0.43). CONCLUSION: Living in a high HIV prevalence stratum, engagement in extra-marital relations and having a higher number of previous marriages were significant risk factors for HIV infection among married couples. Long marital duration was associated with reduced risk of HIV infection. Interventions that increase marital stability and those that promote pre-marital couples' HIV testing before marital formation can reduce HIV transmission risk among married couples in this setting.

Missed opportunities for family planning counselling among HIV-positive women receiving HIV Care in Uganda.

INTRODUCTION: HIV-positive women who are still in the reproductive years need adequate sexual and reproductive health information to make informed reproductive health choices. However, many HIV-positive women who interface with the health system continue to miss out on this information. We sought to: a) determine the proportion of HIV-positive women enrolled in HIV care who missed family planning (FP) counselling; and b) assess if any association existed between receipt of FP counselling and current use of modern contraception to inform programming. METHODS: Data were drawn from a quantitative national cross-sectional survey of 5198 HIV-positive women receiving HIV care at 245 HIV clinics in Uganda; conducted between August and November 2016. Family planning counselling was defined as provision of FP information (i.e. available FP methods and choices) to an HIV-positive woman by a health provider during ANC, at the time of delivery or at the PNC visit. Analyses on receipt of FP counselling were done on 2760 HIV-positive women aged 15-49 years who were not currently pregnant and did not intend to have children in the future. We used a modified Poisson regression model to determine the Prevalence Ratio (PR) as a measure of association between receipt of any FP counselling and current use of modern contraception, controlling for potential confounders. Analyses were performed using STATA statistical software, version 14.1. RESULTS: Overall, 2104 (76.2%) HIV-positive women reported that they received FP counselling at any of the three critical time-points. Of the 24% (n = 656) who did not, 37.9% missed FP counselling at ANC; 41% missed FP counselling during delivery; while 54% missed FP counselling at the post-natal care visit. HIV-positive women who received any FP counselling were significantly more likely to report current use of modern contraception than those who did not (adjusted PR [adj. PR] = 1.21; 95% Confidence Interval [CI]: 1.10, 1.33). CONCLUSION: Nearly one-quarter of HIV-positive women did not receive any form of FP counselling when they interfaced with the healthcare system. This presents a missed opportunity for prevention of unintended pregnancies, and suggests a need for the integration of FP counselling into HIV care at all critical time-points.

Formative research to inform the development of a peer-led HIV self-testing intervention to improve HIV testing uptake and linkage to HIV care among adolescents, young people and adult men in Kasensero fishing community, Rakai, Uganda: a qualitative study.

BACKGROUND: Despite efforts to improve HIV testing and linkage to HIV care among adolescents, young people and adult men, uptake rates remain below global targets. We conducted formative research to generate data necessary to inform the design of a peer-led HIV self-testing (HIVST) intervention intended to improve HIV testing uptake and linkage to HIV care in Kasensero fishing community in rural Uganda. METHODS: This qualitative study was conducted in three study communities in Kasensero fishing community in Rakai district, Uganda, in May 2019. Six single-sex focus group discussions (FGDs) comprising 7-8 participants were conducted with adolescents and young people (15-24 years) and adult men (25+ years). We collected data on people's perceptions about peer-led HIVST; potential acceptability of a peer-led HIVST intervention and suggestions on how to improve linkage to HIV care after a positive HIVST result. Peer-led HIVST was defined as an approach where trained lay people distribute HIVST kits to other people in the community. FGDs were audio-recorded with permission from the participants, transcribed verbatim and analysed manually following a thematic framework approach. RESULTS: Forty-seven participants (31 men and 16 women) participated in the FGDs. Across communities and age-groups, most participants mentioned that peer-led HIVST would be generally acceptable to people in the fishing community but people will need support in performing the test due to fear of performing the test wrongly or failing to cope with HIV-positive results. Most participants felt that peer-led HIVST would bring HIV testing services closer to the community "because [the peer-leader] could be my immediate neighbour", making it easier for people to obtain the kits at any time of their convenience. To improve linkage to HIV care, participants felt that the use of peer-leaders to deliver the initial ART dose to self-tested HIV-positive individuals would be more preferable to the use of community-based ART groups or home-based ART initiation. CONCLUSION: Our study shows that peer-led HIVST is potentially acceptable in the fishing community. These findings suggest that this approach can improve uptake of HIV testing and linkage to HIV care services among populations that are usually missed through conventional HIV testing services.

