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Motivational Interviewing (MI) and Community Health Workers (CHWs) are increasingly utilized in global settings to improve HIV outcomes, yet research exploring implementation strategies using MI and CHWs is lacking. We examined the experiences of CHWs and their clients in a counseling intervention which used MI-informed counseling to increase engagement in HIV prevention and treatment. This study was nested within the mLAKE cluster-randomized trial in a high HIV prevalence fishing community in rural Rakai District, Uganda. We conducted in-depth interviews with purposively-sampled CHWs (n = 8) and clients (n = 51). Transcripts were analyzed thematically to characterize CHWs' implementation of the intervention. Main themes identified included use of specific MI strategies (including evocation, guidance towards positive behavior change, active listening, and open-ended questions), and MI spirit (including collaboration, power-sharing, trust, and non-judgmental relationship building). Through these specific MI mechanisms, CHWs supported client behavior change to facilitate engagement with HIV services. This study provides evidence from a low-resource setting that CHWs with no previous experience in MI can successfully implement MI-informed counseling that is well-received by clients. CHW-led MI-informed counseling appears to be a feasible and effective approach to increase uptake of HIV prevention and care services in low-resource, HIV endemic regions. [ABSTRACT FROM AUTHOR]

Targeted strategies are central to increasing HIV-status awareness and progress on the care cascade among men. We implemented Village-Health-Team (VHT)-delivered HIV self-testing (HIVST) among men in a peri-urban Ugandan district and assessed linkage to confirmatory-testing, antiretroviral-therapy (ART) initiation and HIV-status disclosure following HIVST. We conducted a prospective cohort study from November 2018 to June 2019 and enrolled 1628 men from 30-villages of Mpigi district. VHTs offered each participant one HIVST-kit and a linkage-to-care information leaflet. At baseline, we collected data on demographics, testing history and risk behavior. At one-month, we measured linkage to confirmatory-testing and HIV-status disclosure, and at three months ART-initiation if tested HIV-positive. We used Poisson regression generalized estimating equations to evaluate predictors of confirmatory-testing. We found that 19.8% had never tested for HIV and 43% had not tested in the last 12-months. After receiving HIVST-kits, 98.5% self-reported HIVST-uptake in 10-days, 78.8% obtained facility-based confirmation in 30-days of HIVST with 3.9% tested HIV-positive. Of the positives, 78.8% were newly diagnosed, 88% initiated ART and 57% disclosed their HIV-status to significant others. Confirmatory testing was associated with having a higher level of education and knowing a partner's HIV-status. VHT-delivered HIVST may be effective for boosting testing, ART-initiation and HIV-status disclosure among men. [ABSTRACT FROM AUTHOR]

Youth living with HIV in sub-Saharan Africa have poor HIV care outcomes. We determined the association of recent significant life-events with HIV antiretroviral treatment (ART) initiation and HIV viral suppression in youth aged 15-24 years living with HIV in rural Kenya and Uganda. This was a cross-sectional analysis of 995 youth enrolled in the SEARCH Youth study. At baseline, providers assessed recent (within 6 months) life-events, defined as changes in schooling/employment, residence, partnerships, sickness, incarceration status, family strife or death, and birth/pregnancy, self-reported alcohol use, being a parent, and HIV-status disclosure. We examined the frequencies of events and their association with ART status and HIV viral suppression (2 significant life-events (aOR = 0.61, 95% CI:0.45-0.85) and consuming alcohol (aOR = 0.61, 95% CI:0.43-0.87) were associated with a lower odds of HIV viral suppression, while disclosure of HIV-status to partner (aOR = 2.39, 95% CI:1.6-3.5) or to family (aOR = 1.86, 95% CI:1.3-2.7), being a parent (aOR = 1.8, 95% CI:1.2-2.5), and being single (aOR = 1.6, 95% CI:1.3-2.1) had a higher odds. This suggest that two or more recent life-events and alcohol use are key barriers to ART initiation and achievement of viral suppression among youth living with HIV in rural East Africa.Trial registration: ClinicalTrials.gov identifier: NCT03848728..

