Kukaa Salama (Staying Safe): a pre-post trial of an interactive informational mobile health intervention for increasing COVID-19 prevention practices with urban refugee youth in Uganda.

BACKGROUND: Tailored coronavirus disease 2019 (COVID-19) prevention strategies are needed for urban refugee youth in resource-constrained contexts. We developed an 8-wk interactive informational mobile health intervention focused on COVID-19 prevention practices informed by the Risk, Attitude, Norms, Ability, Self-regulation-or RANAS-approach. METHODS: We conducted a pre-post trial with a community-recruited sample of refugee youth aged 16-24 y in Kampala, Uganda. Data were collected before (T1) and immediately following (T2) the intervention, and at the 16-wk follow up (T3), to examine changes in primary (COVID-19 prevention self-efficacy) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health [SRH] access; food/water security; COVID-19 vaccine acceptability). RESULTS: Participants (n=346; mean age: 21.2 [SD 2.6] y; cisgender women: 50.3%; cisgender men: 48.0%; transgender persons: 1.7%) were largely retained (T2: n=316, 91.3%; T3: n=302, 87.3%). In adjusted analyses, COVID-19 prevention self-efficacy, risk awareness, attitudes and vaccine acceptance increased significantly from T1 to T2, but were not sustained at T3. Between T1 and T3, COVID-19 norms and self-regulation significantly increased, while community violence, water insecurity and community SRH access decreased. CONCLUSIONS: Digital approaches for behaviour change hold promise with urban refugee youth but may need booster messaging and complementary programming for sustained effects.

HIV Vulnerabilities Associated with Water Insecurity, Food Insecurity, and Other COVID-19 Impacts Among Urban Refugee Youth in Kampala, Uganda: Multi-method Findings.

Food insecurity (FI) and water insecurity (WI) are linked with HIV vulnerabilities, yet how these resource insecurities shape HIV prevention needs is understudied. We assessed associations between FI and WI and HIV vulnerabilities among urban refugee youth aged 16-24 in Kampala, Uganda through individual in-depth interviews (IDI) (n = 24), focus groups (n = 4), and a cross-sectional survey (n = 340) with refugee youth, and IDI with key informants (n = 15). Quantitative data was analysed via multivariable logistic and linear regression to assess associations between FI and WI with: reduced pandemic sexual and reproductive health (SRH) access; past 3-month transactional sex (TS); unplanned pandemic pregnancy; condom self-efficacy; and sexual relationship power (SRP). We applied thematic analytic approaches to qualitative data. Among survey participants, FI and WI were commonplace (65% and 47%, respectively) and significantly associated with: reduced SRH access (WI: adjusted odds ratio [aOR]: 1.92, 95% confidence interval [CI]: 1.19-3.08; FI: aOR: 2.31. 95%CI: 1.36-3.93), unplanned pregnancy (WI: aOR: 2.77, 95%CI: 1.24-6.17; FI: aOR: 2.62, 95%CI: 1.03-6.66), and TS (WI: aOR: 3.09, 95%CI: 1.22-7.89; FI: aOR: 3.51, 95%CI: 1.15-10.73). WI participants reported lower condom self-efficacy (adjusted ß= -3.98, 95%CI: -5.41, -2.55) and lower SRP (adjusted ß= -2.58, 95%CI= -4.79, -0.37). Thematic analyses revealed: (1) contexts of TS, including survival needs and pandemic impacts; (2) intersectional HIV vulnerabilities; (3) reduced HIV prevention/care access; and (4) water insecurity as a co-occurring socio-economic stressor. Multi-method findings reveal FI and WI are linked with HIV vulnerabilities, underscoring the need for HIV prevention to address co-occurring resource insecurities with refugee youth.

Findings from the Tushirikiane mobile health (mHealth) HIV self-testing pragmatic trial with refugee adolescents and youth living in informal settlements in Kampala, Uganda.

INTRODUCTION: Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self-testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda. METHODS: We conducted a three-arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer-recruited refugee youth aged 16-24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self-reported HIV testing uptake and correct status knowledge verified by point-of-care testing. Some secondary outcomes included: depression, HIV-related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS-2 dimensions. RESULTS: We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self-reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV-related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow-up). CONCLUSIONS: Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth-focused HIVST trials in urban humanitarian settings.

