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The Need to Reemphasize Behavior Change for HIV Prevention in Uganda: A Qualitative Study
Abstract
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.
... These recent increases in HIV prevalence have reinvigorated an interest in the HIV prevention messages and programs that are currently being implemented, and how they are being understood by community members. In particular, there is concern about behavioral disinhibition because HIV messages in country may now emphasize HIV testing and treatment, rather than sexual behavior change strategies [15,16]. This study aimed to elucidate and examine gendered and generational perspectives on HIV prevention messages in Uganda. ...
... Additional IDIs were conducted to allow for an exploration of individuals' interpretation and response to HIV prevention messages. Two FGDs (one with males and one with females) were conducted in each of the three communities with four age groups-current teenagers (15)(16)(17)(18)(19) year olds), young adults (20-24 year olds), adults (25)(26)(27)(28)(29)(30)(31)(32)(33)(34) year olds), and older adults (35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45) year olds) for a total of 24 FGDs. The four age-group generations were defined to capture respondents who had experienced different generations of HIV/AIDS messages and programs in Uganda. ...
... Abstinence and messages related to being faithful to their partners should also be emphasized for men. Other research suggests that recent HIV prevention efforts in Uganda have de-emphasize partner reduction strategies [15,16]. We found that the partner reduction message was common, but was being used asymmetrically. ...
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.
... These recent increases in HIV prevalence have reinvigorated an interest in the HIV prevention messages and programs that are currently being implemented, and how they are being understood by community members. In particular, there is concern about behavioral disinhibition because HIV messages in country may now emphasize HIV testing and treatment, rather than sexual behavior change strategies [15,16]. This study aimed to elucidate and examine gendered and generational perspectives on HIV prevention messages in Uganda. ...
... Additional IDIs were conducted to allow for an exploration of individuals' interpretation and response to HIV prevention messages. Two FGDs (one with males and one with females) were conducted in each of the three communities with four age groups-current teenagers (15)(16)(17)(18)(19) year olds), young adults (20-24 year olds), adults (25)(26)(27)(28)(29)(30)(31)(32)(33)(34) year olds), and older adults (35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45) year olds) for a total of 24 FGDs. The four age-group generations were defined to capture respondents who had experienced different generations of HIV/AIDS messages and programs in Uganda. ...
... These ideas were particularly prevalent in the group discussions with younger respondents. A group of [15][16][17][18][19] year old men reiterated this idea of behavioral disinhibition and noted, "Some young men have decided to have sex with each and every girl they come across. He does this because he knows there is 'septrin' and ' ARTs' . ...
... Continued close-grained research of sexual practices in the context of Africa's growing HIV epidemic over the ensuing years has resulted in a now considerable body of literature on transactional sex. Our knowledge to date from studies across a range of settings and income categories clearly demonstrates that sexual exchange, or what some refer to as the 'materiality of love', has become a central part of many young women's relationships, and is sociologically distinct from sex work [7][8][9][10][11][12][13][14][15][16][17][18]. In addition, recent epidemiological studies that have attempted to measure the impact of transactional sex on HIV incidence in young women have provided verification that this practice is associated with elevated risk of infection [8]. ...
... In the high-incident HIV countries of eastern and southern Africa, it is the case that money/ gift transfers in nonmarital relationships are definitive expectations, if not immediately than at some time and in one form or another. Recent studies from Uganda [9], Tanzania [10], Malawi [11], Zimbabwe [12], Swaziland [13], Mozambique [14], South Africa [15], Lesotho [16], Botswana [17], "While transactional sex is certainly much incentivized by poverty and economic marginalization, wide allowance for its practice is tied to long-standing cultural expectations in courtship and customary wooing practices." ...
... Designing interventions to directly address this fundamental HIV risk practice is now overdue. The continued high HIV incidence in young African women is strongly related to participation in transactional sexual relationships from which they acquire resources such as food, alcohol, transportation, hair weaves, fashionable clothing, cell phone airtime and rent for a flat in town [7][8][9][10][11][12][13][14][15]. The ways of thinking and doing that affirm and lend legitimacy to sexual exchange for subsistence or consumption are the same. ...
Across sub-Saharan Africa increased media den-sity and the vigorous promotion of consumer values over the past few decades has profoundly influenced the aspirations of youth. Many have been exposed to global imagery of comfortable lifestyles from an early age and are eager for social change and a chance to participate (or at least look the part) in a modern way of life. For this generation, living in contexts where the growth of most local economies lag far behind the growth of aspirations, items of consumption are increasingly perceived as items of subsistence, all of which contribute materially to a life worth living. Among young women the strategy of meeting an ever-expanding continuum of needs and wants through the exchange of sex for gifts, resources and money has gained momentum as normal and acceptable practice [1]. Sexual exchange in ordinary relationships, or transactional sex, has played and will continue to play a major role in making Africa's young peo-ple, especially its young women, highly vulner-able to HIV. This practice also presents a major challenge to the successful creation of an 'AIDS Free Generation' [101]. As long as the dynam-ics of culturally implicit prescriptions for the intertwining of sex and material provision are left unchallenged and unchanged, the chances of young African women attaining HIV-free adulthood remain compromised. Over two decades ago social scientists drew attention to the transactional nature of non-marital relations in sub-Saharan Africa and the need to distinguish these sexual exchange rela-tions from western conceptions of prostitution [2–4]. Those early researchers argued that in the cultures they studied, transactions linked to sex were a normative aspect of relationships. They recognized the important implications of this practice for HIV transmission and its preven-tion, and asserted that the protection of young people against heightened risk of HIV needed to begin with policy makers and programmers gaining a sound understanding of transactional sex [5]. However, dominant HIV paradigms at the time provided little space for alterna-tive understandings of sex linked to economic exchange that did not fit well into existing con-structs of sex work and the behaviors associated with particular 'high-risk' groups [6]. Continued close-grained research of sexual practices in the context of Africa's growing HIV epidemic over the ensuing years has resulted in a now considerable body of literature on trans-actional sex. Our knowledge to date from studies across a range of settings and income categories clearly demonstrates that sexual exchange, or what some refer to as the 'materiality of love', has become a central part of many young women's relationships, and is sociologically distinct from sex work [7–18]. In addition, recent epidemiologi-cal studies that have attempted to measure the impact of transactional sex on HIV incidence in young women have provided verification that this practice is associated with elevated risk of infection [8]. In the high-incident HIV countries of eastern and southern Africa, it is the case that money/ gift transfers in nonmarital relationships are definitive expectations, if not immediately than at some time and in one form or another. Recent studies from Uganda [9], Tanzania [10], Malawi [11], Zimbabwe [12], Swaziland [13], Mozambique [14], South Africa [15], Lesotho [16], Botswana [17],
... Members of the study community reported that they mainly heard HIV prevention messages centered on condoms and testing, a marked shift from the partner reduction messages common during the years in which HIV incidence was declining in Uganda [16]. In focus groups, members of the study community reported that people no longer feared HIV as they had during the epidemic's peak and that this had led to riskier sexual behavior [17]. ...