The uptake of HIV prevention services is lower among youth than adults in sub-Saharan Africa. Existing youth livelihood trainings offer a potential entry point to HIV prevention services. We determined feasibility and preliminary effectiveness of integrating HIV prevention into youth clubs implementing an empowerment and livelihood for adolescents (ELA) intervention in rural Uganda. Staff conducted community mobilization for youth (15-24 years) over one month. Clubs met (3×/week) over six months, with local peer mentors trained to teach life-skills and sexual/reproductive health education. We integrated mentor-led education on HIV prevention, including pre- and post-exposure prophylaxis (PrEP/PEP). Clubs offered on-site HIV testing, a field trip to a local clinic and PrEP referrals after one month and six months. Surveys were conducted at baseline and six months. Forty-two participants (24 adolescent girls/young women (AGYW) and 18 adolescent boys/young men (ABYM)) joined the clubs. At baseline, no participants accepted referral for PrEP, whereas 5/18 (28%) sexually active, HIV-negative AGYW requested PrEP referral at follow-up. One ABYM requested PEP referral. Integration of HIV prevention services into an established ELA curriculum at mentor-led youth clubs in rural Uganda was feasible. PrEP uptake increased among sexually active AGYW. Evaluation of this approach for HIV prevention among youth merits further study.

Fifty-one 18–22-year-old Ugandans took part in asynchronous online discussions about sexual decision-making. To increase generalizability and variability of experience, youth were recruited across the country using social media advertising. Participants were stratified into 8 groups by sex and sexual experience (e.g., women who had not had sex). Participants were asked questions such as, "What role do you think [men/women] play in deciding when a couple is going to play sex?" Several themes emerged. Both young men and women articulated social pressures to be abstinent, particularly to avoid STIs and pregnancy moreso than saving oneself for marriage. That said, women noted pressures to be seen as "pure". There also were pressures to have sex: Men were expected to have sex to demonstrate their virility. Women were expected to have sex if they accepted gifts or other commodities from their partners. It seemed that the specter of HIV and other STIs, as well as unwanted pregnancy, served to mitigate these expectations however, resulting in self-efficacy to use condoms among both men and women. Nonetheless, both men and women acknowledged that it could be hard for women to negotiate condoms. Implications for HIV prevention are discussed. [ABSTRACT FROM AUTHOR]

Survival is possible for children perinatally exposed to or infected by HIV in the post-combined antiretroviral therapy era and identifying factors affecting children's ability to thrive has public health significance. Caregiver mental health is one such factor to consider given its impact on child development, but previous work has not included a full complement of HIV exposure/infection groups within HIV-endemic settings. We compared depressive symptoms among caregivers of 3 groups of 6-10-year-olds in Uganda: children with perinatally acquired HIV infection (CPHIV, n = 102), children with perinatal HIV exposure, but no infection (CPHEU, n = 101), and children without perinatal HIV exposure or infection (CHUU, n = 103). The Hopkins Symptom Checklist was used to assess caregiver depressive symptoms. Generalized linear models were used to estimate group mean differences. Adjusted models included caregiver demographics, social support, and lifetime trauma. Depression symptoms were higher among CPHEU compared to CPHIV caregivers (model coefficient [B] = −3.5, 95%CI −5.3, −1.8). This finding was minimally attenuated following adjustment for covariates (B = −2.2, 95%CI −4.1, −0.4) and among biological mothers. At lower levels of social support and wealth, CPHEU caregivers reported higher levels of depression symptoms than CPHIV caregivers. Our findings point to unmet mental health needs among CPHEU caregivers. [ABSTRACT FROM AUTHOR]