Multi-method findings on COVID-19 vaccine acceptability among urban refugee adolescents and youth in Kampala, Uganda.

ABSTRACTScant studies have explored COVID-19 vaccine acceptability among refugees. However, contexts of forced migration may elevate COVID-19 vulnerabilities, and suboptimal refugee immunisation rates are reported for other vaccine-preventable diseases. We conducted a multi-methods study to describe COVID-19 vaccine acceptability among urban refugee youth in Kampala, Uganda. This study uses cross-sectional survey data from a cohort study with refugees aged 16-24 in Kampala to examine socio-demographic factors associated with vaccine acceptability. A purposively sampled cohort subset (n = 24) participated in semi-structured in-depth individual interviews, as did key informants (n = 6), to explore COVID-19 vaccine acceptance. Among 326 survey participants (mean age: 19.9; standard deviation 2.4; 50.0% cisgender women), vaccine acceptance was low (18.1% reported they were very likely to accept an effective COVID-19 vaccine). In multivariable models, vaccine acceptance likelihood was significantly associated with age and country of origin. Qualitative findings highlighted COVID-19 vaccine acceptability barriers and facilitators spanning social-ecological levels, including fear of side effects and mistrust (individual level), misinformed healthcare, community and family attitudes (community level), tailored COVID-19 services for refugees (organisational and practice setting), and political support for vaccines (policy environment). These data signal the urgent need to address social-ecological factors shaping COVID-19 vaccine acceptability among Kampala's young urban refugees.Trial registration: ClinicalTrials.gov identifier: NCT04631367.

Understanding how social support influences peer-delivered HIV prevention interventions among Ugandan female sex workers: a case study from HIV self-testing.

BACKGROUND: Female sex workers (FSWs) have tightly connected peer networks and remain at high risk of HIV acquisition. Peer delivery of HIV prevention interventions, such as HIV self-testing (HIVST), is a recommended implementation strategy for increasing intervention uptake and continuation among FSWs. We analyzed qualitative data from a peer-delivered HIVST intervention among FSWs in urban Uganda to understand the ways social support within this peer network can motivate or discourage the uptake of peer-delivered HIVST. METHODS: Between February and April 2017, we conducted in-depth interviews (IDIs) with FSWs (n = 30) and focus group discussions (FGDs) with FSW peer educators (PEs, n = 5) finishing participation in a four-month randomized implementation trial testing models of peer-delivered HIVST in Kampala. FSW participants were ≥ 18 years old, self-reported exchanging sex for money or goods (past month) and had not recently tested for HIV (past 3 months). FSW PEs either directly distributed HIVST kits to participants or provided coupons exchangeable for HIVST kits from specified healthcare facilities. In the IDIs and FGDs, we asked participants to share their experiences receiving or delivering peer-delivered HIVST, respectively. Using a hybrid deductive and inductive coding approach, we arranged findings along the dimensions of an established social support theory: informational, instrumental, and emotional support. RESULTS: The median age of participants was 30 years (IQR: 27-33) and PEs was 33 years (IQR: 29-37). We found that social support within FSW peer networks both motivated and discouraged uptake of peer-delivered HIVST. For example, sharing positive HIVST experiences (informational support), directly delivering HIVST kits (instrumental support), and encouraging linkage to care (emotional support) motivated HIVST uptake among FSWs. Conversely, the spread of misinformation (informational support), limited HIVST kit availability fostering mistrust of PEs (instrumental support), and fear of social exclusion following HIV status disclosure (emotional support) discouraged HIVST uptake among FSWs. CONCLUSIONS: In Uganda, social support (e.g., informational, instrumental, and emotional support) among FSW peers can work in ways that both motivate and discourage peer-delivered intervention uptake. Future FSW peer-delivered HIV prevention interventions should be designed around the dimensions of social support within FSW peer networks to maximize initial and repeat intervention delivery and uptake.

The prevalence and correlates of depression before and after the COVID-19 pandemic declaration among urban refugee adolescents and youth in informal settlements in Kampala, Uganda: A longitudinal cohort study.