... We obtained permission for the study from the Resident District Commissioner of Kawempe Division and the local leadership of Tebuyoleka Zone. The local leaders were strongly supportive of the study, as they have been for previous studies conducted by the same research team in this community [15,17,23]. ...
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.
... Multiple concurrent sexual relationships, inconsistent condom use and exchange of sex for money, gifts or favours-referred to as transactional sex-are additional drivers of the HIV epidemic among young people in Uganda [18][19][20][21]. In addition to increasing HIV risk behaviours, a shift in HIV prevention strategies to more testing and treatment services has been suggested as a potential factor for greater HIV transmission in Uganda [22]. ...
Understanding the complexities of sexual relationships is essential to understand the risky sexual behaviours among young people in Ugandan universities. Nine focus group discussions conducted with 31 males and 33 female students in 2014 utilising the grounded theory approach explored the role of sexual relationships in their lives. ‘ Relationships in campus are situationships’ emerged as the core category and referred to the variety of sexual interactions within relationships among young people in a Ugandan university. The study findings indicated that sexual interactions often follow a sexual script that undergoes transitions to negotiate various situations. The sexual scripts in these situationships were strongly influenced by local socio-cultural norms and global aspirations among young people. Students often discussed these sexual scripts within a wider discourse on transactional sexual relationships. The motivations for transactional sexual relationships ranged from ‘fulfilling aspirations’ of various kinds on the one hand to ‘being forced into trading sex’ to overcome socio-economic vulnerabilities. Sexual relationships were facilitated by the perception of a university as a sexualized space in which one may enjoy a period of emerging adulthood characterized by exploration in relationships, access to alcohol and prolonged delay in assuming the traditional adult roles of marriage and family. The sexual scripts at the cultural level were grounded in traditional gender roles although at the same time, were under transition during university life with the growing influence of globalization and consumerism in the Ugandan society. Young men and young women must be engaged to critically challenge the implicit assumptions about sexual interactions within various situations that may put them at risk for poor sexual health outcomes.
... In sub-Saharan Africa, the primary reason why men and women in long-term intimate relationships are at high risk of HIV infection is the widespread social and cultural acceptance of extra-marital partnerships (McGrath et al, 1993;Kajubi et al, 2011;Green et al, 2013;Mbonye et al, 2021). Extra-marital relationships in sub-Saharan Africa are reported to be higher among men than women (Stephenson, 2010); however, the reported prevalence of extra-marital relationships varies: for example such relationships were reported by 1.3 per cent of women and 13 per cent of men in Malawi, and 10-25 per cent of men and less than 10 per cent of women in Kenya and Uganda (Bishai et al, 2009;Clark, 2010;Kasamba et al, 2011;Maher et al, 2011;Conroy, 2014;Kwena et al, 2014a;2014b). ...
This article explores gendered meanings of both faithfulness and sexual exclusivity within intimate long-term relationships, and the implications for HIV prevention messaging. In 2011–12, in-depth interviews were conducted with a random sample of 50 men and women (52 per cent women) in long-term relationships in rural Uganda. Confirming prior research, we found that a double standard exists for sexual exclusivity, where men define faithfulness to mean strict sexual exclusivity by their wife, but women defined it as being for both partners. However, both men and women defined fidelity to imply continued support. Fidelity was perceived to be intact if a man continued to provide material support, despite not being sexually exclusive. These findings highlight the limitations of HIV prevention strategies that emphasise faithfulness, where faithfulness is not synonymous with sexual exclusivity.
... It is important to note that the idea of fidelity in marriage may not primarily constitute MPI in other settings because of diverse HIV-related challenges that communities encounter. For instance, studies in Uganda by Green et al. (2013) noted a shift in the country's AIDS strategy, showing a rise in the promotion of condom use and HIV testing and less emphasis on behaviour change, especially regarding fidelity. Whilst consistent condom use is an effective means of reducing the risk of HIV infection in generalised epidemics, Kajubi et al. (2005) argued that the gains of condom use could be offset by an increase in the number of sexual partners. ...
Male partner involvement (MPI) in the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) is considered as one of the priority interventions in reducing paediatric HIV. However, there is neither a standard definition nor measurement for MPI in PMTCT. The study explored meanings of MPI in PMTCT programmes in Zimbabwe. Eight focus group discussions (FGDs) were conducted with men and women aged 18 years and above. Seven key informants (KII) from health institutions and organisations providing PMTCT services were interviewed. Eight in-depth interviews (IDIs) were conducted with pregnant women at two public health facilities. Thematic analysis was used for data analysis. Five major themes were identified which facilitated our understanding of MPI. Male partner involvement was referred to as participation of male partners in HIV couple counselling and testing. Acceptance of condom use during pregnancy and breastfeeding was deemed vital as this prevents HIV transmission. Male partners were expected to have knowledge of administering antiretroviral drugs to an HIV-exposed child. Provision of financial support was another form of male involvement commonly expected during antenatal and postnatal periods. Faithfulness in marriage was a major theme that was highlighted, especially by respondents in marital relationships. Male partner presence in PMTCT community educational sessions was also considered. However, the provision of male-oriented educational programmes was identified as poor. The study suggested a definition for MPI in PMTCT in Zimbabwe. The merit of this definition was that it took a holistic approach to include activities beyond antenatal activities and HIV testing. Future research should explore how public health institutions could create male-oriented health services within PMTCT programmes, as this has the potential of increasing men’s involvement in PMTCT of HIV.
Contribution: This article contributed to the knowledge on how world views, which is shaped by culture and religion, influenced the formation of meanings on MPI PMTCT programmes.
... In addition to the concerns that have been raised about the content of Uganda's HIV prevention strategies directed at young people, critics have recently pointed out that Uganda's funding and policy strategies disproportionately focus on AIDS treatment rather than on behavioural strategies for reducing HIV transmission (Green et al. 2013;UAC 2015). ...
The Ugandan government has been criticised on several grounds for its abstinence-only policies on sexuality education directed towards young people. These grounds include the failure to recognise the multiple realities faced by young people, some of whom may already be sexually active. In the study reported on this paper, students’ perceptions of relationships and sexual practices were analysed to obtain an understanding of how young people construct and negotiate their sexual agency in the context of abstinence-only messages provided in Ugandan secondary schools and at the wider community level. Ten in-depth interviews and six focus group discussions were conducted with students aged 15–19 years (N = 55) at an urban co-educational secondary school. Data were transcribed verbatim and analysed using grounded theory. Findings show that students engage in sexual activity despite their belief that contraception is ineffective and their fears for the consequences. Students’ age, gender, financial capital and perceived sexual desire further increase risk and vulnerability. To improve their effectiveness, school-based sexuality education programmes should support students to challenge and negotiate structural factors such as gender roles and sociocultural norms that influence sexual practices and increase vulnerability and risk.
... Campaigns at that time urged people to `love faithfully' 4,5 . In the last decade concerns about partner concurrency have African Journal of Reproductive Health December 2014; 18(4): 87 been a theme of prevention messages warning about the danger of HIV spreading through sexual networks 6,7 . While approaches to HIV prevention have been assessed in a number of different studies [8][9][10][11] , less attention has been paid to people's understanding of the key concepts used in these campaigns, such as `abstinence' and `faithfulness' [12][13][14] , as well as what people may mean by `long-term relationship'. ...
