Cardiovascular (Framingham) and type II diabetes (Finnish Diabetes) risk scores: a qualitative study of local knowledge of diet, physical activity and body measurements in rural Rakai, Uganda.

BACKGROUND: Non-communicable diseases such as cardiovascular conditions and diabetes are rising in sub-Saharan Africa. Prevention strategies to mitigate non-communicable diseases include improving diet, physical activity, early diagnosis, and long-term management. Early identification of individuals at risk based on risk-score models - such as the Framingham Risk Score (FRS) for 10-year risk of cardiovascular disease and the Finnish type 2 Diabetes risk score (FINDRISC) for type 2 diabetes which are used in high-income settings - have not been well assessed in sub-Saharan Africa. The purpose of this study was to qualitatively assess local knowledge of components of these risk scores in a rural Ugandan setting. METHODS: Semi-structured qualitative in-depth interviews were conducted with a purposively selected sample of 15 participants who had responded to the FRS and FINDRISC questionnaires and procedures embedded in the Rakai Community Cohort Study. Data were summarized and categorized using content analysis, with support of Atlas.ti. RESULTS: Participants described local terms for hypertension ("pulessa") and type 2 diabetes ("sukaali"). Most participants understood physical activity as leisure physical activity, but when probed would also include physical activity linked to routine farm work. Vegetables were typically described as "plants", "leafy greens", and "side dish". Vegetable and fruit consumption was described as varying seasonally, with peak availability in December after the rainy season. Participants perceived themselves to have good knowledge about their family members' history of type 2 diabetes and hypertension. CONCLUSIONS: While most items of the FRS and FINDRISC were generally well understood, physical activity needs further clarification. It is important to consider the seasonality of fruits and vegetables, especially in rural resource-poor settings. Current risk scores will need to be locally adapted to estimate the 10-year risk of cardiovascular diseases and type 2 diabetes in this setting.

Prevalence and Predictors of Persistent Human Immunodeficiency Virus Viremia and Viral Rebound After Universal Test and Treat: A Population-Based Study.

BACKGROUND: There are limited data on individual human immunodeficiency virus (HIV) viral load (VL) trajectories at the population-level after the introduction of universal test and treat (UTT) in sub-Saharan Africa. METHODS: Human immunodeficiency virus VLs were assessed among HIV-positive participants through 3 population-based surveys in 4 Ugandan fishing communities surveyed between November 2011 and August 2017. The unit of analysis was a visit-pair (2 consecutive person-visits), which were categorized as exhibiting durable VL suppression, new/renewed VL suppression, viral rebound, or persistent viremia. Adjusted relative risks (adjRRs) and 95% confidence intervals (CIs) of persistent viremia were estimated using multivariate Poisson regression. RESULTS: There were 1346 HIV-positive participants (n = 1883 visit-pairs). The population-level prevalence of durable VL suppression increased from 29.7% to 67.9% during UTT rollout, viral rebound declined from 4.4% to 2.7%, and persistent viremia declined from 20.8% to 13.3%. Younger age (15-29 vs 40-49 years; adjRR = 1.80; 95% CI = 1.19-2.71), male sex (adjRR = 2.09, 95% CI = 1.47-2.95), never being married (vs currently married; adjRR = 1.88, 95% CI = 1.34-2.62), and recent migration to the community (vs long-term resident; adjRR = 1.91, 95% CI = 1.34-2.73) were factors associated with persistent viremia. CONCLUSIONS: Despite increases in durable VL suppression during roll out of UTT in hyperendemic communities, a substantial fraction of the population, whose risk profile tended to be younger, male, and mobile, remained persistently viremic.

HIV Prevention Efforts and Incidence of HIV in Uganda.

