Violence outcomes in later adolescence with the Good School Toolkit-Primary: a nonrandomized controlled trial in Uganda.

BACKGROUND: We sought to determine whether the Good School Toolkit-Primary violence prevention intervention was associated with reduced victimisation and perpetration of peer and intimate partner violence four years later, and if any associations were moderated by sex and early adolescent: family connectedness, socio-economic status, and experience of violence outside of school. METHODS: Drawing on schools involved in a randomised controlled trial of the intervention, we used a quasi-experimental design to compare violence outcomes between those who received the intervention during our trial (n = 1388), and those who did not receive the intervention during or after the trial (n = 522). Data were collected in 2014 (mean age 13.4, SD 1.5 years) from participants in 42 schools in Luwero District, Uganda, and 2018/19 from the same participants both in and out of school (mean age 18, SD: 1.77 years). We compared children who received the Good School Toolkit-Primary, a whole school violence prevention intervention, during a randomised controlled trial, to those who did not receive the intervention during or after the trial. Outcomes were measured using items adapted from the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional. We used mixed-effect multivariable logistic regression, with school fitted as a random-effect to account for clustering. RESULTS: 1910 adolescents aged about 16-19 years old were included in our analysis. We found no evidence of an average long-term intervention effect on our primary outcome, peer violence victimization at follow-up (aOR = 0.81, 95%CI = 0.59-1.11); or for any secondary outcome. However, exposure to the intervention was associated with: later reductions in peer violence, for adolescents with high family connectedness (aOR = 0.70, 95% CI 0.49 to 0.99), but not for those with low family connectedness (aOR = 1.07, 95% CI 0.69 to 1.6; p-interaction = 0.06); and reduced later intimate partner violence perpetration among males with high socio-economic status (aOR = 0.32, 95%CI 0.11 to 0.90), but not low socio-economic status (aOR = 1.01 95%CI 0.37 to 2.76, p-interaction = 0.05). CONCLUSIONS: Young adolescents in connected families and with higher socio-economic status may be better equipped to transfer violence prevention skills from primary school to new relationships as they get older. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01678846, registration date 24 August 2012. Protocol for this paper:  https://www.researchprotocols.org/2020/12/e20940 .

A retrospective cross sectional study assessing factors associated with retention and non-viral suppression among HIV positive FSWs receiving antiretroviral therapy from primary health care facilities in Kampala, Uganda.

BACKGROUND: Patient retention in care and sustained viral load suppression are a cornerstone to improved health and quality of life, among people living with HIV. However, challenges of retention on ART remain among female sex workers (FSWs). We report lost to follow up (LTFU), viral load suppression, and the associated factors among FSWs that access HIV treatment at primary health care facilities in Kampala. METHODS: We retrospectively abstracted and analysed patient management data of HIV positive FSWs who enrolled in care between January 2018 to December 2020. LTFU was defined as failure of a FSW to return for treatment at least 90 days from the date of their last clinic appointment. We defined viral suppression as having a last viral load of ≤ 1000 copies/ml preceding data abstraction. Data were analysed using Stata 15.1 software. RESULTS: A total of 275 FSWs were included in our study sample. We found low retention of 85.1% (n = 234) at six months, corresponding to LTFU of 14.9 (n = 41) within the same period. Retention decreased with duration of being in care up to 73.5% (n = 202) at 24 months, and this translates to LTFU of 26.5% (n = 73). Viral load testing coverage was 62% (n = 132) and of these, 90.9% (n = 120) were virally suppressed. Factors associated with LTFU in univariable logistic regression; and viral load suppression in multivariable logistic regression models were; having a telephone contact (OR: 0.3, 95% CI: 0.1-0.9 p = 0.031), having enrolled in HIV care aged ≥ 35 years (OR: 0.5, 95% CI: 0.2-1.0 p = 0.048), (OR:0.03, 95%CI: 0.00-0.5, p = 0.016); and having good ART adherence (OR: 0.2, 95% CI: 0.1-0.5 p = 0.001), (OR:24.0, 95% CI: 3.7-153.4 p = 0.001) respectively. Having good ART adherence remained statistically significant (OR: 0.2, 95% CI: 0.08-0.53 p = 0.001) in multivariable logistic regression for LTFU. CONCLUSION: This study found low retention among HIV diagnosed FSWs in care. Viral load suppression was acceptable and comparable to that of the general population, however viral load coverage was low. Strategies that increase retention in care and access to viral load testing such as individual client centred care models are vital to improve retention and viral load coverage among FSWs.

