RESUMEN
BACKGROUND: Civil war in Northern Uganda resulted in widespread atrocities, human rights violations, and death, and caused millions to flee to internally displaced persons camps. War-related traumas combined with difficulties accessing HIV prevention and health services has led to extreme HIV-related vulnerability among conflict-affected people who survived the war. Objectives were to (1) determine HIV incidence among conflict-affected people in Northern Uganda and (2) identify vulnerabilities associated with HIV infection. METHODS: The Cango Lyec (Healing the Elephant) Project is a prospective cohort involving conflict-affected populations in three districts in Northern Uganda. In 2011, eight randomly selected communities were mapped, and a census was conducted. Consenting participants aged 13-49 years were followed over three rounds of follow-up. Longitudinal data collected included war-related experiences, sexual vulnerabilities, and sociodemographics. Blood samples were tested for HIV-1 at baseline and each 12-month follow-up. Multivariable Cox proportional hazard models determined factors associated with HIV incidence. FINDINGS: Overall, 1920 baseline HIV-negative participants with at least one follow-up contributed 3877 person-years (py) for analysis. Thirty-nine (23 female, 16 male) participants contracted HIV during follow-up. Age- and gender-standardised HIV incidence rate was 10â¢2 per 1000py (95%CI: 7â¢2-14â¢0). Stratified by sex, the age-adjusted HIV incidence was 11â¢0 per 1000py (95%CI: 6â¢9-16â¢6) among women and 9â¢4 per 1000py (95%CI: 5â¢3-15â¢3) among men. Adjusting for confounders, factors associated with risk of HIV included: having been abducted (HR: 3â¢70; 95%CI: 1â¢87-7â¢34), experiencing ≥12 war-related traumatic events (HR: 2â¢91 95%CI: 1â¢28-6â¢60), suicide ideation (HR: 2â¢83; 95%CI: 1â¢00-8â¢03), having ≥2 sexual partners (HR: 4â¢68; 95%CI: 1â¢36-16â¢05), inconsistent condom use (HR: 6â¢75; 95%CI: 2â¢49-18â¢29), and self-reported genital ulcers (HR: 4â¢39; 95%CI: 2â¢04-9â¢45). INTERPRETATION: Conflict-affected participants who had experienced abduction and multiple traumas during the war were at greater risk of HIV infection. Trauma-informed HIV prevention and treatment services, and culturally-safe mental health initiatives, are urgent for Northern Uganda.