BACKGROUND: To assess the effect of a combination strategy for prevention of human immunodeficiency virus (HIV) on the incidence of HIV infection, we analyzed the association between the incidence of HIV and the scale-up of antiretroviral therapy (ART) and medical male circumcision in Rakai, Uganda. Changes in population-level viral-load suppression and sexual behaviors were also examined. METHODS: Between 1999 and 2016, data were collected from 30 communities with the use of 12 surveys in the Rakai Community Cohort Study, an open, population-based cohort of persons 15 to 49 years of age. We assessed trends in the incidence of HIV on the basis of observed seroconversion data, participant-reported use of ART, participant-reported male circumcision, viral-load suppression, and sexual behaviors. RESULTS: In total, 33,937 study participants contributed 103,011 person-visits. A total of 17,870 persons who were initially HIV-negative were followed for 94,427 person-years; among these persons, 931 seroconversions were observed. ART was introduced in 2004, and by 2016, ART coverage was 69% (72% among women vs. 61% among men, P<0.001). HIV viral-load suppression among all HIV-positive persons increased from 42% in 2009 to 75% by 2016 (P<0.001). Male circumcision coverage increased from 15% in 1999 to 59% by 2016 (P<0.001). The percentage of adolescents 15 to 19 years of age who reported never having initiated sex (i.e., delayed sexual debut) increased from 30% in 1999 to 55% in 2016 (P<0.001). By 2016, the mean incidence of HIV infection had declined by 42% relative to the period before 2006 (i.e., before the scale-up of the combination strategy for HIV prevention) - from 1.17 cases per 100 person-years to 0.66 cases per 100 person-years (adjusted incidence rate ratio, 0.58; 95% confidence interval [CI], 0.45 to 0.76); declines were greater among men (adjusted incidence rate ratio, 0.46; 95% CI, 0.29 to 0.73) than among women (adjusted incidence rate ratio, 0.68; 95% CI, 0.50 to 0.94). CONCLUSIONS: In this longitudinal study, the incidence of HIV infection declined significantly with the scale-up of a combination strategy for HIV prevention, which provides empirical evidence that interventions for HIV prevention can have a population-level effect. However, additional efforts are needed to overcome disparities according to sex and to achieve greater reductions in the incidence of HIV infection. (Funded by the National Institute of Allergy and Infectious Diseases and others.).

Using publicly available, interactive epidemiological dashboards: an innovative approach to sharing data from the Rakai Community Cohort Study.

Objectives: Public sharing of de-identified biomedical data promotes collaboration between researchers and accelerates the development of disease prevention and treatment strategies. However, open-access data sharing presents challenges to researchers who need to protect the privacy of study participants, ensure that data are used appropriately, and acknowledge the inputs of all involved researchers. This article presents an approach to data sharing which addresses the above challenges by using a publicly available dashboard with de-identified, aggregated participant data from a large HIV surveillance cohort. Materials and Methods: Data in this study originated from the Rakai Community Cohort Study (RCCS), which was integrated into a centralized data mart as part of a larger data management strategy for the Rakai Health Sciences Program in Uganda. These data were used to build a publicly available, protected health information (PHI)-secured visualization dashboard for general research use. Results: Using two unique case studies, we demonstrate the capability of the dashboard to generate the following hypotheses: firstly, that HIV prevention strategies ART and circumcision have differing levels of impact depending on the marital status of investigated communities; secondly, that ART is very successful in comparison to circumcision as an interventional strategy in certain communities. Discussion: The democratization of large-scale anonymized epidemiological data using public-facing dashboards has multiple benefits, including facilitated exploration of research data and increased reproducibility of research findings. Conclusion: By allowing the public to explore data in depth and form new hypotheses, public-facing dashboard platforms have significant potential to generate new relationships and collaborations and further scientific discovery and reproducibility.

Prevalence of cardiovascular risk factors by HIV status in a population-based cohort in South Central Uganda: a cross-sectional survey.

