Patient experiences of switching from Efavirenz- to Dolutegravir-based antiretroviral therapy: a qualitative study in Uganda.

BACKGROUND: In 2019, the World Health Organisation (WHO) recommended Dolutegravir (DTG) as the preferred first-line antiretroviral treatment (ART) for all persons with HIV. ART regimen switches may affect HIV treatment adherence. We sought to describe patient experiences switching from EFV to DTG-based ART in Kampala, Uganda. METHODS: Between July and September 2019, we purposively sampled adults living with HIV who had switched to DTG at the Infectious Diseases Institute HIV clinic. We conducted in-depth interviews with adults who switched to DTG, to explore their preparation to switch and experiences on DTG. Interviews were audio-recorded, transcribed and analysed thematically using Atlas ti version 8 software. RESULTS: We interviewed 25 adults: 18 (72%) were women, and the median age was 35 years (interquartile range [IQR] 30-40). Median length on ART before switching to DTG was 67 months (IQR 51-125). Duration on DTG after switching was 16 months (IQR 10-18). Participants reported accepting provider recommendations to switch to DTG mainly because they anticipated that swallowing a smaller pill once a day would be more convenient. While most participants initially felt uncertain about drug switching, their providers offer of frequent appointments and a toll-free number to call in the event of side effects allayed their anxiety. At the same time, participants said they felt rushed to switch to the new ART regimen considering that they had been on their previous regimen(s) for several years and the switch to DTG happened during a routine visit when they had expected their regular prescription. Some participants felt unprepared for new adverse events associated with DTG and for the abrupt change in treatment schedule. Most participants said they needed additional support from their health providers before and after switching to DTG. CONCLUSION AND RECOMMENDATIONS: Adults living with HIV stable on an EFV-based regimen but were switched to DTG in a program-wide policy change found the duration between counselling and drug switching inadequate. DTG was nonetheless largely preferred because of the small pill size, once daily dosing, and absence of EFV-like side effects. Community-engaged research is needed to devise acceptable ways to prepare participants for switching ART at scale.

Assessment of an HIV-prevention intervention for couples in peri-urban Uganda: pervasive challenges to relationship quality also challenge intervention effectiveness.

Reducing multiple and concurrent partnerships has been identified as a priority in generalised HIV epidemics, yet developing successful interventions to bring about such behaviour change has proven challenging. We offered a three-session intervention aimed to improve couple relationship quality and address HIV risk factors, particularly concurrent sexual partnerships (CSP), in a peri-urban community of Kampala, Uganda. Before launching the intervention, a different group of community members participated in eight single-gender focus group discussions (FGDs) which explored issues of couple relationship quality and satisfaction. Findings from the FGDs guided the intervention. All 162 couples invited to the intervention completed a survey pre- and post-intervention. In FGDs, women and men discussed challenges faced in their relationships, including pervasive dissatisfaction, financial constraints, deception and lack of trust, poor communication, lack of sexual satisfaction, and concurrent sexual partnerships. A difference-in-difference analysis showed no measurable impact of the intervention on relationship quality or sexual risk behaviours over a six-month follow-up among 183 individuals who participated in the intervention, although many stated in response to open-ended questions that they had experienced positive relationship changes. Qualitative findings suggest high demand for couple-focused interventions but also reveal many individual-, couple-, community- and structural-level factors which contribute to women and men seeking concurrent sexual partnerships. More intensive interventions may be needed to overcome these barriers to behaviour change and reduce HIV risk. These findings also raise questions about how to interpret divergent qualitative and quantitative data, a topic which has received little attention in the literature.

Couple Relationship Functioning as a Source or Mitigator of HIV Risk: Associations Between Relationship Quality and Sexual Risk Behavior in Peri-urban Uganda.

Despite evidence that a greater focus on couples could strengthen HIV prevention efforts, little health-related research has explored relationship functioning and relationship quality among couples in Africa. Using data from 162 couples (324 individuals) resident in a peri-urban Ugandan community, we assessed actor and partner effects of sexual risk behaviors on relationship quality, using psychometric measures of dyadic adjustment, sexual satisfaction, commitment, intimacy, and communication. For women and men, poor relationship quality was associated with having concurrent sexual partners and suspecting that one's partner had concurrent sexual partners (actor effects). Women's poor relationship quality was also associated with men's sexual risk behaviors (partner effects), although the inverse partner effect was not observed. These findings suggest that relationship quality is linked to HIV risk, particularly through the pathway of concurrent sexual partnerships, and that positive relationship attributes such as sexual satisfaction, intimacy, and constructive communication can help couples to avoid risk.

Prevention messages and AIDS risk behavior in Kampala, Uganda.