Synergistic associations between social inequities and HIV vulnerabilities – known as a syndemic – are understudied with youth in humanitarian settings. We explored refugee youths' HIV prevention needs in Bidi Bidi Refugee Settlement, Uganda. This multi-methods study involved 6 focus groups and 12 in-depth individual interviews (IDI) with refugee youth (n = 60) aged 16–24, and IDI with refugee elders (n = 8) and healthcare providers (n = 8). We then conducted cross-sectional surveys with refugee youth (16–24 years) (n = 115) to assess: poverty, recent sexual and gender-based violence (SGBV), and condom engagement motivation (CEM) (wanting to learn about condoms for HIV prevention). Multivariable logistic regression was used to estimate adjusted odds ratios for associations between poverty and SGBV with CEM. Qualitative narratives revealed poverty and trauma elevated substance use, and these converged to exacerbate SGBV. SGBV and transactional sex increased HIV vulnerabilities. Among survey participants, poverty and recent SGBV were associated with reduced odds of CEM. The interaction between poverty and recent SGBV was significant: the predicted probability of CEM among youth who experienced both poverty and SGBV was almost half than among youth who experienced poverty alone, SGBV alone, or neither. Findings signal the confluence of poverty, violence, and substance use elevate refugee youth HIV vulnerabilities. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) has been associated with delays throughout the HIV care continuum. This study explored prospective associations between experiences of past-year IPV and two HIV care outcomes in the context of current universal test and treat guidelines using two consecutive rounds of an ongoing HIV surveillance study conducted in the Rakai region of Uganda. Longitudinal logistic regression models examined associations between IPV, use of antiretroviral therapy (ART) and viral load suppression (VS), adjusting for outcome variables at baseline. To address differences in ART retention by IPV, propensity scores were used to create inverse-probability-of-treatment-and-censoring-weighted (IPTCW) models. At baseline, of 1923 women with HIV (WWH), 34.6%, 26.5%, 13.5% reported past-year verbal, physical and sexual IPV; a lower proportion of persons who experienced physical IPV (79.4%) were VS than those who did not (84.3%; p = 0.01). The proportion VS at baseline also significantly differed by exposure to verbal IPV (p = 0.03). However, in adjusted longitudinal models, IPV was not associated with lower odds of ART use or VS at follow-up. Among WWH in the Rakai region, IPV does not appear to be a barrier to subsequent ART use or VS. However, given the prevalence of IPV in this population, interventions are needed. [ABSTRACT FROM AUTHOR]

Depression is a common cause of morbidity globally and can impact adherence to medications, posing challenges to medication-based HIV prevention. The objectives of this work are to describe the frequency of depression symptoms in a cohort of 499 young women in Kampala, Uganda and to determine the association of depression symptoms with use of HIV pre-exposure prophylaxis (PrEP). Mild or greater depression, assessed by the patient health questionnaire (PHQ-9), was experienced by 34% of participants at enrollment. Participants with mild depression symptoms tended to uptake PrEP, request PrEP refills, and adhere to PrEP with similar frequency to women with no/minimal signs of depression. These findings highlight opportunities to leverage existing HIV prevention programs to identify women who may benefit from mental health services and may not otherwise be screened. Trial registration: ClinicalTrials.gov identifier: NCT03464266.. [ABSTRACT FROM AUTHOR]

There are limited data characterizing HIV retesting among high-risk adults in sub-Saharan Africa. From October-December 2018, we distributed recruitment cards offering health evaluations with HIV testing at venues frequented by individuals at-risk of HIV infection in Southwest Uganda. Those who attended were asked about their HIV testing history and risk factors: having >1 sexual partner, an HIV+ partner, STIs, and/or transactional sex. We defined "highest risk" as ≥3 risk factors and "frequent testing" as ≥3 tests within the past year. Of 1,777 cards distributed, 1,482 (83%) adults came to clinic: median age was 26(IQR: 22-31), 598 (40%) were men, and 334 (23%) were HIV+. Of 1,148 HIV-negative adults, 338 (29%) were highest risk and 205 (18%) were frequent testers. Frequent testing was similar in women (19%) and men (16%, p = 0.22). Among women, those at highest risk were more likely to report any testing (90% vs. 81%, p = 0.01) and frequent testing (25% vs. 18%, p = 0.06) than those at lower risk. Among men, any testing and frequent testing were similar between risk levels. Among adults recruited from high-risk venues in peri-urban Uganda, HIV risk behaviors were commonly reported, yet frequent retesting remained low. Interventions to promote retesting are needed, particularly among men.