INTRODUCTION: Cardiovascular disease is one of the leading causes of mortality for people living with HIV, but limited population-based data are available from sub-Saharan Africa. This study aimed to determine the prevalence of key cardiovascular disease risk factors, 10-year risk of cardiovascular disease and type 2 diabetes mellitus through risk scores by HIV status, as well as investigate factors associated with hyperglycaemia, hypertension and dyslipidaemia in South-Central Uganda. METHODS: A cross-sectional study was conducted in 37 communities of the population-based Rakai Community Cohort Study from May 2016 to May 2018. In total, 990 people living with HIV and 978 HIV-negative participants aged 35-49 years were included. Prevalence estimates and 10-year cardiovascular and type 2 diabetes risk were calculated by sex and HIV serostatus. Multivariable logistic regression was used to determine associations between socio-demographic, lifestyle and body composition risk factors and hyperglycaemia, hypertension and dyslipidaemia. RESULTS: Overweight (21%), obesity (9%), abdominal obesity (15%), hypertension (17%) and low high-density lipoprotein (HDL) (63%) were the most common cardiovascular risk factors found in our population. These risk factors were found to be less common in people living with HIV apart from hypertension. Ten-year risk for cardiovascular and type 2 diabetes mellitus risk was low in this population with <1% categorized as high risk. In HIV-adjusted multivariable analysis, obesity was associated with a higher odds of hypertension (odds ratio [OR] = 2.31, 95% confidence interval [CI] 1.35-3.96) and high triglycerides (OR = 2.08, CI 1.25-3.47), and abdominal obesity was associated with a higher odds of high triglycerides (OR = 2.55, CI 1.55-4.18) and low HDL (OR = 1.36, CI 1.09-1.71). A positive HIV status was associated with a lower odds of low HDL (OR = 0.43, CI 0.35-0.52). CONCLUSIONS: In this population-based study in Uganda, cardiovascular risk factors of obesity, abdominal obesity, hypertension and dyslipidaemia were found to be common, while hyperglycaemia was less common. Ten-year risk for cardiovascular and type 2 diabetes mellitus risk was low. The majority of cardiovascular risk factors were not affected by HIV status. The high prevalence of dyslipidaemia in our study requires further research.

Effect of HIV Self-Testing on PrEP Adherence Among Gender-Diverse Sex Workers in Uganda: A Randomized Trial.

BACKGROUND: HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) are complementary tools that could empower sex workers to control their HIV protection, but few studies have jointly evaluated PrEP and HIVST in any setting. METHODS: The Empower Study was an open-label randomized trial in Uganda. Sex workers were offered F/tenofovir disoproxil fumarate and randomized 1:1 to monthly HIVST and quarterly in-clinic testing (intervention) or quarterly in-clinic HIV testing alone (standard of care) and followed up for 12 months. PrEP adherence was measured using electronic adherence monitoring and tenofovir diphosphate (TFV-DP) levels in dried blood spots. Adherence outcomes and sexual behaviors were compared by arm using generalized estimating equation models. RESULTS: We enrolled 110 sex workers: 84 cisgender women, 14 transgender women, 10 men who have sex with men, and 2 transgender men. The median age was 23 years. The 12-month retention was 75%. Nearly all (99.4%) used ≥1 HIVST kit. The proportion with TFV-DP levels ≥700 fmol/punch in the HIVST and standard of care arms at the 3-, 6-, 9-, and 12-month visits was 2.4%, 2.3%, 0%, and 0% and 7.9%, 0%, 0%, and 0%, respectively, with no differences by randomization arm (P > 0.2). Self-reported condomless sex acts with paying partners was similar by arm [adjusted incidence rate ratio 0.70; 95% confidence interval (CI): 0.42 to 1.17; P = 0.18]. One seroconversion occurred (HIV incidence, 0.9/100 person-years); TFV-DP was not detected at any visit. CONCLUSIONS: A gender-diverse sample of sex workers in Uganda used HIVST but not daily oral PrEP for HIV protection. Alternate approaches to promote PrEP use, including long-acting formulations, should be considered in this population.

Smoker characteristics and trends in tobacco smoking in Rakai, Uganda, 2010-2018.