Long-term, monogamous, relationships are often portrayed as protective in HIV prevention campaigns. Focusing on marriage in a community in south west Uganda, we examine why and how people enter long term relationships, what their expectations are and what factors sustain those relationships. Qualitative data were collected using in-depth interviews with 50 men and women randomly selected from a General Population Cohort. The results showed that managing expectations to sustain marriage is challenging; however the socio-economic and cultural benefits of marriage: having children, property acquisition as well as securing societal status tend to overshadow the costs associated with risks from infidelity such as sexually transmitted infections (including HIV). Recognising the compromises that couples may make to sustain their marriage is an important step towards acknowledging that 'being faithful' may be about staying together and showing commitment, not sexual exclusivity.
... 14, No. 5, 556-567, http://dx.doi.org/10.1080/14681811.2014 year-olds and from 4.7% to 5.4% among 20-to 24-year-olds (Ministry of Health Uganda et al. 2011;Green et al. 2013). Rates of premarital sex among young people 1 aged 15-24 also increased for young women, while condom use at last sex fell among unmarried young men and women (Ministry of Health Uganda et al. 2011). ...
Uganda is recognised as an early success story in the HIV epidemic at least in part due to an open and vigorous national dialogue about HIV prevention. This study examined the national discourse about HIV, AIDS, and young people in New Vision, Uganda's leading national newspaper between 1996 and 2011, building from a previous archival analysis of New Vision reporting by Kirby (1986–1995). We examined the continuing evolution in the public discourse in Uganda, focusing on reporting about young people. An increase in reporting on HIV and AIDS occurred after 2003, as antiretroviral treatment was becoming available. While the emphasis in newspaper reporting about adults and the population at large evolved to reflect the development of new HIV treatment and prevention methods, the majority of the articles focused on young people did not change. Articles about young people continued to emphasise HIV acquisition due to early and premarital sexual activity and the need for social support services for children affected by HIV and AIDS. Articles often did not report on the complex social conditions that shape HIV-related risk among young people, or address young people who are sexually active, married, and/or HIV-infected. With HIV prevalence now increasing among young people and adults in Uganda, greater attention to HIV prevention is needed.
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.
Background
Risk perception has been found to be a crucial factor explaining inconsistent or non-use of HIV prevention interventions. Considerations of risk need to expand beyond risk of infection to also include the personal, social, emotional, and economic risks associated with prevention intervention use.
Objectives
This systematic review of qualitative peer-reviewed literature from sub-Saharan Africa examines perceptions of risk associated with HIV infection and HIV prevention intervention use.
Data sources
We searched Medline, Embase, PsychInfo, Africa Wide Info, CINAHL, and Global Health for publications and screened them for relevance.
Study eligibility criteria
Peer-reviewed qualitative studies published since 2003 were eligible for inclusion if they examined risk perception or uncertainty in the context of a medically regulated intervention. Only studies focusing on adults were included.
Study appraisal and synthesis methods
Included publications were quality assessed using the Hawker method and coded thematically.
Results
10318 unique papers were identified, of which 29 are included. Among the themes identified, a particularly salient one was the potential of HIV prevention interventions to threaten the stability of a relationship and impact on how and when people may—or may not—choose to use prevention interventions.
Limitations
This literature review excludes grey-literature, which may have distinct valuable insights. We also excluded quantitative studies that may have challenged or triangulated our findings.
Conclusions and implications
When considering the risk of HIV acquisition, it is insufficient to examine biological risk in isolation from the personal, relational and economic costs associated with intervention use. This loss of emotional, physical, or material support may be perceived as more consequential than the prevention of a potential infection.
The impact of the widespread availability of antiretroviral therapy (ART) on the human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) related attitudes, behaviours and practices of the general population in Sub-Saharan Africa is understudied. We assessed the impact of ART availability on the fear of HIV/ AIDS (measured at both community and personal levels) and HIV prevention practices in Rwimi, Uganda using a cross-sectional survey. The fear of HIV/AIDS was described as a perceived threat to either self and/or community regarding the risk of contracting the disease, whereby the higher the perception of the threat, the greater the fear. We assessed associations between the outcomes of the dependent variables on both the community and personal fear of HIV/AIDS, and the independent variables of HIV/AIDS-related knowledge and demographics. Qualitative data was also generated from focus group discussions (FGD) on the context of the fear of HIV/AIDS and HIV pre- vention practices. The majority of participants (89.4%; males - 86.8%; females - 90.8%) felt that ART availability has reduced the fear of HIV/AIDS in the community. In contrast, fewer participants (22.4%; males - 24.4%; females – 21.2%) mentioned that their personal fear of HIV/AIDS has been reduced with the availability of ART. From the qualitative study, factors identified as influencing the fear of HIV/AIDS included stigma, fear of infection, and the inconvenience of being on ART. Although fear of HIV/AIDS persists, the fear is reduced because of the availability of life-prolonging ART. HIV prevention practices are influenced by socio-cultural norms (gender roles, relationship dynamics, power and trust), which, we argue, should be considered when de-signing sustainable HIV/AIDS prevention programs.
The discourse of ‘the white man’s burden’ that originated in the nineteenth century with missionaries and colonialism still underpins much of the development ideology towards Africa today. The overwhelming assumption that rich Western countries can and should address ‘underdevelopment’ through aid only stigmatizes African reality, framing it to mirror the worldview of the international donors who fund most non-profit interventionist documentaries.
In the ‘parachute filmmaking’ style that results, facilitated by financial resources and reflecting the self-serving intentions of the donors, the non-profit filmmaker functions simply as an agent of meaning rather than authentic author of the text. Challenged by limited production schedules and lacking in cultural understanding most donor-sponsored films fall back on an ethnocentric one-size-fits-all template of an ‘inferior other’ who needs to be ‘helped’. This study sets out to challenge the ‘donor gaze’ in documentary films which ‘speak about’ Africa, arguing instead for a more inclusive style of filmmaking that gives voice to its subjects by ‘speaking with’ them. The special focus is on black African women whose images are used to signify helplessness, vulnerability and ignorance, particularly in donor-funded documentaries addressing HIV/AIDS. Through case studies of four films this study asks:
1. How do documentary films reinforce the donor gaze? (how is the film speaking and why?)
2. Can the donor gaze be challenged? (should intentionality always override subjectivity of the filmed subjects?)
Film studies approach the gaze psychoanalytically (e.g. Mulvey 1975) but this study focuses on the conscious gaze of filmmakers because they reinforce or challenge ‘the pictures in our heads.’ Sight is an architect of meaning. Gaze orders reality but the documentary gaze can re-order it. The study argues that in Africa, the ‘donor gaze’ constructs meaning by ‘speaking about’ reality and calls instead for a new approach for documentary to ‘speak with’ reality.
Introduction: HIV/AIDS is the leading cause of death in Malawi. Stigma surrounding voluntary counseling and testing and multiple sexual partnerships are key factors. Mass media programing, including radio, can reduce HIV risk of exposure by motivating people to take protective behavioral action. However, little is known about how health communication in the form of reality radio can influence HIV/AIDS-related behaviors.