"My condition is my secret": perspectives of HIV positive female sex workers on differentiated service delivery models in Kampala Uganda.

BACKGROUND: Differentiated service delivery (DSD) models for female sex workers (FSWs) continue to be scaled up with the goal of expanding access to HIV services and treatment continuity. However, little is known about FSWs' perspectives on their preferences, facilitators, and barriers to the effective utilization of various DSD models. METHODS: We conducted 24 in-depth interviews among FSWs on antiretroviral therapy for at least one year in two drop-in centres and two public health facilities in Kampala, Uganda in January 2021. RESULTS: The facility-based individual management model was most preferred, due to a wide array of comprehensive health services, privacy, and professional health workers. Community DSD models were physically accessible, but least preferred due to stigmatization and discrimination, lack of privacy and confidentiality, and limited health services offered. CONCLUSION: Targeted strategies to reduce stigma and discrimination and the provision of high-quality services have potential to optimise FSWs' access to HIV services.

Context of Violence in Adolescence Cohort (CoVAC) study: protocol for a mixed methods longitudinal study in Uganda.

BACKGROUND: Violence exposure in adolescence is associated with a range of poor health and social outcomes, including both the perpetration and experience of violence in later intimate relationships. However, there is little longitudinal evidence on how both individual and contextual characteristics encourage or interrupt these associations. We designed the Contexts of Violence in Adolescence Cohort study (CoVAC) to provide evidence on these pathways for Ugandan adolescents, with the aim of providing information to improve the design of violence prevention interventions for adolescents and young adults. METHODS: CoVAC is a mixed-methods prospective cohort study with three parallel strands. Between 2014 and 2022, the study comprises three waves of quantitative survey data collection; qualitative data from five time points; and a series of workshops to facilitate direct use of emerging findings by intervention developers at Uganda-based NGO Raising Voices in their ongoing work to prevent violence. 3431 adolescents participated in a survey in 2014 when the majority were aged 11-14 years, and agreed to be re-contacted for a Wave 2 survey in 2018 (aged about 15-18 years); and again in 2021 (aged 18-21 years). 36 young people from Wave 1 survey sample will be invited to participate in longitudinal qualitative data collection. Adolescents aged 18 years and over will provide informed consent; for those under age 18 years, adolescents will be invited to assent, except in cases where caregivers, following notification, have opted not to consent to their adolescent's participation. Quantitative and qualitative data will be analysed iteratively, and triangulation will be used to confirm, clarify and deepen our interpretation of findings. We will hold regular structured meetings so that emerging findings can be integrated into intervention development. DISCUSSION: This will be the first longitudinal study on the aetiology of violence over adolescence in sub-Saharan Africa which will enable examination of pathways using mixed methods at multiple time points. Quantitative mediation analysis, and annual qualitative fieldwork will provide detailed insights into how adolescents' violence-related experiences, perspectives and practices relate to their social contexts and how these change over time. Results will feed directly into intervention development to reduce violence and harmful sequelae. TRIAL REGISTRATION: This study is a long-term follow up of participants in the Good Schools Study (NCT01678846, clinicaltrials.gov). This protocol is for cohort follow-up only; we have a separate protocol paper describing an evaluation of the long-term effects of the Good School Toolkit (In preparation).

Assessment of community mobilization and home-based HIV counselling and testing offered by health facilities in rural Uganda.