INTRODUCTION: Tobacco use is a major public health concern, particularly in low- and middle-income countries where 80% of the world's smokers reside. There is limited population-based data from rural Africa on patterns of tobacco smoking and smoker characteristics. We assessed trends in rates of smoking, characteristics of smokers, and factors associated with smoking using repeat population-based cross-sectional surveys in south-central Uganda. METHODS: Data accrued over five survey rounds (2010-2018) of the Rakai Community Cohort Study (RCCS) from consenting individuals aged 15-49 years including sociodemographic and behavioral characteristics and smoking status. Proportions of smokers per survey were compared using χ2 test for trends, and factors associated with smoking were assessed by multivariable logistic regression. RESULTS: The prevalence of tobacco smoking in the general population declined from 7.3% in 2010-2011 to 5.1% in 2016-2018, p<0.001. Smoking rates declined among males (13.9-9.2%) and females (2.2-1.8%) from 2010-2011 to 2016-2018. Smoking prevalence was higher among previously married (11.8-11.7%) compared to currently (8.4-5.3%) and never married persons (3.1-1.8%) from 2010-2011 to 2016-2018. Older age (≥35 years) was associated with higher odds of smoking (AOR=8.72; 95% CI: 5.68-13.39 in 2010-2011 and AOR=9.03; 95% CI: 5.42-15.06 in 2016-2018) compared to those aged <35 years (AOR=4.73; 95% CI: 3.15-7.12 in 2010-2011 and AOR=4.83; 95% CI: 2.95-7.91 in 2016-2018). Primary and secondary/higher education level was significantly associated with lower odds of smoking (AOR=0.20; 95% CI: 0.14-0.29 in 2010-2011 and AOR=0.26; 95% CI: 0.18-0.39 in 2016-2018) compared to no education (AOR=0.43; 95% CI: 0.31-0.59 in 2010-2011 and AOR=0.48; 95% CI: 0.34-0.68 in 2016-2018). Number of sexual partners and HIV status were not associated with smoking. CONCLUSIONS: We observed declining trends in tobacco smoking in the Rakai region of rural Uganda. Smoking was more prevalent in men, older individuals, individuals who were previously married, and individuals with lower education. The decline in smoking may be due to tobacco control efforts, but there is a continued need to target sub-populations with higher smoking prevalence.

Alcohol use during pregnancy in Rakai, Uganda.

INTRODUCTION: Antenatal alcohol use is linked to adverse maternal and neonatal outcomes. Uganda has one of the highest rates of alcohol use in sub-Saharan Africa, but the prevalence of antenatal alcohol use has not been reported in the Rakai region. METHODS: We used cross-sectional data from pregnant women in the Rakai Community Cohort Study between March 2017 and September 2018. Using bivariate and multivariable analyses, we assessed associations between self-reported antenatal alcohol use and sociodemographic characteristics, intimate partner violence (IPV), and HIV status. RESULTS: Among 960 pregnant women, the median age was 26 years, 35% experienced IPV in the past 12 months, 13% were living with HIV, and 33% reported alcohol use during their current pregnancy. After adjusting for marital status, education, smoking, and HIV status; Catholic religion (AOR: 3.54; 95% CI: 1.89-6.64; compared to other), bar/restaurant work (AOR: 2.40; 95% CI: 1.17-4.92; compared to agriculture), >one sex partner in past year (AOR: 1.92; 95% CI: 1.17-3.16), a partner that drank before sex in past year (AOR: 2.01; 95% CI: 1.48-2.74), and past year IPV (AOR: 1.55; 95% CI: 1.14-2.11) were associated with antenatal alcohol use. CONCLUSION: We found that alcohol use during pregnancy was common and associated with religion, occupation, higher numbers of past year sex partners, having a partner who drank before sex in the past 12 months, and IPV experience. More research is needed to understand the quantity, frequency, and timing of antenatal alcohol use; and potential impacts on neonates; and to identify services that are acceptable and effective among pregnant women.

Prevalence of Untreated HIV and Associated Risk Behaviors Among the Sexual Partners of Recent Migrants and Long-term Residents in Rakai, Uganda.

BACKGROUND: Migrants in sub-Saharan Africa are at increased risk of HIV acquisition after migration, but little is known about their sexual partners at place of destination. SETTING: Rakai Community Cohort Study (RCCS) in Uganda. METHODS: From 1999 to 2016, persons aged 15-49 years were surveyed in the RCCS and reported on their 4 most recent sexual partners in the last year. We compared the characteristics of sexual partners reported by migrants moving into RCCS communities in the last 2 years (ie, in-migrants) with those of long-term residents with no recent migration history. Among a subset of participants in cohabitating epidemiologically linked couples of known HIV serostatus, we also assessed prevalence of having ≥1 untreated HIV-positive partner among in-migrants and long-term residents. RESULTS: One hundred sixteen thousand seven hundred forty-four sexual partners were reported by 29,423 participants. The sexual partnerships of in-migrants were significantly less likely to be marital, more likely to span community boundaries, and shorter in duration than those of long-term residents. In-migrants also reported more sexual partners and were less likely to know their partner's HIV status or to have told their partner their HIV status. Among 7558 epidemiologically linked couples, HIV-negative in-migrants were more likely to partner with untreated HIV-positive persons compared with HIV-negative long-term residents (women: 6.3% vs. 4.1%; prevalence risk ratio = 1.77, 95% confidence interval: 1.49 to 2.11; men: 6.9% vs. 3.9%; prevalence risk ratio = 1.72, 95% confidence interval: 1.38-2.14). CONCLUSION: There is a higher frequency of risky sexual behaviors among the partnerships of in-migrants compared with those of long-term residents. Among cohabitating couples, in-migrants are more likely to partner with untreated HIV-positive individuals.