Uganda was one of the first countries to substantially reduce HIV rates through behavior change, but these gains have not continued in recent years. Little is known about what messages Ugandans are currently hearing about AIDS prevention, what they themselves believe to be important prevention strategies, and how these beliefs are associated with behavior. We interviewed men and women aged between 20 and 39 in two poor peri-urban areas of Kampala, using a random sample, cross-sectional household survey design. Respondents provided detailed reports of sexual behavior over the past six months, the main prevention message they are currently hearing about AIDS, and their own ranking of the importance of prevention strategies. Condom use was the main AIDS prevention message that respondents reported hearing, followed by getting tested. These were also what respondents themselves considered most important, followed closely by faithfulness. Abstinence was the lowest ranked strategy, but a higher ranking for this prevention strategy was the only one consistently associated with less risky behavior. A higher ranking for condoms was associated with higher levels of risk behavior, while the ranking of testing made no difference in any behavior. These results present challenges for AIDS prevention strategies that rely primarily on promoting condoms and testing. HIV prevention programs need to assess their impact on behavior.

Perceptions and Attitudes Toward an Interactive Voice Response Tool (Call for Life Uganda) Providing Adherence Support and Health Information to HIV-Positive Ugandans: Qualitative Study.

BACKGROUND: The continuing decline in AIDS-related deaths in the African region is largely driven by the steady scale-up of antiretroviral therapy. However, there are challenges to retaining people living with HIV on treatment. Call for Life Uganda (CFLU) is an interactive voice response tool using simple analogue phones. CFLU supports patients with daily pill reminders, preappointment reminders, symptom reporting and management, and weekly health promotion tips. Mobile health tools are being increasingly used in resource-limited settings but are often adopted without rigorous evaluation. OBJECTIVE: This qualitative study conducted at 12 months after enrollment assessed patients' experiences, perceptions, and attitudes regarding CLFU. METHODS: We conducted a qualitative substudy within an open-label randomized controlled trial titled "Improving outcomes in HIV patients using mobile phone based interactive software support." Data were collected through 6 focus group discussions with participants sampled based on proportion of calls responded to-<25%, between 25% and 50%, and >50%-conducted at the Infectious Diseases Institute, Mulago, and the Kasangati Health Centre IV. NVivo (version 11; QSR International) was used in the management of the data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis. RESULTS: There was consensus across all groups that they had more positive than negative experiences with the CFLU system. Participants who responded to >50% of the calls reported more frequent use of the specific elements of the CFLU tool and, consequently, experienced more benefits from the system than those who responded to calls less frequently. Irrespective of calls responded to, participants identified pill reminders as the most important aspect in improved quality of life, followed by health promotion tips. The most common challenge faced was difficulty with the secret personal identification number. CONCLUSIONS: Findings showed participants' appreciation, high willingness, and interest in the intervention, CFLU, that demonstrated great perceived potential to improve their access to health care; adherence to treatment; health awareness; and, consequently, quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT02953080; https://clinicaltrials.gov/ct2/show/NCT02953080.

Measurement of internalized homonegativity in gay and bisexual men in Uganda: Cross-cultural properties of the Internalized Homonegativity scale.

Internalized homonegativity (IH) measures the internalization of homophobia in gay and bisexual men. We obtained data on Ross and Rosser's 26-item IH scale from 216 gay and bisexual men in Kampala, Uganda and used confirmatory factor analysis to compare the structure of the Ugandan responses to those of a large US sample of gay and bisexual men. The data indicated that the structure of a reduced 8-item version of the scale was closely matched between the US and Ugandan samples. The three factors that consistently emerged were personal comfort with being gay; social comfort with other gay people; and public identification as being gay. Men who experienced violence or abuse for being gay had significantly higher scores on the personal discomfort with being gay subscale. These data indicate that the structure of IH in gay and bisexual men in East Africa is congruent with that in equivalent western samples and that the IH scale is cross-culturally robust.

Correlates of unprotected receptive anal intercourse among gay and bisexual men: Kampala, Uganda.

We conducted a respondent-driven sampling survey (N = 215) to characterize correlates of risk for HIV infection among gay and bisexual men in Kampala, Uganda. We used RDSAT software to produce population estimates for measures and created exportable weights for multivariable analysis. Overall, 60.5% of gay/bi men identify as gay and 39.5% as bisexual; 91.6% are Ugandans. Unprotected receptive anal intercourse (URAI) was associated with identifying as gay, being younger and having had an HIV test in the past 6 months. Perceptions of being low risk to acquire or transmit HIV infection were paradoxically associated with higher likelihood of URAI. Programs to address risk of HIV infection among gay and bisexual men in Kampala need to address perceptions of risk among gay identified men.

Identifying barriers to and facilitators of tuberculosis contact investigation in Kampala, Uganda: a behavioral approach.

