Motivational interviewing experiences from a community health worker-led HIV prevention and care intervention in rural Uganda: a qualitative study.

Motivational Interviewing (MI) and Community Health Workers (CHWs) are increasingly utilized in global settings to improve HIV outcomes, yet research exploring implementation strategies using MI and CHWs is lacking. We examined the experiences of CHWs and their clients in a counseling intervention which used MI-informed counseling to increase engagement in HIV prevention and treatment. This study was nested within the mLAKE cluster-randomized trial in a high HIV prevalence fishing community in rural Rakai District, Uganda. We conducted in-depth interviews with purposively-sampled CHWs (n = 8) and clients (n = 51). Transcripts were analyzed thematically to characterize CHWs' implementation of the intervention. Main themes identified included use of specific MI strategies (including evocation, guidance towards positive behavior change, active listening, and open-ended questions), and MI spirit (including collaboration, power-sharing, trust, and non-judgmental relationship building). Through these specific MI mechanisms, CHWs supported client behavior change to facilitate engagement with HIV services. This study provides evidence from a low-resource setting that CHWs with no previous experience in MI can successfully implement MI-informed counseling that is well-received by clients. CHW-led MI-informed counseling appears to be a feasible and effective approach to increase uptake of HIV prevention and care services in low-resource, HIV endemic regions.

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.

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.

Dissolution of transactional sex relationships during COVID-19: a qualitative study of Ugandan men's experiences during COVID-19 lockdowns.

The COVID-19 pandemic and subsequent mitigation measures led to social disruption and negative economic shocks for a large proportion of Uganda's population. The social and economic consequences of COVID-19 on Ugandan men's sexual behaviours, including transactional sex relationships, are unclear. We conducted in-depth interviews between November 2021-February 2022 with 26 men in a high HIV prevalence region of Uganda. Data were analysed thematically to understand how sexual relationships, including transactional sex, were impacted by COVID-19. We found that COVID-19 mitigation measures had far-reaching social and economic impacts on most respondents, particularly those employed in the informal economy. Men described experiencing job loss, food insecurity and restricted mobility, which limited opportunities to provide for and meet with transactional sex partners. Inability to provide financial resources meant that men could not form new transactional sex relationships and men who could no longer provide for their existing transactional sex partners consistently reported relationship dissolution. Men who reported stable employment during the pandemic described few changes in transactional sex relationships. Similarly, men in non-transactional relationships did not report relationship dissolution despite decreased financial provision. Further research should assess the potential short- and long-term impacts of COVID-19 mitigation measures on transactional sex relationships.

HIV Prevention and Treatment Behavior Change and the Situated Information Motivation Behavioral Skills (sIMB) Model: A Qualitative Evaluation of a Community Health Worker Intervention in Rakai, Uganda.

A community health worker (CHW) model can promote HIV prevention and treatment behaviors, especially in highly mobile populations. In a fishing community in Rakai, Uganda, the Rakai Health Sciences Program implemented a CHW HIV intervention called Health Scouts. The situated Information, Motivation, and Behavioral Skills (sIMB) framework informed the design and a qualitative evaluation of the intervention. We interviewed 51 intervention clients and coded transcripts informed by sIMB framework dimensions. Clients reported that Health Scouts provided information about HIV prevention and treatment behaviors and helped them manage personal and social motivations to carry out health-promoting behavior. Prominent barriers which moved clients away from behavior change included daily pill burdens, anticipated stigma, serostatus disclosure, substance use at social gatherings, and anticipated reactions of partners. Our study adds to the evidence establishing CHWs as facilitators of behavior change, positioned to offer supportive encouragement and navigate contextualized circumstances.

Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda.