Objectives: This study sought to understand the impact of a reality radio program on HIV/AIDS testing and multiple sexual partnerships among Malawians.
Methods: This study analyzed radio listener feedback in the form of text messages.
Results: Listeners reported that the reality radio program helped them understand the importance of HIV testing, enhanced their HIV/AIDS risk perception, aided them in becoming faithful within marriages, and enhanced their understanding of the consequences of multiple sexual partnerships on their families.
Conclusions: Reality radio approaches have not been studied widely, and, based on the results of this study, should be further explored as an innovative health communication approach for health behavior change.
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.
To identify the changes in sexual behaviour that led to the dramatic reduction in the prevalence of HIV in Uganda in the early 1990s.
Seven different types of evidence were examined: (1) models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda; (2) reports of behaviour change in the primary newspaper in Uganda; (3) surveys with questions about perceptions of personal behaviour change; (4) large demographic and health surveys (DHS) collected in 1988/9 and 1995 and large Global Program on AIDS (GPA) surveys in 1989 and 1995 with questions about reported sexual behaviour; (5) smaller less representative surveys of reported sexual behaviour collected in other years; (6) reports of numbers of condoms shipped to Uganda; and (7) historical documents describing the implementation of HIV prevention programmes in Uganda.
All seven types of data produced consistent evidence that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships, and then increased their use of condoms with non-marital and non-cohabiting partners.
Consistent with basic theories about transmission of sexually transmitted infections, first reducing the number of sexual partners and breaking up sexual networks and then reducing the chances of HIV transmission with remaining casual partners by using condoms can be achieved and can dramatically reduce the sexual transmission of HIV in generalised epidemics.
The transmission through contacts among MSM (men who have sex with men) is one of the dominating contributors to HIV prevalence in industrialized countries. In Amsterdam, the capital of the Netherlands, the MSM risk group has been traced for decades. This has motivated studies which provide detailed information about MSM's risk behavior statistically, psychologically and sociologically. Despite the era of potent antiretroviral therapy, the incidence of HIV among MSM increases. In the long term the contradictory effects of risk behavior and effective therapy are still poorly understood.
Using a previously presented Complex Agent Network model, we describe steady and casual partnerships to predict the HIV spreading among MSM. Behavior-related parameters and values, inferred from studies on Amsterdam MSM, are fed into the model; we validate the model using historical yearly incidence data. Subsequently, we study scenarios to assess the contradictory effects of risk behavior and effective therapy, by varying corresponding values of parameters. Finally, we conduct quantitative analysis based on the resulting incidence data.
The simulated incidence reproduces the ACS historical incidence well and helps to predict the HIV epidemic among MSM in Amsterdam. Our results show that in the long run the positive influence of effective therapy can be outweighed by an increase in risk behavior of at least 30% for MSM.
We recommend, based on the model predictions, that lowering risk behavior is the prominent control mechanism of HIV incidence even in the presence of effective therapy.
Roughly 3 million people worldwide were receiving antiretroviral therapy (ART) at the end of 2007, but an estimated 6.7 million were still in need of treatment and a further 2.7 million became infected with HIV in 2007. Prevention efforts might reduce HIV incidence but are unlikely to eliminate this disease. We investigated a theoretical strategy of universal voluntary HIV testing and immediate treatment with ART, and examined the conditions under which the HIV epidemic could be driven towards elimination.
We used mathematical models to explore the effect on the case reproduction number (stochastic model) and long-term dynamics of the HIV epidemic (deterministic transmission model) of testing all people in our test-case community (aged 15 years and older) for HIV every year and starting people on ART immediately after they are diagnosed HIV positive. We used data from South Africa as the test case for a generalised epidemic, and assumed that all HIV transmission was heterosexual.
The studied strategy could greatly accelerate the transition from the present endemic phase, in which most adults living with HIV are not receiving ART, to an elimination phase, in which most are on ART, within 5 years. It could reduce HIV incidence and mortality to less than one case per 1000 people per year by 2016, or within 10 years of full implementation of the strategy, and reduce the prevalence of HIV to less than 1% within 50 years. We estimate that in 2032, the yearly cost of the present strategy and the theoretical strategy would both be US$1.7 billion; however, after this time, the cost of the present strategy would continue to increase whereas that of the theoretical strategy would decrease.
Universal voluntary HIV testing and immediate ART, combined with present prevention approaches, could have a major effect on severe generalised HIV/AIDS epidemics. This approach merits further mathematical modelling, research, and broad consultation.
Uganda provides the clearest example that human immunodeficiency virus (HIV) is preventable if populations are mobilized to avoid risk. Despite limited resources, Uganda has shown a 70% decline in HIV prevalence since the early 1990s, linked to a 60% reduction in casual sex. The response in Uganda appears to be distinctively associated with communication about acquired immunodeficiency syndrome (AIDS) through social networks. Despite substantial condom use and promotion of biomedical approaches, other African countries have shown neither similar behavioral responses nor HIV prevalence declines of the same scale. The Ugandan success is equivalent to a vaccine of 80% effectiveness. Its replication will require changes in global HIV/AIDS intervention policies and their evaluation.
The ABC strategy is credited for bringing the HIV/AIDS epidemic under control in Uganda. By promoting abstinence, being faithful, and condom use, safe(r) behaviours have been identified that are applicable to people in different circumstances. However, scaling-up of antiretroviral therapy in the country raised concerns that HIV prevention messages targeting the uninfected population are not taking sufficient account of inherent complexities. Furthermore, there is debate in the country over relative importance of abstinence in reduction of HIV incidence as well as over the morality and effectiveness of condoms. The purpose of this paper is to examine each component of ABC in light of current developments. It is argued that there is still a strong justification for condom use to complement abstinence and being faithful. There is an urgent need to update and relaunch Uganda's ABC strategy--its three elements are complementary, synergistic, and inseparable in the national HIV prevention programme.
This study examines the association between optimistic perceptions about AIDS and unprotected sex among men who have sex with men (MSM) in the city of São Paulo, Brazil.
A cross-sectional study was carried out among MSM in leisure areas of São Paulo in 2003. We interviewed 161 participants aged 18-30 years.
Thirty-nine per cent (95% confidence interval 32-47%) reported unprotected anal sex with steady or casual partners in the previous 6 months. The optimistic perception score created for this study was associated with unprotected sex (P = 0.01) and higher education (P = 0.02). The quartile with the most optimistic perception was 1.8 times more likely to engage in unprotected anal sex compared with the quartile with the least optimistic perception.
This study suggests that the current situation regarding AIDS, which is seemingly favourable, may create optimistic perceptions leading to unprotected sexual practices. Prevention programmes, particularly for MSM, need to take this into account.