BACKGROUND: The World Health Organization recommends routine household tuberculosis contact investigation in high-burden countries but adoption has been limited. We sought to identify barriers to and facilitators of TB contact investigation during its introduction in Kampala, Uganda. METHODS: We collected cross-sectional qualitative data through focus group discussions and interviews with stakeholders, addressing three core activities of contact investigation: arranging household screening visits through index TB patients, visiting households to screen contacts and refer them to clinics, and evaluating at-risk contacts coming to clinics. We analyzed the data using a validated theory of behavior change, the Capability, Opportunity, and Motivation determine Behavior (COM-B) model, and sought to identify targeted interventions using the related Behavior Change Wheel implementation framework. RESULTS: We led seven focus-group discussions with 61 health-care workers, two with 21 lay health workers (LHWs), and one with four household contacts of newly diagnosed TB patients. We, in addition, performed 32 interviews with household contacts from 14 households of newly diagnosed TB patients. Commonly noted barriers included stigma, limited knowledge about TB among contacts, insufficient time and space in clinics for counselling, mistrust of health-center staff among index patients and contacts, and high travel costs for LHWs and contacts. The most important facilitators identified were the personalized and enabling services provided by LHWs. We identified education, persuasion, enablement, modeling of health-positive behaviors, incentivization, and restructuring of the service environment as relevant intervention functions with potential to alleviate barriers to and enhance facilitators of TB contact investigation. CONCLUSIONS: The use of a behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers to and facilitators of TB contact investigation. The behavioral determinants identified here may be useful in tailoring interventions to improve implementation of contact investigation in Kampala and other similar urban settings.

Tensions in Communication between Children on Antiretroviral Therapy and Their Caregivers: A Qualitative Study in Jinja District, Uganda.

INTRODUCTION: HIV treatment and disclosure guidelines emphasize the importance of communicating diagnosis and treatment to infected children in ways that are appropriate to children's developmental stage and age. Minimal attention, however, has been given to communication challenges confronted by HIV-infected children and their caregivers. This study examined the tensions between children and their caregivers arising from differing perspectives regarding when and what to communicate about antiretroviral therapy (ART). METHODS: This qualitative study was conducted between November 2011 and December 2012 and involved 29 HIV-infected children aged 8-17 years on ART and their caregivers. Data were collected through observations and in-depth interviews, which took place in homes, treatment centres and post-test clubs. Children and caregivers were sampled from among the 394 HIV-infected children and (their) 393 caregivers who participated in the cross-sectional survey that preceded the qualitative study. ATLAS.ti. Version 7 was used in the management of the qualitative data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis. RESULTS: While the children felt that they were mature enough to know what they were suffering and what the medications were for, the caregivers wanted to delay discussions relating to the children's HIV diagnosis and medication until they felt that the children were mature enough to deal with the information and keep it a secret and this caused a lot of tension. The children employed different tactics including refusing to take the medicines, to find out what they were suffering from and what the medications were for. Children also had their own ideas about when, where and with whom to discuss their HIV condition, ideas that did not necessarily coincide with those of their caregivers, resulting in tensions. CONCLUSIONS: Guidelines should take into consideration differing perceptions of maturity when recommending ages at which caregivers should communicate with their children about diagnosis and ART. Health care providers should also encourage caregivers to recognize and respect children's efforts to learn about and manage their condition. Children's questions and expressions of feelings should be treated as openings for communication on these issues.

Communication between HIV-infected children and their caregivers about HIV medicines: a cross-sectional study in Jinja district, Uganda.

INTRODUCTION: Knowledge of antiretroviral therapy (ART) among children with HIV depends on open communication with them about their health and medicines. Guidelines assign responsibility for communication to children's home caregivers. Other research suggests that communication is poor and knowledge about ART is low among children on treatment in low-income countries. This study sought to describe communication about medicine for HIV in quantitative terms from the perspectives of both children and caregivers. Thereafter, it established the factors associated with this communication and with children's knowledge about their HIV medicines. METHODS: We undertook a cross-sectional survey of a random sample of 394 children with HIV on treatment and their caregivers at nine health facilities in Jinja District, Uganda. We assessed reported frequency and content of communication regarding their medicines as well as knowledge of what the medicines were for. Logistic regression analysis was used to determine the factors associated with communication patterns and children's knowledge of HIV medicines. RESULTS: Although 79.6% of the caregivers reported that they explained to the children about the medicines, only half (50.8%) of the children said they knew that they were taking medicines for HIV. Older children aged 15-17 years were less likely to communicate with a caregiver about the HIV medicines in the preceding month (OR 0.5, 95% CI 0.3-0.7, p=0.002). Children aged 11-14 years (OR 6.1, 95% CI 2.8-13.7, p<0.001) and 15-17 years (OR 12.6, 95% CI 4.6-34.3, p<0.001) were more likely to know they were taking medicines for HIV compared to the younger ones. The least common reported topic of discussion between children and caregivers was "what the medicines are for" while "the time to take medicines" was by far the most mentioned by children. CONCLUSIONS: Communication about, and knowledge of, HIV medicines among children with HIV is low. Young age (less than 15 years) was associated with more frequent communication. Caregivers should be supported to communicate diagnosis and treatment to children with HIV. Age-sensitive guidelines about the nature and content of communication should be developed.