Although there is evidence of individual associations between depressive symptoms and hazardous alcohol use with suboptimal antiretroviral therapy (ART) adherence among people living with HIV (PLWH), few studies have established how the two risk factors may interact to predict viral suppression. We conducted secondary data analyses with two cohorts of Ugandan PLWH (N = 657) to investigate the hypothesized interaction between depressive symptoms (Center for Epidemiological Studies Depression Scale) and hazardous alcohol use (Alcohol Use Disorder Identification Test -Consumption and/or Phosphatidylethanol biomarker) prior to ART initiation with viral suppression (

Assisted partner notification (APN) program was adopted by Uganda to increase individuals testing for HIV through their partners who test HIV positive. Thus, early enrollment in treatment and ensuring prevention services for the affected couple. However, APN is associated with high levels of Intimate partner violence (IPV). We aimed at determining the prevalence of IPV following APN in a cross-sectional study of newly diagnosed HIV clients in southwestern Uganda. We used the modified version of the Conflict Tactics Scale to assess IPV. We also collected information on sociodemographics of the index clients and their sexual partners, and outcome of linkage to care of partner. Logistic regression was used to determine the factors associated with IPV. We enrolled 327 index clients, mean age was 39.1, 63.6% were female and 35.5 experienced IPV following APN. The likelihood of experiencing IPV was more than twice if a health worker/provider disclosed the status to the partner. However, if the partners turned out to be HIV positive, it was protective against experiencing IPV, adjusted odds ratio 0.39, 95% confidence interval 0.23–0.69, p = 0.001. We conclude that IPV is common following partner notification in rural Uganda and should be screened and addressed. [ABSTRACT FROM AUTHOR]

Decision-making errors such as present bias (PB) can have important consequences for health behaviors, but have been largely studied in the financial domain. We conducted a mixed-method study on PB in the context of ART adherence among clinic-enrolled adults in Uganda (n = 39). Specifically, we quantified PB by asking about preferences between medication available sooner to minimize headaches versus available later to cure headaches. We describe demographic similarities among PB participants and qualitatively explored how participants reflected on their PB (or absence thereof) in the context of health. Participants reporting PB were predominantly male, single/unmarried, older, had higher levels of education and income and more advanced HIV progression. Three common reasons for more present-biased choices provided were: (1) wanting to avoid pain, (2) wanting to return to work, and (3) fear of one's health worsening if s/he did not address their illness immediately. While PB in the financial domain often suggests that poorer individuals are more likely to prefer immediate rewards over their wealthier counterparts, our results suggest poor health is potentially a driving factor of PB. Further research is needed to build on these finding and inform how programs can frame key messages regarding ART adherence to patients displaying PB. Trial registration: ClinicalTrials.gov identifier: NCT03494777. [ABSTRACT FROM AUTHOR]

Rates of Isoniazid Preventive Therapy (IPT) completion remain low in programmatic settings in sub-Saharan Africa. Differentiated HIV care models may improve IPT completion by addressing joint barriers to IPT and HIV treatment. However, the impact of differentiated care on IPT completion remains unknown. In a cross-sectional study of people with HIV on antiretroviral therapy in 5 communities in rural Uganda, we compared IPT completion between patients receiving HIV care via a differentiated care model versus a standard HIV care model and assessed multi-level predictors of IPT completion. A total of 103/144 (72%) patients received differentiated care and 85/161 (53%) received standard care completed IPT (p < 0.01). Adjusting for age, gender and community, patients receiving differentiated care had higher odds of completing IPT (aOR: 2.6, 95% CI: 1.5-4.5, p < 0.01). Predictors of IPT completion varied by the care model, and differentiated care modified the positive association between treatment completion and the belief in the efficacy of IPT and the negative association with side-effects. Patients receiving a multi-component differentiated care model had a higher odds of IPT completion than standard care, and the model's impact on health beliefs, social support, and perceived side effects to IPT may underlie this positive association.