Uganda piloted HIV pre-exposure prophylaxis (PrEP) for priority populations (sex workers, fishermen, truck drivers, discordant couples) in 2017. To assess facilitators and barriers to PrEP uptake and adherence, we explored perceptions of PrEP before and experiences after rollout among community members and providers in south-central Uganda. We conducted 75 in-depth interviews and 12 focus group discussions. We analyzed transcripts using a team-based thematic framework approach. Partners, family, peers, and experienced PrEP users provided adherence support. Occupational factors hindered adherence for sex workers and fishermen, particularly related to mobility. Pre-rollout concerns about unskilled/untrained volunteers distributing PrEP and price-gouging were mitigated. After rollout, awareness of high community HIV risk and trust in PrEP effectiveness facilitated uptake. PrEP stigma and unexpected migration persisted as barriers. Community-initiated, tailored communication with successful PrEP users may optimize future engagement by addressing fears and rumors, while flexible delivery and refill models may facilitate PrEP continuation and adherence.

RESUMEN: En 2017, Uganda introdujo profilaxis pre-exposición (PrEP), dirigida a las populaciones con alto riesgo de contraer al VIH (trabajadoras sexuales, pescadores, camioneros, parejas sero-discordantes). Para investigar facilitadores y barreras para la adopción y la adherencia a la PrEP, exploramos percepciones de PrEP antes y después de su introducción en Uganda. Realizamos 75 entrevistas y 12 grupos focales con miembros de la comunidad y trabajadores de salud. Analizamos las transcripciones temáticamente usando un marco de referencia. Parejas, familias, compañeros, y clientes usando PrEP apoyaron a los demás mantener adherencia. Movilidad fue una barrera para la adherencia a la PrEP para trabajadoras sexuales y pescadores. Preocupaciones sobre el entrenamiento de los distribuidores de PrEP y la especulación de precios no fueron realizadas. Percepciones del riesgo del VIH y confianza en la eficacia de PrEP facilitaron su adopción. Estigma y migración inesperada persistieron como barreras para la adopción de PrEP. Comunicaciones manejadas por clientes usando PrEP pueden motivar interés en PrEP y abordar rumores. Sistemas flexibles del entrego y la recarga de medicinas pueden permitir continuación de, y adherencia a, la PrEP.

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.

Antiretroviral treatment sharing among highly mobile Ugandan fisherfolk living with HIV: a qualitative study.

Antiretroviral treatment (ART) diversion from prescribed to non-prescribed users (i.e., sharing or selling) is an understudied dimension of HIV treatment adherence. We sought to explore ART diversion patterns in high-prevalence fishing communities on Lake Victoria, Uganda. We implemented a qualitative study in two fishing communities on Lake Victoria in south-central Uganda to identify facilitators of and pathways to ART diversion. We conducted 25 semi-structured interviews with HIV-positive fishermen (n = 25) and female sex workers (n = 10) covering personal and community experiences with ART selling/sharing, reasons for medication diversion, and potential solutions to reduce diversion. Data were analyzed using an adapted framework analysis approach. Participants reported frequent ART sharing within occupational networks, but no selling. Mobility was the principal driver of ART sharing and was associated with other barriers to treatment access including stigma, fear of negative health provider interactions, and transportation. ART sharing appears to emerge in response to short-term treatment interruptions in this setting. Future studies should explore characteristics and drivers of ART diversion in other high-burden settings and identify how these practices are correlated with key health outcomes like virologic failure and drug resistance.

Alcohol use in fishing communities and men's willingness to participate in an alcohol, violence and HIV risk reduction intervention: qualitative findings from Rakai, Uganda.