Most American health professionals who work in HIV/AIDS do not support the use of fear arousal in AIDS preventive education, believing it to be counterproductive. Meanwhile, many Africans, whether laypersons, health professionals, or politicians, seem to believe there is a legitimate role for fear arousal in changing sexual behavior. This African view is the one more supported by the empirical evidence, which suggests that the use of fear arousal in public health campaigns often works in promoting behavior change, when combined with self-efficacy. The authors provide overviews of the prevailing American expert view, African national views, and the most recent findings on the use of fear arousal in behavior change campaigns. Their analysis suggests that American, post-sexual-revolution values and beliefs may underlie rejection of fear arousal strategies, whereas a pragmatic realism based on personal experience underlies Africans' acceptance of and use of the same strategies in AIDS prevention campaigns.
There has been considerable interest in understanding what may have led to Uganda's dramatic decline in HIV prevalence, one of the world's earliest and most compelling AIDS prevention successes. Survey and other data suggest that a decline in multi-partner sexual behavior is the behavioral change most likely associated with HIV decline. It appears that behavior change programs, particularly involving extensive promotion of "zero grazing" (faithfulness and partner reduction), largely developed by the Ugandan government and local NGOs including faith-based, women's, people-living-with-AIDS and other community-based groups, contributed to the early declines in casual/multiple sexual partnerships and HIV incidence and, along with other factors including condom use, to the subsequent sharp decline in HIV prevalence. Yet the debate over "what happened in Uganda" continues, often involving divisive abstinence-versus-condoms rhetoric, which appears more related to the culture wars in the USA than to African social reality.
Uganda is one of only two countries in the world that has successfully reversed the course of its HIV epidemic. There remains much controversy about how Uganda's HIV prevalence declined in the 1990s. This article describes the prevention programs and activities that were implemented in Uganda during critical years in its HIV epidemic, 1987 to 1994. Multiple resources were aggregated to fuel HV prevention campaigns at multiple levels to a far greater degree than in neighboring countries. We conclude that the reversed direction of the HIV epidemic in Uganda was the direct result of these interventions and that other countries in the developing world could similarly prevent or reverse the escalation of HIV epidemics with greater availability of HIV prevention resources, and well designed programs that take efforts to a critical breadth and depth of effort.
The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.
This book presents a history of AIDS control in Uganda, from the start of the epidemic in the early 1980s up until 2005. Uganda is well known internationally as an AIDS ‘success story’, both for its bringing down HIV incidence and prevalence over the 1990s, and for its innovative approach to scaling up the provision of antiretroviral therapy.
AIDS, Behavior, and Culture presents a bold challenge to the prevailing wisdom of “the global AIDS industry” and offers an alternative framework for understanding what works in HIV prevention. Arguing for a behavior-based approach, Green and Ruark make the case that the most effective programs are those that encourage fundamental behavioral changes such as faithfulness, avoidance of concurrent or overlapping sexual partners, delay of age of first sex, and complete recovery from drug addiction. Successful programs are locally based, low cost, low tech, innovative, and built on existing cultural structures. In contrast, they argue that anthropologists and public health practitioners focus on counseling, testing, condoms, and treatment, and impose their Western values, culture, and political ideologies in an attempt to “liberate” non-Western people from sexual repression and homophobia. This provocative book is essential reading for anyone working in HIV/AIDS prevention, and a stimulating introduction to the key controversies and approaches in global health and medical anthropology for students and general readers.
Uganda's HIV success story has become increasingly focused around the idea of ‘ABC’ (Abstain, Be faithful or use Condoms). During the George W. Bush administration, the US Government has promoted one specific ABC model for its development agencies, with a particular emphasis on abstinence. Yet other actors have contested this view. To understand Uganda's success, it is imperative to look at what ABC was in Uganda when critical changes in behaviour were occurring. This paper investigates Uganda's HIV success, the politicised meanings of ‘ABC’, and the implications this may have for future HIV prevention in Uganda and beyond. Copyright (C) 2010 John Wiley & Sons, Ltd.
Antiviral agents can be used to prevent HIV transmission before exposure as preexposure prophylaxis (PrEP), after exposure as postexposure prophylaxis, and as treatment of infected people for secondary prevention. Considerable research has shed new light on antiviral agents for PrEP and for prevention of secondary HIV transmission. While promising results have emerged from several PrEP trials, the challenges of poor adherence among HIV-negative clients and possible increase in sexual risk behaviors remain a concern. In addition, a broader pipeline of antiviral agents for PrEP that focuses on genital tract pharmacology and safety and resistance issues must be developed. Antiretroviral drugs have also been used to prevent HIV transmission from HIV-infected patients to their HIV-discordant sexual partners. The HIV Prevention Trials Network 052 trial demonstrated nearly complete prevention of HIV transmission by early treatment of infection, but the generalizability of the results to other risk groups - including intravenous drug users and MSM - has not been determined. Most importantly, the best strategy for use of antiretroviral agents to reduce the spread of HIV at either the individual level or the population level has not been developed, and remains the ultimate goal of this area of investigation.
Antiretrovirals face formidable obstacles for wide-scale prevention of HIV infection.
There have been dramatic increases in access to antiretroviral therapy (ART) across the developing world, and growing public health attention has focused on the possibility of utilizing ART as a means of slowing the global HIV epidemic. The preventive impact of ART will likely depend on decreasing levels of sexual risk behaviors following treatment initiation. The current review study examines the impact of wider access to ART on sexual risk behaviors among HIV-infected individuals in the developing world. The observational studies to date demonstrate that ART is associated with a significant reduction in unprotected sex following treatment initiation. Although data on the impact of ART on possible risk compensation are rapidly expanding across the developing world, more evidence is still needed before we can safely conclude expanded treatment will result in durable decreases in sexual risk behaviors.
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.
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.
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.
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.
Few HIV prevention interventions have been evaluated in randomized controlled trials (RCTs). We examined design, implementation, and contextual considerations that may limit detection of a positive or adverse effect in HIV prevention trials.
A systematic review of late phase RCTs for prevention of sexual transmission of HIV that randomly allocated intervention and comparison groups; evaluated interventions to prevent sexual transmission in nonpregnant populations; and reported HIV incidence as the primary or secondary outcome.
PubMed/MEDLINE, other electronic databases, and electronic conference proceedings of recent HIV/AIDS-related conferences were searched to identify published or unpublished trials meeting the inclusion criteria. Descriptive, methodological, and contextual factors were abstracted from each trial.
The review included 37 HIV prevention RCTs reporting on 39 unique interventions. Only six RCTs, all evaluating biomedical interventions, demonstrated definitive effects on HIV incidence. Five of the six RCTs significantly reduced HIV infection: all three male circumcision trials, one trial of sexually transmitted infection treatment and care, and one vaccine trial. One microbicide trial of nonoxynol-9 gel produced adverse results. Lack of statistical power, poor adherence, and diluted versions of the intervention in comparison groups may have been important issues for the other trials that demonstrated 'flat' results.
Almost 90% of HIV prevention trials had 'flat' results, which may be attributable to trial design and/or implementation. The HIV prevention community must not only examine evidence from significant RCTs, but must also examine flat trials and address design and implementation issues that limit detection of an effect.