There is an urgent need for greater provision of mental health services to people living with HIV. HIV testing and counselling (HTC) sessions diagnose HIV and offer appropriate psychosocial support and behavioural messages to support people to link into HIV care. It is not known to what extent HTC currently addresses mental health. We examined transcriptions of 116 audio-recorded HTC sessions delivered in Uganda against a checklist of mental health techniques. Hierarchical cluster analysis explored co-occurrence of techniques. Core counselling skills were very commonly present, and co-occurred. Assessment techniques were not commonly seen. Specific therapy techniques to treat anxiety or depression were not present. HTC staff are a resource for delivering mental health care for people with HIV, owing to their strong fundamental counselling skills. However, training is needed in assessment and evidence-based therapies. Provision of fuller assessment and interventions may increase detection and signposting for mental health and alcohol use, both of which may affect linkage into care. HTC staff have fundamental skills that could also be developed to train and supervise other staff to provide much needed mental health support to people living with HIV. Future research should develop brief mental health interventions for delivery by HTC staff. [ABSTRACT FROM AUTHOR]

Contraceptive adherence during acute and recent HIV-1 infection is important to maternal and child health given the elevated risk of vertical HIV-1 transmission and additional complications of pregnancy. Injectable contraception (IC) is the most common non-barrier modern contraception method used in sub-Saharan Africa (SSA). Adherence to IC after HIV-1 seroconversion is not well understood. We examined factors associated with IC discontinuation among women in SSA diagnosed with HIV-1 infection while participating in a clinical trial of biomedical HIV-1 prevention. After diagnosis with HIV-1 infection in the VOICE trial, 255 women from South Africa, Uganda, and Zimbabwe enrolled in a longitudinal observational study (MTN-015). Contraceptive method was assessed at MTN-015 baseline and at 3, 12, and 24 months post-seroconversion. Correlates of IC discontinuation were examined by Cox proportional hazard modeling. IC use was reported at baseline by 78% of women enrolled (198/255), of which 92% (182/198) completed at least one follow-up visit. Two-thirds of women (66%, 121/182) continued on IC during the follow-up period (median 24 months). Lower rates of IC discontinuation were observed in women who reported having had at least one child (HR 0.39, 95% CI 0.20-0.82) or earning a personal income (HR 0.51, 95% CI 0.30-0.87) at baseline. These findings suggest that many women with HIV-1 infection face complex decision-making regarding family planning in the years that follow seroconversion and highlight that some women may discontinue IC use despite on-site provision of family planning services. Understanding the broader context of family planning choices in recently seroconverted women may be key to more effective linkages between family planning services and HIV-1 testing and care.

Youth living with HIV (YLWHIV) have an increased cancer risk. Our objective is to describe the prevalence of medical record (MR) reported suspected cancers in a contemporary cohort of YLWHIV in Uganda that was assembled through MR reviews of patients 10 to 24 years old across 35 Ugandan HIV care health facilities. Clinical data were abstracted to identify suspected cancer cases and information about HIV care. Among 3728 YLWHIV, we identified eight suspected cancer cases. The most common suspected types were Kaposi sarcoma (n=4) followed by lymphoma (n=3). Challenges encountered in data abstraction were missing data for several variables and confirmatory cancer diagnostic information. In follow-up of suspected cases referred for diagnosis at the Uganda Cancer Institute (UCI), none had diagnosis records in UCI files. In addition, ∼18% of patients (n=686) were lost-to-follow-up (LTF) defined as not having returned to the clinic in ≥183 days and three patients died from presumed Kaposi sarcoma. Although our results suggest that cancer is rare in YLWHIV, the possibility that the cancer burden is higher cannot be excluded due to incomplete information in MRs and high LTF rates. Further, our study raises concern that patients referred for diagnosis are not accessing potential life-saving care. [ABSTRACT FROM AUTHOR]