Alcohol use, intimate partner violence (IPV) and HIV infection are associated, but few programmes and interventions have addressed their synergistic relationship or been evaluated for effectiveness and acceptability. This is a critical gap in populations with high rates of alcohol use, HIV and IPV, such as Uganda's fishing communities. This study examined drinking norms, barriers and facilitators to engagement in a risk reduction programme, and ideas for tailoring. Results showed that alcohol use is common in fishing villages. While men and women drink, gendered notions of femininity deem alcohol largely unacceptable for women. Plastic sachets of liquor were the most common alcoholic drink. Participants did not understand the definition of 'hazardous drinking', but recognised connections between drinking, violence and sexual risk-taking. The idea of an alcohol, IPV and HIV risk reduction intervention was supported, but barriers need to be addressed, including how best to help those uninterested in reducing their drinking, addressing normalisation of drinking and how best to inform those who truly need intervention. Intervention to people living with HIV around the time of diagnosis and treatment may be warranted. Study findings highlight the potential to integrate alcohol and IPV reduction programmes into an HIV service provision.

Women's role in male circumcision promotion in Rakai, Uganda.

Medical male circumcision (MMC) has expanded in sub-Saharan Africa, yet uptake remains sub-optimal. We sought to understand women's perceptions of and influence on MMC in Rakai, Uganda. We conducted in-depth interviews with 27 women in fishing and trading communities, including women married to circumcised and uncircumcised men, single women, and sex workers. Data analysis followed a team-based framework approach. All female participants preferred circumcised men because of perceived reduced HIV and sexually transmitted infection (STI) risk, improved penile hygiene, and increased sexual pleasure. Perceived negative aspects included abstinence during wound healing, potentially increased male sexual risk behaviors, fear of being blamed for HIV acquisition, and economic insecurity due to time off work. Participants felt women could persuade their partners to be circumcised, accompany them to the clinic, refuse sex with uncircumcised men, and participate in community MMC activities. Findings support women's important role in MMC acceptance.

HIV Partner Notification Values and Preferences Among Sex Workers, Fishermen, and Mainland Community Members in Rakai, Uganda: A Qualitative Study.

HIV partner notification involves contacting sexual partners of people who test HIV positive and referring them to HIV testing, treatment, and prevention services. To understand values and preferences of key and general populations in Rakai, Uganda, we conducted 6 focus group discussions and 63 in-depth interviews in high prevalence fishing communities and low prevalence mainland communities. Participants included fishermen and sex workers in fishing communities, male and female mainland community members, and healthcare providers. Questions explored three approaches: passive referral, provider referral, and contract referral. Qualitative data were coded and analyzed using a team-based matrix approach. Participants agreed that passive referral was most suitable for primary partners. Provider referral was acceptable in fishing communities for notifying multiple, casual partners. Healthcare providers voiced concerns about limited time, resources, and training for provider-assisted approaches. Options for partner notification may help people overcome barriers to HIV serostatus disclosure and help reach key populations.

Multilevel influences on acceptance of medical male circumcision in Rakai District, Uganda.

Despite access to safe medical male circumcision (MMC) and proven effectiveness of the procedure in reducing acquisition of HIV and other sexually transmitted infections, uptake remains suboptimal in many settings in sub-Saharan Africa, including Rakai District, Uganda. This study explored multilevel barriers and facilitators to MMC in focus group discussions (FGDs) (n = 35 groups) in Rakai. Focus groups were conducted from May through July 2012 with adolescent and adult males, with a range of HIV risk and reproductive health service use profiles, and with adolescent and adult females. Data were analyzed using Atlas.ti and an inductive approach. Participants' discussions produced several key themes representing multilevel influences that may facilitate or create barriers to uptake of MMC. These include availability of MMC services, economic costs, masculine ideals, religion, and social influence. Understanding how males and females view MMC is a crucial step towards increasing uptake of the procedure and reducing disease transmission.

Contraceptive knowledge, perceptions, and concerns among men in Uganda.