A comparison of HIV|AIDS policies in Botswana and Uganda is revealing. It helps to highlight the kinds of policies that are necessary to come to terms with the pandemic in Africa, where it is already a public health disaster. It is argued that the promotion of condoms at an early stage proved to be counter-productive in Botswana, whereas the lack of condom promotion during the 1980s and early 1990s contributed to the relative success of behaviour change strategies in Uganda. Other important factors included national and local-level leadership, the engagement (or alienation) of religious groups and local healers and, most controversially, procedures of social compliance. We end with a call for more draconian measures than are currently envisaged. Copyright © 2004 John Wiley & Sons, Ltd.
To describe recent trends in HIV-related behaviors and knowledge in Uganda between 1989 and 2005.
Population-based, cross-sectional national surveys of adult women and men.
Trend analysis of selected HIV-related behavior and knowledge indicators, using data from the 2004-2005 Uganda HIV/AIDS Sero-Behavioral Survey and the 2000-2001, 1995, and 1988-1989 Uganda Demographic and Health Surveys. Responses to similar questions across the different surveys were compared to determine trends in indicators.
HIV/AIDS knowledge increased to a high level by 2001 and remained stable thereafter. Some self-reported risk behaviors improved, whereas others deteriorated. Among 15- to 24-year-old women and men, primary abstinence increased, from 23% in 1989 to 32% in 2005 and from 32% in 1995 to 42% in 2005, respectively. In men, there were increases in sex with multiple partners and sex with nonspousal partners, although reported condom use during nonspousal sex declined. Of men aged 15-49 years, self-reported multiple sex partnership increased from 24% in 2001 to 29% in 2005 and nonspousal sex increased from 28% in 2001 to 37% in 2005. Between 2001 and 2005, condom use during last nonspousal sex declined from 65% to 55% in men aged 15-24 years.
Although substantial improvements in HIV-related risk behaviors and knowledge occurred since 1989, recent increases in some HIV-related risk behaviors were observed, indicating a shift toward more risk-taking behaviors. Prevention efforts should be reinvigorated to address this, otherwise the past success in the HIV fight will be reversed. Monitoring of HIV-related indicators should be continued.
Throughout the 1990s, HIV-1 prevalence and incidence were falling in Uganda. Recently, some researchers have noticed that HIV-1 prevalence is levelling off. We examine prevalence, incidence, and sexual behaviour trends in a rural population cohort in Uganda over 16 years.
We report prevalence by survey round and incidence by calendar year from a prospective general population cohort study. Using logistic regression Wald tests, we examined casual partners, condom use, and pregnancies. We examined age at sexual debut by means of life tables.
HIV-1 prevalence declined from 8.5% in 1990/1991 to 6.2% in 1999/2000, and thereafter rose to 7.7% in 2004/2005. Incidence (per 1000 person-years at risk) fell from 7.5 in 1990 to 4.1 in 1998, and thereafter increased to 5.0 by 2004. The 2005 incidence estimate reached an all-time low of 2.5, but the preliminary 2006 estimate shows a rise again. Incidence trends varied by age and sex. Some sexual behaviour indicators showed more risky behaviour in recent years compared with the 1990s, whereas others indicated that the reduction in risky behaviour that began in the 1990s continues.
HIV-1 prevalence is rising in this cohort. Incidence is stabilizing, and shows signs of increasing among some subgroups. The extent to which changing sexual behaviour has played a role in these epidemiological trends is unclear, but it is likely to have contributed. To solidify the success that Uganda had throughout the 1990s in controlling the HIV epidemic, the efforts in HIV prevention need to be re-strengthened, using all strategies known.
The fight against HIV/AIDS poses enormous challenges worldwide, generating fears that success may be too difficult or even impossible to attain. Uganda has demonstrated that an early, consistent and multisectoral control strategy can reduce both the prevalence and the incidence of HIV infection. From only two AIDS cases in 1982, the epidemic in Uganda grew to a cumulative 2 million HIV infections by the end of 2000. The AIDS Control Programme established in 1987 in the Ministry of Health mounted a national response that expanded over time to reach other relevant sectors under the coordinating role of the Uganda AIDS Commission. The national response was to bring in new policies, expanded partnerships, increased institutional capacity for care and research, public health education for behaviour change, strengthened sexually transmitted disease (STD) management, improved blood transfusion services, care and support services for persons with HIV/AIDS, and a surveillance system to monitor the epidemic. After a decade of fighting on these fronts, Uganda became, in October 1996, the first African nation to report declining trends in HIV infection. Further decline in prevalence has since been noted. The Medical Research Council (UK) and the Uganda Virus Research Institute have demonstrated declining HIV incidence rates in the general population in the Kyamulibwa in Masaka Districts. Repeat knowledge, attitudes, behaviour and practice studies have shown positive changes in the priority prevention indicators. The data suggest that a comprehensive national response supported by strong political commitment may be responsible for the observed decline. Other countries in sub-Saharan Africa can achieve similar results by these means. Since success is possible, anything less is unacceptable.
We examined HIV optimism and unprotected anal intercourse (UAI) in a nationwide sample of gay and homosexually active men. Questionnaires were distributed throughout Australia through pornographic catalogues. 1832 men responded, 1181 (64.5%) classified as gay community attached (GCA) and 651 (35.5%) as non-GCA (NGCA). Mean HIV optimism scores tended toward scepticism rather than optimism, with no significant difference between GCA and NGCA men. Men who had UAI with regular partners were significantly more optimistic than men who did not (P<0.001). There was a significant UAI-casual/GCA interaction (P<0.001). GCA men who engaged in UAI-casual were significantly more optimistic than GCA men who did not (P<0.001). Likewise, NGCA men who had UAI-casual were significantly more optimistic than NGCA men who did not (P<0.001). These findings corroborate earlier evidence that gay men's UAI is associated with - not necessarily caused by - HIV optimism. Importantly, these data come from a broad national sample rather than one drawn from within a 'gay precinct'.
To determine whether attitudes towards highly active antiretroviral therapy (HAART) are associated with unprotected anal sex among sexually active homosexual men.
Cross-sectional study nested within an ongoing prospective cohort study.
Multicenter AIDS Cohort Study, from April through September 1999.
Five-hundred and forty-seven homosexual men reporting anal sex (218 HIV-negative and 329 HIV-positive) during study interviews in 1999, including a 20-item validated scale on attitudes toward HAART and HIV risk behaviors (e.g., 'Because of HAART, I am less concerned about becoming HIV-infected or infecting someone'), and safer sex fatigue (e.g., 'I am tired of always having safer sex').
Self-reported unprotected receptive anal sex (RAS) and insertive anal sex (IAS) in the prior 6 months.
More than 50% of HIV-negative and HIV-positive men who reported having anal sex also reported recent unprotected RAS and/or IAS. HIV-negative men who most agreed that HAART reduced concern about becoming infected were more likely to report unprotected RAS compared to other HIV-negative men [adjusted odds ratio (AOR), 3.31; 95% confidence interval (CI), 1.27-8.62]. Moreover, HIV-positive men with greatest reduced concern due to HAART or safer sex fatigue were more likely to report unprotected IAS (AOR, 6.05; 95% CI, 2.24-16.63 and AOR, 4.57; 95% CI, 1.70-12.24, respectively) compared to other HIV-positive men.