The need to reemphasize behavior change for HIV prevention in Uganda: a qualitative study.

Uganda has long been considered an AIDS success story, although in recent years declines in prevalence and incidence appear to have stalled or even reversed. During the early stages of Uganda's AIDS prevention program, health messages emphasized behavior change, especially fidelity. Ugandans were made to fear AIDS and feel personally at risk of dying from a new, poorly understood disease. In this research, six focus group discussions with 64 participants in peri-urban and rural areas outside Kampala suggest that HIV prevention messages have shifted in the direction of risk reduction: condoms, testing, and drugs. Ugandans now seem less afraid of becoming infected with HIV, at least in part because antiretroviral therapy is available, and this diminished fear may be having a disinhibiting effect on sexual behavior. Participants believe that HIV rates are on the rise, that more individuals are engaged in multiple and concurrent sexual partnerships, and that sexual behavior is less restrained than a generation ago. These findings suggest that AIDS-prevention programs in Uganda would benefit from refocusing on the content that yielded success previously-sexual behavior change strategies.

Multiple sexual partnerships among poor urban dwellers in Kampala, Uganda.

BACKGROUND: This study examined 2 issues of current importance for AIDS prevention in Uganda: the frequency of multiple sexual partnerships and whether optimistic perceptions about the severity of AIDS are associated with riskier sexual behavior. METHODS: Four hundred five men and women aged 20-39 from 2 poor neighborhoods of Kampala were interviewed about their sexual behavior over the prior 6 months and about other partners during current relationships. They also completed a 7-item scale measuring perception of the severity of HIV/AIDS. RESULTS: About 21.2% of men and 2.9% of women reported ongoing concurrent partnerships; 28.8% and 6.8% reported more than 1 partner in the past 6 months. About 22.2% of men and 32.4% of women believed their partner had had other partners during the relationship. Overall, 56.1% of men and 57.0% of women reported potentially being involved in a multiple or concurrent partnership. Respondents rating AIDS as more severe were more likely to be monogamous. CONCLUSIONS: Multiple sexual partnerships may be more common in Uganda than generally supposed, and optimism about the severity of AIDS is associated with having multiple partners. These findings have important implications for HIV/AIDS epidemiology and prevention.

Gay and bisexual men in Kampala, Uganda.

HIV/AIDS disproportionately affects gay and bisexual men around the world; however, little is known about this population in sub-Saharan Africa. We conducted a respondent-driven sampling survey of gay and bisexual men in Kampala, Uganda (N = 224). Overall, 61% reported themselves as "gay" and 39% as "bisexual". Gay and bisexual men were 92% Ugandan; 37% had unprotected receptive anal sex in the last six months, 27% were paid for sex, 18% paid for sex, 11% had history of urethral discharge. Perception that gay and bisexual men are at risk for HIV infection was low. Gay and bisexual men in Kampala are overwhelmingly Ugandan nationals from all parts of society. Recognition of gay and bisexual men in local HIV prevention programs and education messages are urgently needed. Our study demonstrates that gay and bisexual men in Uganda are willing to identify themselves and participate in research.

Increasing condom use without reducing HIV risk: results of a controlled community trial in Uganda.

BACKGROUND: Although consistent condom use is effective in reducing individual risk for HIV infection, the public health impact of condom promotion in a generalized epidemic is less clear. We assess the change in condom uptake and number of sex partners after a condom promotion trial in Kampala, Uganda. METHODS: Two similar poor urban communities near Kampala were randomized. One received a condom promotion program that taught condom technical use skills in workshops for men aged 18 to 30 years (n = 297) and encouraged condom use. Men in the control community (n = 201) received a brief informational presentation about AIDS. Participants received coupons redeemable for free condoms from distributors in both communities and completed questionnaires at baseline and 6 months later. RESULTS: Six-month follow-up was completed for 213 men (71.7%) in the intervention group and for 165 (82.1%) men in the control group. Men in the intervention group redeemed significantly more condom coupons than men in the control group (on average, 110 vs. 13 each; P = 0.002). Men in the intervention group increased their number of sex partners by 0.31 compared with a decrease of 0.17 partners in the control group (P = 0.004). Other measures did not support a net reduction in sexual risk in the intervention community compared with the control community and, in fact, showed trends in the opposite direction. CONCLUSIONS: In this study, gains in condom use seem to have been offset by increases in the number of sex partners. Prevention interventions in generalized epidemics need to promote all aspects of sexual risk reduction to slow HIV transmission.