BACKGROUND: Low contraceptive uptake and high unmet need for contraception remain significant issues in Uganda compared to neighboring countries such as Kenya, Ethiopia, and Rwanda. Although prior research on contraceptive uptake has indicated that male partners strongly influence women's decisions around contraceptive use, there is limited in-depth qualitative research on knowledge and concerns regarding modern contraceptive methods among Ugandan men. METHODS: Using in-depth interviews (N = 41), this qualitative study investigated major sources of knowledge about contraception and perceptions of contraceptive side effects among married Ugandan men. RESULTS: Men primarily reported knowledge of contraceptives based on partner's experience of side effects, partner's knowledge from health providers and mass media campaigns, and partner's knowledge from her peers. Men were less likely to report contraceptive knowledge from health care providers, mass media campaigns, or peers. Men's concerns about various contraceptive methods were broadly associated with failure of the method to work properly, adverse health effects on women, and severe adverse health effects on children. Own or partner's human immunodeficiency virus (HIV) status did not impact on contraceptive knowledge. CONCLUSIONS: Overall, we found limited accurate knowledge about contraceptive methods among men in Uganda. Moreover, fears about the side effects of modern contraceptive methods appeared to be common among men. Family planning services in Uganda could be significantly strengthened by renewed efforts to focus on men's knowledge, fears, and misconceptions.

Re-focusing HIV prevention messages: a qualitative study in rural Uganda.

BACKGROUND: After 30 years, the human immunodeficiency virus (HIV) remains an epidemic of global concern. To support the increasing emphasis on biomedical interventions for prevention requires a renewed and reframed focus on HIV prevention messages to motivate engagement in risk-reduction activities. This paper examines youth and adult perceptions of HIV prevention messages and HIV risk assessment in a generalized HIV epidemic context in Uganda. METHODS: We conducted 24 focus group discussions and 24 in-depth interviews with 15-45 year olds (n = 218) from three communities in the Rakai district of Uganda in 2012. RESULTS: We found generational differences in the how people viewed HIV, skepticism around introduction of new interventions, continued misconceptions and fears about condoms, and gender differences in content and salience of HIV prevention messages. CONCLUSIONS: Shifts in HIV education are needed to address gaps in HIV messaging to foster engagement in risk reduction strategies and adoption of newer biomedical approaches to HIV prevention.

Fatherhood, marriage and HIV risk among young men in rural Uganda.

Compared to a large body of work on how gender may affect young women's vulnerability to HIV, we know little about how masculine ideals and practices relating to marriage and fertility desires shape young men's HIV risk. Using life-history interview data with 30 HIV-positive and HIV-negative young men aged 15-24 years, this analysis offers an in-depth perspective on young men's transition through adolescence, the desire for fatherhood and experience of sexual partnerships in rural Uganda. Young men consistently reported the desire for fatherhood as a cornerstone of masculinity and transition to adulthood. Ideally young men wanted children within socially sanctioned unions. Yet, most young men were unable to realise their marital intentions. Gendered expectations to be economic providers combined with structural constraints, such as limited access to educational and income-generating opportunities, led some young men to engage in a variety of HIV-risk behaviours. Multiple partnerships and limited condom use were at times an attempt by some young men to attain some part of their aspirations related to fatherhood and marriage. Our findings suggest that young men possess relationship and parenthood aspirations that - in an environment of economic scarcity - may influence HIV-related risk.

Importance of relationship context in HIV transmission: results from a qualitative case-control study in Rakai, Uganda.

We present results from life history interviews with 60 young adults from southern Uganda. Using a novel qualitative case-control design, we compared newly HIV-positive cases with HIV-negative controls matched on age, gender, marital status, and place of residence. Relationship context was the most salient theme differentiating cases from controls. Compared with HIV-negative respondents, recent seroconverters described relationships marked by poorer communication, greater suspicion and mistrust, and larger and more transitory sexual networks. Results highlight the importance of dyadic approaches to HIV and possibly of couple-based interventions. Using HIV-matched pairs allowed additional understanding of the factors influencing transmission. This hybrid methodological approach holds promise for future studies of sexual health.

Use of withdrawal (coitus interruptus) for both pregnancy and HIV prevention among young adults in Rakai, Uganda.