Prevalence and correlates of men's and women's alcohol use in agrarian, trading and fishing communities in Rakai, Uganda.

INTRODUCTION: Uganda has one of the highest rates of alcohol use in sub-Saharan Africa but prevalence and correlates of drinking are undocumented in the Rakai region, one of the earliest epicenters of the HIV/AIDS epidemic in East Africa. METHODS: We analyzed cross-sectional data from 18,700 persons (8,690 men, 10,010 women) aged 15-49 years, living in agrarian, trading and fishing communities and participating in the Rakai Community Cohort Study (RCCS) between March 2015 and September 2016. Logistic regression models assessed associations between past year alcohol use and sociodemographic characteristics, other drug use and HIV status, controlling for age, religion, education, occupation, marital status, and household socioeconomic status. RESULTS: Past year alcohol prevalence was 45%. Odds of drinking were significantly higher in men (versus women) and fishing communities (versus agrarian areas). Odds of drinking increased with age, previous (versus current) marriage and past year drug use. By occupation, highest odds of drinking were among fishermen and (in women) bar/restaurant workers. Alcohol-related consequences were more commonly reported by male (vs. females) drinkers, among whom up to 35% reported alcohol dependence symptoms (e.g., unsteady gait). HIV status was strongly associated with alcohol use in unadjusted but not adjusted models. CONCLUSIONS: Alcohol use differed by gender, community type and occupation. Being male, living in a fishing community and working as a fisherman or restaurant/bar worker (among women) were associated with higher odds of drinking. Alcohol reduction programs should be implemented in Uganda's fishing communities and among people working in high risk occupations (e.g., fishermen and restaurant/bar workers).

The Effect of Antiretroviral Therapy Initiation on the Vaginal Microbiome in HIV-Infected Women.

BACKGROUND: The impact of antiretroviral therapy (ART) initiation on the vaginal microbiome is unknown. This is of particular importance among women living in sub-Saharan Africa. Understanding this relationship could help elucidate if and how the host immune system interacts with the vaginal microbiome. METHODS: The vaginal microbiome of HIV-1/HSV-2-coinfected women (n = 92) in Uganda was evaluated from self-collected vaginal swabs 1 month pre-ART and at 4 and 6 months post-ART initiation. The vaginal microbiome was characterized by 16S rRNA gene-based sequencing and quantitative polymerase chain reaction. Vaginal community state types (CSTs) were identified using proportional abundance data. Changes in microbiome composition were assessed with permutational analyses of variance (PerMANOVA). RESULTS: Five vaginal CSTs were identified, which varied significantly by bacterial load (P < .01): CST-1 was characterized by Lactobacillus iners, CST-2 by Gardnerella, CST-3 by Gardnerella and Prevotella, CST-4 by Lactobacillus crispatus, and CST-5 was highly diverse. Vaginal microbiome composition also did not change significantly after ART initiation (P = .985). Immune reconstitution after ART initiation did not affect vaginal microbiome CST assignment (P = .722) or individual-level changes in bacterial load (log response ratio [interquartile range], -0.50 [-2.75 to 0.38] vs -0.29 [-2.03 to 1.42]; P = .40). CONCLUSIONS: The vaginal microbiome of HIV-infected women was not affected by the initiation of ART or immune reconstitution in this observational study. Further research is needed to explore the long-term effects of ART treatment on the vaginal microbiome.

Impact of combination HIV interventions on HIV incidence in hyperendemic fishing communities in Uganda: a prospective cohort study.