Among sexually active homosexual men, lessened concern about HIV transmission due to HAART was strongly associated with sexual risk taking, as was safer sex fatigue among HIV-positive men. Prevention programs should take into account underlying attitudes for unprotected sex in the era of HAART among both HIV-infected and uninfected men.
To examine whether HIV optimism (i.e. optimism in the light of new HIV drug therapies) can account for the recent increase in high-risk sexual behaviour among London gay men.
Gay men (n = 2938) using London gyms were surveyed annually between 1998 and 2001. Information was collected on HIV status, unprotected anal intercourse (UAI) in the previous 3 months, and agreement with two statements concerning the severity of and susceptibility to HIV infection. Those who agreed were classified as 'optimistic'.
Between 1998 and 2001, the percentage of men reporting high-risk UAI (i.e. UAI with a casual partner of unknown or discordant HIV status) increased: HIV-positive men 15.3-38.8%; HIV-negative men 6.8-12.1%; never-tested men 2.1-7.7%; (P < 0.01). Overall, less than a third were optimistic. In cross-sectional analysis, optimistic HIV-positive and -negative men were more likely to report high-risk UAI than other men (P < 0.05). However, the increase in high-risk UAI between 1998 and 2001 was seen in those who were optimistic and those who were not (P < 0.05). In multivariate analysis, the modelled increase in high-risk UAI over time remained significant after controlling for HIV optimism (P < 0.01), with no significant interaction between optimism and time.
Among London gay men, no difference was detected between those who were optimistic and those who were not in the rate of increase in high-risk sexual behaviour between 1998 and 2001. Our findings suggest that HIV optimism is unlikely to explain the recent increase in high-risk sexual behaviour in these men.
The HIV pandemic is a major threat to young people. UNAIDS estimates that 11·8 million people aged 15–24 years are living with HIV/AIDS. Half of all new infections— almost 6000 daily—now occur in young people and in some populations up to a third of those entering adolescence are expected to die of AIDS. Faced with this situation what has been achieved in terms of developing evaluating and implementing effective risk-reduction interventions against HIV infection in young people? Blood-donor screening and anti-HIV therapy to reduce mother-to-child transmission are highly effective interventions that should be implemented more widely. Reducing sexual transmission through changing behaviour is a more challenging though equally pressing priority. In a recent meta-analysis B Johnson and colleagues examined 56 interventions to reduce the risk of sexual transmission of HIV among 11–18-year-olds. They found significant improvements in risk-reduction skills and behaviours although average follow-up was only 14 weeks. 23% of the studies did not randomise participants to an intervention or comparison group (which might weaken their findings) and the size of benefit for key behavioural outcomes (eg condom use) was modest. (excerpt)
To assess the acceptance of voluntary HIV counseling and testing (VCT) and the effects of VCT on sexual risk behavior and HIV acquisition in Rakai, Uganda.
In a rural cohort, 10 694 consenting adults were interviewed, provided blood for HIV testing and were offered free VCT by community resident counselors. The proportions receiving VCT and the adjusted risk ratio (adj. RR) of VCT acceptance were estimated by log binomial regression. Risk behaviors and HIV incidence per 100 person-years (PY) in HIV-negative acceptors and non-acceptors of VCT were assessed prospectively.
Although 93% initially requested HIV results, 62.2% subsequently accepted VCT. VCT acceptance was lower among persons with no prior VCT [Adj. RR = 0.88; 95% confidence interval (CI), 0.85-0.90], individuals with primary education (adj. RR = 0.94; 95% CI, 0.90-0.99) or higher (adj. RR = 0.91; 95% CI, 0.87-0.97), individuals who were HIV-positive (adj. RR = 0.72; 95% CI, 0.68-0.76), and persons reporting condom use in the past 6 months (inconsistent users, adj. RR = 0.95; 95% CI, 0.90-0.99; consistent users, adj. RR = 0.88; 95% CI, 0.82-0.95). VCT acceptance was higher among the currently married (adj. RR = 1.14; 95% CI, 1.08-1.20) and previously married (adj. RR = 1.11; 95% CI, 1.04-1.18). Receipt of results was not significantly associated with age, gender, and self-perception of HIV risk. There were no significant differences in sexual risk behaviors, or in HIV incidence between acceptors (1.6/100 PY) and non-acceptors (1.4/100 PY) of VCT.
In this rural cohort where VCT services are free and accessible, there is self-selection of individuals accepting VCT, and no impact of VCT on subsequent risk behaviors or HIV incidence.
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.
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.
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.
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.
We examined whether use of antiretroviral (ARV) therapy is associated with increased sexual risk behavior in a cross-sectional study of patients undergoing ARV therapy (ARV experienced) compared to patients not undergoing ARV therapy (ARV-naïve) attending an urban HIV clinic in Kampala, Uganda. Sexual behavior during the prior 6 months and sexually transmitted disease (STD) treatment was determined by face-to-face structured interviews. Multiple logistic regression was used to identify independent correlates of sexual activity, multiple sexual partners, inconsistent condom use, and STD treatment during the prior 6 months. Three hundred forty-seven (48%) of the 723 respondents reported a history of sexual intercourse in the 6 months prior to the interview (sexually active). Receipt of ARV therapy was not associated with a significantly higher likelihood of being sexually active (adjusted odds ratio [AOR], 2.0 95% confidence interval [CI], 0.3-9.9). Among both ARV-experienced and ARV-naïve persons who were sexually active, 35% (120) reported one or more casual sexual partners in addition to a main partner (no difference by ARV status). Consistent condom use with spouse, regular, casual, and commercial partners was reported by 57%, 65%, 85%, and 85% of the sexually active respondents, respectively. The ARV-experienced respondents were more likely to report consistent condom use with their spouses than were ARV-naïve respondents (OR 2.82 95% CI 1.74-4.6). ARV-experienced respondents were more likely than ARV-naïve respondents to have disclosed their HIV status to their spouses (OR 1.57 95% CI 1.07-2.30).The ARV-experienced group was more likely to report STD treatment in the prior 6 months (AOR 2.62 95% CI 1.8-3.83) than the ARV-naïve group. The findings suggest that in this population, use of ARV therapy was not associated with risky sexual behavior in the prior 6 months. Still, recall and social desirability biases remain important limitations in interpreting these conclusions.
Poverty and limited health services in rural Africa present barriers to adherence to antiretroviral therapy that necessitate innovative options other than facility-based methods for delivery and monitoring of such therapy. We assessed adherence to antiretroviral therapy in a cohort of HIV-infected people in a home-based AIDS care programme that provides the therapy and other AIDS care, prevention, and support services in rural Uganda.
HIV-infected individuals with advanced HIV disease or a CD4-cell count of less than 250 cells per muL were eligible for antiretroviral therapy. Adherence interventions included group education, personal adherence plans developed with trained counsellors, a medicine companion, and weekly home delivery of antiretroviral therapy by trained lay field officers. We analysed factors associated with pill count adherence (PCA) of less than 95%, medication possession ratio (MPR) of less than 95%, and HIV viral load of 1000 copies per mL or more at 6 months (second quarter) and 12 months (fourth quarter) of follow-up.