PURPOSE: There is scant research examining urban refugee youth mental health outcomes, including potential impacts of the COVID-19 pandemic. We examine prevalence and ecosocial risk factors of depression in the periods before and after the COVID-19 pandemic declaration among urban refugee youth in Kampala, Uganda. METHODS: Data from a cohort of refugee youth (n = 367) aged 16-24 years were collected in periods before (February 2020) and after (December 2020) the WHO COVID-19 pandemic declaration. We developed crude and adjusted generalized estimating equation logistic regression models to examine demographic and ecosocial factors (food insecurity, social support, intimate partner violence) associated with depression, and include time-ecosocial interactions to examine if associations differed before and after the pandemic declaration. RESULTS: The prevalence of depression was high, but there was no significant difference before (27.5%), and after (28.9%) the pandemic declaration (P = .583). In adjusted models, food insecurity (aOR: 2.54; 95% CI: 1.21-5.33) and experiencing violence (aOR: 2.53; 95% CI: 1.07-5.96) were associated with increased depression, and social support was associated with decreased depression (aOR: 0.85; 95% CI: 0.81-0.89). CONCLUSIONS: These findings highlight the urgent need for interventions to address chronic depression, food insecurity, and ongoing effects of violence exposure among urban refugee youth in Kampala.

Exploring resource scarcity and contextual influences on wellbeing among young refugees in Bidi Bidi refugee settlement, Uganda: findings from a qualitative study.

BACKGROUND: Contextual factors including poverty and inequitable gender norms harm refugee adolescent and youths' wellbeing. Our study focused on Bidi Bidi refugee settlement that hosts more than 230,000 of Uganda's 1.4 million refugees. We explored contextual factors associated with wellbeing among refugee adolescents and youth aged 16-24 in Bidi Bidi refugee settlement. METHODS: We conducted 6 focus groups (n = 3: women, n = 3: men) and 10 individual interviews with young refugees aged 16-24 living in Bidi Bidi. We used physical distancing practices in a private outdoor space. Focus groups and individual interviews explored socio-environmental factors associated with refugee youth wellbeing. Focus groups were digitally recorded, transcribed verbatim, and coded by two investigators using thematic analysis. Analysis was informed by a social contextual theoretical approach that considers the interplay between material (resource access), symbolic (cultural norms and values), and relational (social relationships) contextual factors that can enable or constrain health promotion. RESULTS: Participants included 58 youth (29 men; 29 women), mean age was 20.9 (range 16-24). Most participants (82.8%, n = 48) were from South Sudan and the remaining from the Democratic Republic of Congo (17.2% [n = 10]). Participant narratives revealed the complex interrelationships between material, symbolic and relational contexts that shaped wellbeing. Resource constraints of poverty, food insecurity, and unemployment (material contexts) produced stress and increased sexual and gender-based violence (SGBV) targeting adolescent girls and women. These economic insecurities exacerbated inequitable gender norms (symbolic contexts) to increase early marriage and transactional sex (relational context) among adolescent girls and young women. Gendered tasks such as collecting water and firewood also increased SGBV exposure among girls and young women, and this was exacerbated by deforestation. Participants reported negative community impacts (relational context) of COVID-19 that were associated with fear and panic, alongside increased social isolation due to business, school and church closures. CONCLUSIONS: Resource scarcity produced pervasive stressors among refugee adolescents and youth. Findings signal the importance of gender transformative approaches to SGBV prevention that integrate attention to resource scarcity. These may be particularly relevant in the COVID-19 pandemic. Findings signal the importance of developing health enabling social contexts with and for refugee adolescents and youth.

Unintended uses, meanings, and consequences: HIV self-testing among female sex workers in urban Uganda.

ABSTRACTFemale sex workers (FSWs) are at increased risk of HIV and face significant barriers to clinic-based HIV testing, including provider stigma and privacy constraints. HIV self-testing (HIVST) has been proven to significantly increase HIV testing among FSWs. Less is known, however, about how FSWs make meaning of oral-fluid HIV self-tests, and the unintended ways they use and understand this novel technology. From October 2016 to March 2017, we conducted 61 in-depth interviews with FSWs (n = 31) in Kampala, Uganda. Eligible participants were: female, ≥18 years, exchanged sex for money or goods, and had not recently tested for HIV. We used inductive coding to identify emerging themes and re-arranged these into an adapted framework. Unintended desirable ways FSWs described self-testing included as a means to test others, to bolster their reputation as a health-conscious sex worker, and to avoid bearing witness to suffering at health facilities. Unintended undesirable meanings ascribed to self-testing included misunderstandings about how HIV is transmitted (via saliva versus blood) and whether self-tests also test for other infections. HIVST can increase FSWs' knowledge of their own HIV status and that of their sexual partners, but messaging and intervention design must address misunderstandings and misuses of self-testing.Trial registration: ClinicalTrials.gov identifier: NCT02846402.