Health providers' experiences, perceptions and readiness to provide HIV services to men who have sex with men and female sex workers in Uganda - a qualitative study.

BACKGROUND: Access to HIV services among men who have sex with men (MSM) and female sex workers (FSWs) remains suboptimal globally. While the reasons for this dismal performance have been documented, limited evidence exists on the experiences, perceptions and readiness of health providers to provide HIV services to MSM and FSWs. METHODS: This analysis uses data collected from 48 key informants (health providers in public and private health facilities) as part of a larger study conducted in 12 districts of Uganda between October and December 2013. Data were collected on health providers' experiences and readiness to provide HIV services to MSM and FSWs and their perceptions on the effect of existing legislation on HIV services provision to MSM and FSWs. Data were captured verbatim, transcribed and analyzed following a thematic framework approach. RESULTS: All health providers reported that they had ever provided HIV services to FSWs and a majority of them were comfortable serving them. However, no health provider had ever served MSM. When asked if they would be willing to serve MSM, nearly three-quarters of the health providers indicated that they would be bound by the call of duty to serve them. However, some health providers reported that they "would feel very uncomfortable" handling MSM because they engage in "a culture imported into our country". A majority of the health providers felt that they did not have adequate skills to effectively serve MSM and called for specific training to improve their clinical skills. There were mixed reactions as to whether existing criminal laws would affect MSM or FSWs access to HIV services but there was agreement that access to HIV services, under the existing laws, would be more constrained for MSM than FSWs since society "does not blame FSWs [as much as it does] with MSM". CONCLUSION: A majority of the health providers were generally comfortable serving FSWs but there were strong homophobic tendencies towards MSM. A majority of the health providers lacked skills in how to handle MSM. Interventions aimed at improving health providers' skills in handling MSM while minimizing the negative attitude towards them are urgently needed.

Spatial and temporal trends of cesarean deliveries in Uganda: 2012-2016.

BACKGROUND: Cesarean section (CS) is an important intervention in complicated births when the safety of the mother or baby is compromised. Despite worldwide concerns about the overutilization of CS in recent years, many African women and their newborns still die because of limited or no access to CS services. We evaluated temporal and spatial trends in CS births in Uganda and modeled future trends to inform programming. METHODS: We performed secondary analysis of total births data from the Uganda National Health Management Information System (HMIS) reports during 2012-2016. We reviewed data from 3461 health facilities providing basic, essential obstetric and emergency obstetric care services in all 112 districts. We defined facility-based CS rate as the proportion of cesarean deliveries among total live births in facilities, and estimated the population-based CS rate using the total number of cesarean deliveries as a proportion of annual expected births (including facility-based and non-facility-based) for each district. We predicted CS rates for 2021 using Generalised Linear Models with Poisson family, Log link and Unbiased Sandwich Standard errors. We used cesarean deliveries as the dependent variable and calendar year as the independent variable. RESULTS: Cesarean delivery rates increased both at facility and population levels in Uganda. Overall, the CS rate for live births at facilities was 9.9%, increasing from 8.5% in 2012 to 11% in 2016. The overall population-based CS rate was 4.7%, and increased from 3.2 to 5.9% over the same period. Health Centre IV level facilities had the largest annual rate of increase in CS rate between 2012 and 2016. Among all 112 districts, 80 (72%) had a population CS rate below 5%, while 38 (34%) had a CS rate below 1% over the study period. Overall, Uganda's facility-based CS rate is projected to increase by 36% (PRR 1.36, 95% CI 1.35-1.36) in 2021 while the population-based CS rate is estimated to have doubled (PRR 2.12, 95% CI 2.11-2.12) from the baseline in 2016. CONCLUSION: Cesarean deliveries are increasing in Uganda. Health center IVs saw the largest increases in CS, and while there was regional heterogeneity in changes in CS rates, utilization of CS services is inadequate in most districts. We recommend expansion of CS services to improve availability.