BACKGROUND: Targeting combination HIV interventions to locations and populations with high HIV burden is a global priority, but the impact of these strategies on HIV incidence is unclear. We assessed the impact of combination HIV interventions on HIV incidence in four HIV-hyperendemic communities in Uganda. METHODS: We did an open population-based cohort study of people aged 15-49 years residing in four fishing communities on Lake Victoria. The communities were surveyed five times to collect self-reported demographic, behavioural, and service-uptake data. Free HIV testing was provided at each interview, with referral to combination HIV intervention services as appropriate. From November, 2011, combination HIV intervention services were rapidly expanded in these geographical areas. We evaluated trends in HIV testing coverage among all participants, circumcision coverage among male participants, antiretroviral therapy (ART) coverage and HIV viral load among HIV-positive participants, and sexual behaviours and HIV incidence among HIV-negative participants. FINDINGS: From Nov 4, 2011, to Aug 16, 2017, data were collected from five surveys. Overall, 8942 participants contributed 20 721 person-visits; 4619 (52%) of 8942 participants were male. HIV prevalence was 41% (1598 of 3870) in the 2011-12 baseline survey and declined to 37% (1740 of 4738) at the final survey (p<0·0001). 3222 participants who were HIV-negative at baseline, and who had at least one repeat visit, contributed 9477 person-years of follow-up, and 230 incident HIV infections occurred. From the first survey in 2011-12 to the last survey in 2016-17, HIV testing coverage increased from 68% (2613 of 3870) to 96% (4526 of 4738; p<0·0001); male circumcision coverage increased from 35% (698 of 2011) to 65% (1630 of 2525; p<0·0001); ART coverage increased from 16% (254 of 1598) to 82% (1420 of 1740; p<0·0001); and population HIV viral load suppression in all HIV-positive participants increased from 34% (546 of 1596) to 80% (1383 of 1734; p<0·0001). Risky sexual behaviours did not decrease over this period. HIV incidence decreased from 3·43 per 100 person-years (95% CI 2·45-4·67) in 2011-12 to 1·59 per 100 person-years (95% CI 1·19-2·07) in 2016-17; adjusted incidence rate ratio (IRR) 0·52 (95% CI 0·34-0·79). Declines in HIV incidence were similar among men (adjusted IRR 0·53, 95% CI 0·30-0·93) and women (0·51, 0·27-0·96). The risk of incident HIV infection was lower in circumcised men than in uncircumcised men (0·46, 0·32-0·67). INTERPRETATION: Rapid expansion of combination HIV interventions in HIV-hyperendemic fishing communities is feasible and could have a substantial impact on HIV incidence. However, incidence remains higher than HIV epidemic control targets, and additional efforts will be needed to achieve this global health priority. FUNDING: The National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, the National Cancer Institute, the National Institute for Allergy and Infectious Diseases Division of Intramural Research, Centers for Disease Control and Prevention Uganda, Karolinska Institutet, and the Johns Hopkins University Center for AIDS Research.

Brief Report: Age-Disparate Relationships and HIV Prevalence Among Never Married Women in Rakai, Uganda.

BACKGROUND: Age-disparate relationships are associated with increased HIV prevalence. We determined whether the frequency of age-disparate relationships in never married women changed over time and whether they are associated with HIV prevalence in Rakai, Uganda. METHODS: A total of 10,061 never married women, aged 15-49 years, in the Rakai Community Cohort Study provided information on the age of their male sexual partners from 1997 to 2013. Logistic regression was used to assess trends in age-disparate relationships (≥5 years) between never married women and their male partners. Log-binomial regression was used to estimate adjusted prevalence ratios (adjPR) of HIV prevalence associated with age-disparate relationships. RESULTS: Two thousand nine hundred ninety-nine women (30%) had a male partner ≥5 years older, which remained stable over time. The prevalence of HIV among women in age-disparate relationships was 14%, 10% for women in relationships with men 0-4 years older (adjPR 1.36, 95% confidence interval: 1.22 to 1.53) not controlling women's age; however, after age adjustment, the impact of age-disparate relationships on HIV prevalence was attenuated. Age-disparate relationships were associated with increased HIV prevalence among women aged 15-17 years (adjPR 1.83, 95% confidence interval: 1.10 to 3.17), but not in other age groups. CONCLUSIONS: The frequency of age-disparate relationships among never married women was unchanged over a 15-year period in Rakai, Uganda. Age-disparate relationships were associated with increased HIV prevalence among adolescents aged 15-17 years, but not older women.