Home-based HIV counselling and testing (HBHCT) and community mobilization have been proven to be effective in increasing the number of people linked to HIV care and treatment. An assessment was conducted in 18 health facilities in Uganda to evaluate the availability and extent of home based testing services and community mobilization activities in underserved communities. The performance of the health facilities was assessed using a checklist with indicators of HBHCT and community mobilization. While most of the health facilities (72.2%) had active community mobilization, only 12.2% had HBHCT services and this might have affected universal access to HIV prevention, care and treatment. The health facilities did not accompany their intensive community mobilization activities with HBHCT yet this provided the ideal entry point and opportunity to improve linkage to HIV treatment and care.

Factors associated with adherence to HIV testing guidelines among HIV-negative female sex workers in Kampala, Uganda.

Background: Frequent human immunodeficiency virus (HIV) testing is recommended among female sex workers. This study examined the extent to which HIV-negative female sex workers (FSWs) in Kampala adhere to the HIV testing guidelines, and identified associated factors. Methods: This cross-sectional study used a simple random sampling method to select 12 sex work hotspots. Two hundred participants were allocated proportionally in each hotspot. Frequencies were used to describe categorical characteristics of FSWs, and a multivariable logistic regression model was used to determine the factors associated with adherence to the HIV testing guidelines. Results: Eighty-eight percent of the 200 study participants reported their HIV testing status; of these, 56% had tested three or more times in the 12 months preceding the survey. Attaining a secondary education was associated with adherence to the HIV testing guidelines [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.01-3.44; P=0.047]. Sexually transmitted infection testing in the preceding 3 months (OR 2.13, 95% CI 0.95-4.74; P=0.065) and accessing HIV testing at a drop-in centre (OR 5.90, 95% CI 0.71-49.1; P=0.101) were associated with higher odds of adherence to the HIV testing guidelines. Conclusion: Adherence to the HIV testing guidelines was suboptimal, indicating the need to scale up interventions to improve access to HIV testing, including rigorous behaviour change communication.

Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa. METHODS: We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics. RESULTS: The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage. CONCLUSIONS: The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020157623.

Maternal Vaccination in Uganda: Exploring Pregnant Women, Community Leaders and Healthcare Workers' Perceptions.

Background: We investigated pregnant women, community leaders, healthcare workers (HCWs) and programme managers' perceptions of maternal vaccination in Kampala, Uganda. Methods: We conducted focus group discussions, key informant interviews and in-depth discussions with HCWs (3), community leaders (3), pregnant women (8) and programme managers (10) between November 2019 and October 2020. Data were analysed thematically. Results: Pregnant women, community leaders and some HCWs had limited maternal immunisation knowledge. There was confusion over what constitutes a vaccine. Pregnant women may not receive vaccines because of mistrust of government; use of expired vaccines; reliance on traditional medicine; religious beliefs; fear of side effects; HCWs attitudes; and logistical issues. The key facilitators of maternal vaccination were a desire to prevent diseases, positive influences from HCWs and information about vaccine side effects. Community leaders and some pregnant women highlighted that pregnant women do not make decisions about maternal vaccination independently and are influenced by different individuals, including other pregnant women, older people, partners, relatives (parents), community leaders, HCWs and the government. Conclusions: Our results indicate that public health messaging should target all community members, including partners and parents of pregnant women as well as HCWs, to improve knowledge of and confidence in maternal vaccines.

Effect of female sex work-targeted community-based interventions along the HIV treatment cascade in sub-Saharan Africa: a systematic review protocol.