987 adults who had received no previous antiretroviral therapy (median CD4-cell count 124 cells per muL, median viral load 217,000 copies per mL) were enrolled between July, 2003, and May, 2004. PCA of less than 95% was calculated for 0.7-2.6% of participants in any quarter and MPR of less than 95% for 3.3-11.1%. Viral load was below 1000 copies per mL for 894 (98%) of 913 participants in the second quarter and for 860 (96%) of 894 of participants in the fourth quarter. In separate multivariate models, viral load of at least 1000 copies per mL was associated with both PCA below 95% (second quarter odds ratio 10.6 [95% CI 2.45-45.7]; fourth quarter 14.5 [2.51-83.6]) and MPR less than 95% (second quarter 9.44 [3.40-26.2]; fourth quarter 10.5 [4.22-25.9]).
Good adherence and response to antiretroviral therapy can be achieved in a home-based AIDS care programme in a resource-limited rural African setting. Health-care systems must continue to implement, evaluate, and modify interventions to overcome barriers to comprehensive AIDS care programmes, especially the barriers to adherence with antiretroviral therapy.
To examine the determinants of uptake of voluntary counselling and testing (VCT) services, to assess changes in sexual risk behaviour following VCT, and to compare HIV incidence amongst testers and non-testers.
Prospective population-based cohort study of adult men and women in the Manicaland province of eastern Zimbabwe. Demographic, socioeconomic, sexual behaviour and VCT utilization data were collected at baseline (1998-2000) and follow-up (3 years later). HIV status was determined by HIV-1 antibody detection. In addition to services provided by the government and non-governmental organizations, a mobile VCT clinic was available at study sites.
Lifetime uptake of VCT increased from under 6% to 11% at follow-up. Age, increasing education and knowledge of HIV were associated with VCT uptake. Women who took a test were more likely to be HIV positive and to have greater HIV knowledge and fewer total lifetime partners. After controlling for demographic characteristics, sexual behaviour was not independently associated with VCT uptake. Women who tested positive reported increased consistent condom use in their regular partnerships. However, individuals who tested negative were more likely to adopt more risky behaviours in terms of numbers of partnerships in the last month, the last year and in concurrent partnerships. HIV incidence during follow-up did not differ between testers and non-testers.
Motivation for VCT uptake was driven by knowledge and education rather than sexual risk. Increased sexual risk following receipt of a negative result may be a serious unintended consequence of VCT. It should be minimized with appropriate pre- and post-test counselling.
The speed with which Thailand has scaled up public provision of antiretroviral therapy (ART) has been unprecedented, with more than 80 000 individuals on treatment at the end of 2006 through Thailand's National Access to Antiretroviral Program for People Living with HIV/AIDS (NAPHA). This paper projects the cost effectiveness, the affordability and the future fiscal burden of NAPHA to the government of Thailand under several different policy scenarios until the year 2025.
An economic/epidemiological model of access to ART was constructed, and this composite model was calibrated to economic and epidemiological data from Thailand and other countries. The economic model adopts the conditional logit specification of demand allocation across multiple treatment modes, and the epidemiological model is a deterministic difference-equation model fitted to the cumulated data on HIV incidence in each risk group.
The paper estimates that under 2005 prices NAPHA will save life-years at approximately US$736 per life-year saved with first-line drugs alone and for approximately US$2145 per life-year if second-line drugs are included. Enhancing NAPHA with policies to recruit patients soon after they are first eligible for ART or to enhance their adherence would raise the cost per life-year saved, but the cost would be small per additional life-year saved, and is therefore justifiable. The fiscal burden of a policy including second as well as first-line drugs would be substantial, rising to 23% of the total health budget by 2014, but the authors judge this cost to be affordable given Thailand's strong overall economic performance. The paper estimates that a 90% reduction in the future cost of second-line therapy by the exercise of Thailand's World Trade Organization authority to issue compulsory licences would save the government approximately US$3.2 billion to 2025 and reduce the cost of NAPHA per life-year saved from US$2145 to approximately US$940.
Randomised trials of HIV prevention are difficult to do and nearly all such trials have failed to show protection from HIV infection and a few have shown increases in risk. In todays Lancet Nancy Padian and colleagues for the MIRA (Methods for Improving Reproductive Health in Africa) team report that a trial of a diaphragm and lubricant gel with condoms failed to show lower HIV incidence in the intervention group than in the controls (condoms alone).The MIRA trial was carefully designed well done and appropriately analysed. With 4948 participants the study was adequately powered to detect efficacy. However despite the investigators efforts to promote safe sex in all participants self-reported condom use at last intercourse was substantially higher in the controls (85%) than in the intervention group (54%) possibly because women using a diaphragm were less motivated to use an additional barrier method. (excerpt)
HIV on the rise again in Uganda ”Globe and Mail
- York Geoffrey
York, Geoffrey. 2011. "HIV on the rise again in Uganda," Globe and Mail, 9 December.
The impact of ART awareness on risk behavior among nonpatients
- Mead Over
- Damien De Walque
- Harounan Kazianga India
- Burkina Thailand
- Ghana Faso
Over, Mead, Damien de Walque, and Harounan Kazianga. 2007. " The impact of ART awareness on risk behavior
among nonpatients: India, Thailand, Burkina Faso, and Ghana. " Presentation at the Roundtable on the Health
Systems Aspects of Antiretroviral Access, 22–23 October, Bloemfontein, South Africa.
Let my people go AIDS profiteers
- Ruteikara Sam
Ruteikara, Sam. 2008. "Let my people go, AIDS profiteers." Washington Post, 30 June.
Secret Lovers Kill: A national mass media campaign to address multiple and concurrent partnerships AIDSTAR-One Case Study Series
- Aldo Spina
Spina, Aldo. 2009. " Secret Lovers Kill: A national mass media campaign to address multiple and concurrent partnerships. " AIDSTAR-One Case Study Series. Arlington, VA: John Snow. <http://pdf.usaid.gov/pdf_docs/
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Uganda HIV Modes of Transmission and Prevention Response Analysis: Final Report
- Fred Wabwire-Mangen
- Martin Odiit
- Wilford Kirungi
- David Kaweesa Kisitu
- James Okara Wanyama
Wabwire-Mangen, Fred, Martin Odiit, Wilford Kirungi, David Kaweesa Kisitu, and James Okara Wanyama. 2009.
Uganda HIV Modes of Transmission and Prevention Response Analysis: Final Report. Kampala: Uganda AIDS
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The status and trends of the HIV/AIDS Epidemic in the world
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- Brown
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HIV prevalence and incidence are no longer falling in southwest Uganda: Evidence from a rural population cohort
- Leigh Shafer
- Samuel Anne
- Jessica Biraro
- Nakiyingi-Miiro
Shafer, Leigh Anne, Samuel Biraro, Jessica Nakiyingi-Miiro, et al. 2008. "HIV prevalence and incidence are no
longer falling in southwest Uganda: Evidence from a rural population cohort 1989-2005," AIDS 22(13):
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