Mobility among youth in Rakai, Uganda: Trends, characteristics, and associations with behavioural risk factors for HIV.

Mobility, including migration and travel, influences risk of HIV. This study examined time trends and characteristics among mobile youth (15-24 years) in rural Uganda, and the relationship between mobility and risk factors for HIV. We used data from an annual household census and population-based cohort study in the Rakai district, Uganda. Data on in-migration and out-migration were collected among youth (15-24 years) from 43 communities from 1999 to 2011 (N = 112,117 observations) and travel among youth residents from 2003 to 2008 (N = 18,318 observations). Migration and travel were more common among young women than young men. One in five youth reported out-migration. Over time, out-migration increased among youth and in-migration remained largely stable. Primary reasons for migration included work, living with friends or family, and marriage. Recent travel within Uganda was common and increased slightly over time in teen women (15-19 years old), and young adult men and women (20-24 years old). Mobile youth were more likely to report HIV-risk behaviours including: alcohol use, sexual experience, multiple partners, and inconsistent condom use. Our findings suggest that among rural Ugandan youth, mobility is increasingly common and associated with HIV-risk factors. Knowledge of patterns and characteristics of a young, high-risk mobile population has important implications for HIV interventions.

Rising School Enrollment and Declining HIV and Pregnancy Risk Among Adolescents in Rakai District, Uganda, 1994-2013.

BACKGROUND: Poverty, family stability, and social policies influence the ability of adolescents to attend school. Likewise, being enrolled in school may shape an adolescent's risk for HIV and pregnancy. We identified trends in school enrollment, factors predicting school enrollment (antecedents), and health risks associated with staying in or leaving school (consequences). METHODS: Data from the Rakai Community Cohort Study (RCCS) were examined for adolescents 15-19 years (n=21,735 person-rounds) from 1994 to 2013. Trends, antecedents, and consequences were assessed using logistic and linear regression with robust variance estimation. Qualitative data were used to explore school leaving among HIV+ and HIV- youth (15-24 years). RESULTS: School enrollment and socioeconomic status (SES) rose steadily from 1994 to 2013 among adolescents; orphanhood declined after availability of antiretroviral therapy. Antecedent factors associated with school enrollment included age, SES, orphanhood, marriage, family size, and the percent of family members <20 years. In qualitative interviews, youth reported lack of money, death of parents, and pregnancy as primary reasons for school dropout. Among adolescents, consequences associated with school enrollment included lower HIV prevalence, prevalence of sexual experience, and rates of alcohol use and increases in consistent condom use. Young women in school were more likely to report use of modern contraception and never being pregnant. Young men in school reported fewer recent sexual partners and lower rates of sexual concurrency. CONCLUSIONS: Rising SES and declining orphanhood were associated with rising school enrollment in Rakai. Increasing school enrollment was associated with declining risk for HIV and pregnancy.

Prevalence of Sexual Experience and Initiation of Sexual Intercourse Among Adolescents, Rakai District, Uganda, 1994-2011.

PURPOSE: The purpose of the study was to identify risk factors and time trends for sexual experience and sexual debut in rural Uganda. METHODS: Using population-based, longitudinal data from 15- to 19-year olds in Rakai, Uganda, we examined temporal trends in the prevalence of sexual experience and potential risk factors for sexual experience (n = 31,517 person-round observations) using logistic regression. We then identified factors associated with initiation of sex between survey rounds, using Poisson regression to estimate incidence rate ratios (IRR; n = 5,126 person-year observations). RESULTS: Sexual experience was more common among adolescent women than men. The prevalence of sexual experience rose for most age-gender groups after 1994 and then declined after 2002. Factors associated with higher prevalence of sexual experience (without adjustment for other factors) included age, not enrolled in school, orphanhood, lower socioeconomic status, and drinking alcohol in the past 30 days; similar factors were associated with initiation of sex. Factors independently associated with initiation of sex included older age, nonenrollment in school (IRR = 1.7 for women and 1.8 for men), alcohol use (IRR = 1.3 for women and men), and being a double orphan among men (IRR = 1.2). Sexual experience began to decline around 2000, whereas increases in school enrollment began as early as 1994 and declines in orphanhood occurred after 2004 (as antiretroviral therapy became available). CONCLUSIONS: Sexual experience among youth in Rakai was associated with social factors particularly school enrollment. Changes in these social factors also appear to influence change over time in sexual experience.