Knowledge of HIV Status Is Associated With a Decrease in the Severity of Depressive Symptoms Among Female Sex Workers in Uganda and Zambia.

BACKGROUND: Knowledge of HIV-positive status may result in depressive symptoms, which may be a concern to scaling novel HIV testing interventions that move testing outside the health system and away from counselor support. SETTING: Uganda and Zambia. METHODS: We used longitudinal data from 2 female sex worker (FSW) cohorts in Uganda (n = 960) and Zambia (n = 965). Over 4 months, participants had ample opportunity to HIV testing using standard-of-care services or self-tests. At baseline and 4 months, we measured participants' perceived knowledge of HIV status, severity of depressive symptoms (continuous PHQ-9 scale, 0-27 points), and prevalence of likely depression (PHQ-9 scores ≥10). We estimated associations using individual fixed-effects estimation. RESULTS: Compared with unknown HIV status, knowledge of HIV-negative status was significantly associated with a decrease in depressive symptoms of 1.06 points in Uganda (95% CI -1.79 to -0.34) and 1.68 points in Zambia (95% CI -2.70 to -0.62). Knowledge of HIV-positive status was significantly associated with a decrease in depressive symptoms of 1.01 points in Uganda (95% CI -1.82 to -0.20) and 1.98 points in Zambia (95% CI -3.09 to -0.88). The prevalence of likely depression was not associated with knowledge of HIV status in Uganda but was associated with a 14.1% decrease with knowledge of HIV-negative status (95% CI -22.1% to -6.0%) and a 14.3% decrease with knowledge of HIV-positive status (95% CI -23.9% to -4.5%) in Zambia. CONCLUSIONS: Knowledge of HIV status, be it positive or negative, was significantly associated with a decrease in depressive symptoms in 2 FSW populations. The expansion of HIV testing programs may have mental health benefits for FSWs.

Acceptability of HIV self-testing to support pre-exposure prophylaxis among female sex workers in Uganda and Zambia: results from two randomized controlled trials.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is highly effective for prevention of HIV acquisition, but requires HIV testing at regular intervals. Female sex workers (FSWs) are a priority population for HIV prevention interventions in many settings, but face barriers to accessing healthcare. Here, we assessed the acceptability of HIV self-testing for regular HIV testing during PrEP implementation among FSWs participating in a randomized controlled trial of HIV self-testing delivery models. METHODS: We used data from two HIV self-testing randomized controlled trials with identical protocols in Zambia and in Uganda. From September-October 2016, participants were randomized in groups to: (1) direct delivery of an HIV self-test, (2) delivery of a coupon, exchangeable for an HIV self-test at nearby health clinics, or (3) standard HIV testing services. Participants completed assessments at baseline and 4 weeks. Participants reporting their last HIV test was negative were asked about their interest in various PrEP modalities and their HIV testing preferences. We used mixed effects logistic regression models to measure differences in outcomes across randomization arms at four weeks. RESULTS: At 4 weeks, 633 participants in Zambia and 749 participants in Uganda reported testing negative at their last HIV test. The majority of participants in both studies were "very interested" in daily oral PrEP (91% Zambia; 66% Uganda) and preferred HIV self-testing to standard testing services while on PrEP (87% Zambia; 82% Uganda). Participants in the HIV self-testing intervention arms more often reported preference for HIV self-testing compared to standard testing services to support PrEP in both Zambia (P = 0.002) and Uganda (P < 0.001). CONCLUSION: PrEP implementation programs for FSW could consider inclusion of HIV self-testing to reduce the clinic-based HIV testing burden. TRIAL REGISTRATION: ClinicalTrials.gov NCT02827240 and NCT02846402 .