INTRODUCTION: Although understudied in the context of AIDS, use of withdrawal (coitus interruptus) with or in place of other prevention methods affects exposure to both pregnancy and human immunodeficiency virus (HIV). AIM: We used mixed methods to assess use of withdrawal among 15-24-year-olds in a rural Ugandan setting with considerable HIV prevalence. METHODS: We measured withdrawal reporting among (i) sexually active 15-24-year-olds enrolled in a quantitative community survey (n = 6,722) and (ii) in-depth qualitative interview participants systematically selected from the latest round of the community survey (N = 60). Respondents were asked about family planning and HIV prevention practices, including a direct question about withdrawal in the in-depth interviews. MAIN OUTCOME MEASURES: The main outcome measures were reports of current use of withdrawal on the quantitative survey (general question about family planning methods) and reports of current or recent use withdrawal in qualitative interviews (specific question about withdrawal). Qualitative interviews also probed for factors associated with withdrawal use. RESULTS: Although less than 1% of quantitative survey participants spontaneously named withdrawal as their current family planning method, 48% of qualitative interview respondents reported current or lifetime use of withdrawal. Withdrawal was often used as a pleasurable alternative to condoms, when condoms were not available, and/or as a "placeholder" method before obtaining injectable contraception. A few respondents described using withdrawal to reduce HIV risk. CONCLUSION: Qualitative findings revealed widespread withdrawal use among young adults in Rakai, mainly as a condom alternative. Thus, withdrawal may shape exposure to both pregnancy and HIV. Future behavioral surveys should assess withdrawal practices directly--and separately from other contraceptives and HIV prevention methods. Further clinical research should further document withdrawal's association with HIV risk.

Understanding the drivers of preferential migration of people living with HIV to fishing communities of Lake Victoria in Uganda.

Fishing communities around Lake Victoria have among the highest burdens of HIV globally. Growing evidence suggests that high HIV prevalence is partially due to selective migration of people living with HIV to fishing communities. However, the reasons for this preferential migration are unclear. We recruited 60 men and women for qualitative in-depth interviews (30% living with HIV; 70% recent migrants of unknown HIV status) from seven Ugandan fishing communities. Interviews discussed mobility histories and the social context surrounding migration. Interviews were audio-recorded, transcribed, and translated. A version of the 'Push-Pull' theory of migration helped structure a conceptual thematic framework for data analysis. Unfavourable conditions related primarily to stigma, social discrimination, humiliation, rejection or HIV labelling, and violence, induced individuals to leave their home communities. Factors which eventually resulted in migration to fishing communities included anticipating less HIV-related stigma and a safe, friendly environment that accommodates all people. Access to healthy food (fish) and the perceived availability of community-based HIV care services were also attractions. We found that stigma is the major social phenomenon shaping preferential migration to fishing communities in Uganda.

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.

The Acceptability of Self-Collected Samples for STI Testing: A Qualitative Study Among Adults in Rakai, Uganda.

Introduction: Self-collected samples (SCS) for sexually transmitted infection (STI) testing have been shown to be feasible and acceptable in high-resource settings. However, few studies have assessed the acceptability of SCS for STI testing in a general population in low-resource settings. This study explored the acceptability of SCS among adults in south-central Uganda. Methods: Nested within the Rakai Community Cohort Study, we conducted semi-structured interviews with 36 symptomatic and asymptomatic adults who self-collected samples for STI testing. We analyzed the data using an adapted version of the Framework Method. Results: Overall, participants did not find SCS physically uncomfortable. Reported acceptability did not meaningfully differ by gender or symptom status. Perceived advantages to SCS included increased privacy and confidentiality, gentleness, and efficiency. Disadvantages included the lack of provider involvement, fear of self-harm and the perception that SCS was unhygienic. Most participants preferred provider-collected samples to SCS. Nevertheless, almost all said they would recommend SCS and would do it again in the future. Conclusion: Despite a preference for provider-collection, SCS are acceptable among adults in this setting and support expanded access to STI diagnostic services.