Factors associated with incident HIV infection versus prevalent infection among youth in Rakai, Uganda.

Factors associated with prevalent and incident HIV infection were compared among sexually experienced Ugandans aged 15-24. Most factors were similar. However, in women, older age and current marriage were associated with prevalent, but not incident, infection. It is important to recognize the limitations of prevalence analyses for identifying at-risk youth.

Marriage and the risk of incident HIV infection in Rakai, Uganda.

OBJECTIVE: Studies suggest that the prevalence of HIV is higher among long-term marital/consensual relationships than in the unmarried. We assessed the risk of incident HIV infection by marital status in rural Rakai, Uganda. DESIGN: Longitudinal data from the Rakai Community Cohort Study between 1999 and 2011. METHODS: We estimated HIV incidence per 100 person years (py) in sexually active individuals aged 15-49 years with a total of 44,179.6 py who were never married (women 2929 py and men 4261 py), currently married or in long-term consensual relationships (currently married women 29,823 py and men 21,299 py) and previously married (women 3563 py and men 1475). Poisson multivariable regression was used to estimate the unadjusted and adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) of HIV acquisition. RESULTS: The HIV incidence among currently married persons was 0.93/100 py, which was lower than that for the never-married (1.51/100 py) and previously married (2.85/100 py) persons. The risk of HIV acquisition was significantly lower in the currently married compared with that in the never married among women (Adj IRR = 0.26, 95% CI: 0.16 to 0.42), but not among men (Adj IRR = 0.69, 95% CI: 0.31 to 1.52). HIV incidence was lower among first marriages (0.73/100 py) compared with that among second- or higher-order marriages (1.38/100 py). Multiple sex partners significantly increased the risk of HIV acquisition in both women (Adj IRR = 2.53, 95% CI: 1.6 to 3.97) and men (Adj IRR = 1.77, 95% CI: 1.20 to 2.60). CONCLUSIONS: Current marriage especially first-order marriage was associated with a reduced risk of HIV acquisition in women, but not in men, and multiple sex partnerships increased HIV risk for both sexes.

Behavioral, biological, and demographic risk and protective factors for new HIV infections among youth in Rakai, Uganda.

BACKGROUND: Prevalence of HIV infection is considerable among youth, although data on risk factors for new (incident) infections are limited. We examined incidence of HIV infection and risk and protective factors among youth in rural Uganda, including the role of gender and social transitions. METHODS: Participants were sexually experienced youth (15-24 years old) enrolled in the Rakai Community Cohort Study, 1999-2008 (n = 6741). Poisson regression with robust standard errors was used to estimate incident rate ratios (IRR) and 95% confidence intervals (CI) of incident HIV infection. RESULTS: HIV incidence was greater among young women than young men (14.1 vs. 8.3 per 1000 person-years, respectively); this gender disparity was greater among teenagers (14.9 vs. 3.6). Beyond behavioral (multiple partners and concurrency) and biological factors (sexually transmitted infection symptoms), social transitions such as marriage and staying in school influenced HIV risk. In multivariate analyses among women, HIV incidence was associated with living in a trading village (adjusted IRR (aIRR) = 1.48; 95% CI: 1.04 to 2.11), being a student (aIRR = 0.22; 95% CI: 0.07 to 0.72), current marriage (aIRR = 0.55; 95% CI: 0.37 to 0.81), former marriage (aIRR = 1.73; 95% CI: 1.01 to 2.96), having multiple partners, and sexually transmitted infection symptoms. Among men, new infections were associated with former marriage (aIRR = 5.57; 95% CI: 2.51 to 12.36), genital ulceration (aIRR = 3.56; 95% CI: 1.97 to 6.41), and alcohol use (aIRR = 2.08; 95% CI: 1.15 to 3.77). CONCLUSIONS: During the third decade of the HIV epidemic in Uganda, HIV incidence remains considerable among youth, with young women particularly at risk. The risk for new infections was strongly shaped by social transitions such as leaving school, entrance into marriage, and marital dissolution; the impact of marriage was different for young men than women.