INTRODUCTION: Female sex workers (FSWs) are a known high-risk group that are at increased risk of HIV transmission due to exposure to multiple sexual partners and inability to negotiate safe sex attributed to challenging economic circumstances. Previous systematic reviews have examined the effectiveness of HIV interventions prioritising FSWs and have shown that targeted interventions improve access to HIV prevention and treatment services. Interventions that increase FSWs' uptake of services are well documented; however, evidence on specific interventions aimed at improving FSWs' continuity in HIV care along the treatment cascade is lacking. This systematic review aims to document the performance of community-based interventions along the HIV treatment cascade. METHODS AND ANALYSIS: We will use a sensitive search strategy for electronic bibliographic databases, bibliographies of included articles and grey literature sources. In addition, the Joint United Nations Programme on HIV/AIDS and the WHO websites, peer-reviewed conference papers and grey literature sources will be searched for additional reports of sex work programmes. We will include randomised controlled trials, cross-sectional surveys and cohort interventions where community-based HIV services were provided to FSWs and measure the performance of the HIV intervention on one or more cascade stages. We will conduct a systematic review of studies published from 2004 to present within the sub-Saharan Africa region. We will report quantitative study outcomes of HIV testing and diagnosis, linkage to care, initiation on antiretroviral therapy and viral suppression. We will analyse the data using the random-effects meta-analysis method, and funnel plots will be used to assess the publication bias. ETHICS AND DISSEMINATION: This systematic review will not require ethical approval; we will publish data from manuscripts. The results of this study will be disseminated in peer-reviewed journals and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42020157623.

Long-Term Outcomes of the Good School Toolkit Primary School Violence Prevention Intervention Among Adolescents: Protocol for a Nonrandomized Quasi-Experimental Study.

BACKGROUND: Violence against children in schools is a global public health problem. There is growing evidence that school-based interventions can be effective in reducing violence against children in schools. However, there is little evidence on the long-term impact of such interventions. The Good School Toolkit, developed by Raising Voices, a Uganda-based nonprofit organization, is a whole-school violence prevention intervention that aims to change the operational culture of primary schools. In 2014, the Good School Toolkit was evaluated through a cluster randomized controlled trial (Good Schools Study) and found to reduce teacher-to-student and student-to-student violence. OBJECTIVE: This protocol describes quantitative analyses to explore long-term outcomes of the Good School Toolkit intervention among adolescents in Uganda, including the extent to which it is associated with peer-violence victimization (primary outcome) and peer-violence perpetration, intimate-partner violence, acceptance of teacher-violence, equitable gender attitudes, agency, self-regulation, peer connectedness, social assets, psychological assets, and retention in school (secondary outcomes). METHODS: This is a nonrandomized quasi-experimental 4-year follow-up study of adolescents who attended the 42 Good Schools Study primary schools in 2014; 21 schools initiated the Good School Toolkit intervention during the trial from 2012, and 19 schools initiated the intervention after the trial (during the later delivery phase) from 2015; 2 schools did not implement the intervention. Students in the final school grade (Primary 7) during 2014 of the 19 primary schools in the later delivery phase are expected to have left school prior to toolkit delivery in 2015. Wave 1 data were collected in 2014 from 3431 grade Primary 5 to Primary 7 school students aged 11-14 years; these students were followed up in 2018-2019 when aged 16-19 years and invited to participate in the Wave 2 survey. Data were collected in face-to-face interviews by trained Ugandan field researchers. Toolkit exposure groups are defined as exposed during the Good Schools Study trial (from 2012), as exposed during later delivery (from 2015), or not exposed including those expected to have completed Primary 7 prior to later delivery or from the 2 schools that did not implement the toolkit. Associations between outcomes at Wave 2 and toolkit exposure groups will be analyzed using mixed-effect multivariable logistic and linear regression models for binary and continuous outcomes, respectively. This analysis is exploratory and aims to generate hypotheses on if, and under what circumstances, the toolkit influences later adolescent outcomes. RESULTS: Data collection was completed in August 2019. CONCLUSIONS: To our knowledge, this is the first long-term follow-up study of adolescents exposed to a school-based violence-prevention intervention in sub-Saharan Africa. If the intervention reduces violence and improves other outcomes in later adolescence, then this study supports primary school interventions as key to achieving long-term population impacts. The pattern of effects will inform where reinforced or additional interventions are needed. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20940.