Under-reporting of alcohol use by HIV-infected patients could adversely impact clinical care. This study examined factors associated with under-reporting of alcohol consumption by patients who denied alcohol use in clinical and research settings using an alcohol biomarker. We enrolled ART-naïve, HIV-infected adults at Mbarara Hospital HIV clinic in Uganda. We conducted baseline interviews on alcohol use, demographics, Spirituality and Religiosity Index (SRI), health and functional status; and tested for breath alcohol content and collected blood for phosphatidylethanol (PEth), a sensitive and specific biomarker of alcohol use. We determined PEth status among participants who denied alcohol consumption to clinic counselors (Group 1, n = 104), and those who denied alcohol use on their research interview (Group 2, n = 198). A positive PEth was defined as ≥8 ng/ml. Multiple logistic regression models were used to examine whether testing PEth-positive varied by demographics, literacy, spirituality, socially desirable reporting and physical health status. Results showed that, among the 104 participants in Group 1, 28.8% were PEth-positive. The odds of being PEth-positive were higher for those reporting prior unhealthy drinking (adjusted odds ratio (AOR): 4.7, 95% confidence interval (CI): 1.8, 12.5). No other factors were statistically significant. Among the 198 participants in Group 2, 13.1% were PEth-positive. The odds of being PEth-positive were higher for those reporting past unhealthy drinking (AOR: 4.6, 95% CI: 1.8, 12.2), the Catholics (AOR: 3.8, 95% CI: 1.3, 11.0) compared to Protestants and lower for the literate participants (AOR: 0.3, 95% CI: 0.1, 0.8). We concluded that under-reporting of alcohol use to HIV clinic staff was substantial, but it was lower in a research setting that conducted testing for breath alcohol and PEth. A report of past unhealthy drinking may highlight current alcohol use among deniers. Strategies to improve alcohol self-report are needed within HIV care settings in Uganda.

Achieving universal HIV test-and-treat will require targeted interventions for those with worse outcomes, including advanced HIV. We conducted qualitative, semi-structured interviews with healthcare workers (HCWs) and people living with HIV (PLWH) at 5 HIV clinics in Kampala, Uganda, to understand barriers to care. PLWH enrolled started/restarted on HIV treatment ≤3 months prior. PLWH were grouped as 1) "ART-experienced" or those restarted therapy after ≥12 months off, 2) ART naïve CD4 count <100 cells/uL "late presenters" or 3) ART naïve CD4 count >350 cells/uL "early presenters". In-depth interviews were conducted in Luganda, translated, and transcribed verbatim. Between May and August 2017, 58 PLWH and 20 HCWs were interviewed. High stigma and low social support emerged as themes among all as barriers to care. Alcohol abuse was a barrier for men. Fear of domestic violence and abandonment were barriers for women, limiting disclosure of their HIV status to their male partners. Clinic factors such as rapport with staff, distance, efficiency, and privacy impacted care. Future interventions to decrease delayed ART initiation should target stigma and social support. Assisted disclosure, contact tracing, and alcohol abuse treatment should be implemented. Strengthening client support, reducing wait times, and increasing privacy assurances would improve care-seeking behaviors. [ABSTRACT FROM AUTHOR]

Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Displaced populations, including refugees, face health challenges such as resource shortages, food and housing insecurity, violence, and disrupted social support. People living with HIV in refugee settings have decreased engagement with HIV services compared to non-refugee populations, and interventions are needed to enhance linkage to care. However, designing health interventions in humanitarian settings is challenging. We used Intervention Mapping (IM), a six-step method for developing theory- and evidence-based health interventions, to design a program to increase linkage to HIV care for refugees and Ugandan nationals in Nakivale Refugee Settlement in Uganda. We engaged a diverse group of stakeholders (N = 14) in Nakivale, including community members and humanitarian actors, in an interactive workshop focusing on IM steps 1–4. We developed a chronic care program that would integrate HIV care with services for hypertension and diabetes at accessible community sites, thereby decreasing stigma around HIV treatment and improving access to care. IM provided an inclusive, efficient method for integrating community members and program implementers in the intervention planning process, and can be used as a method-driven approach to intervention design in humanitarian settings. [ABSTRACT FROM AUTHOR]

HIV stigma is a major barrier to HIV care and treatment among people living with HIV (PLWH). Evidence suggests that expansion in antiretroviral therapy (ART) may reduce stigma. However, there are limited longitudinal studies examining temporal trends in HIV stigma in sub-Saharan Africa in the Undetectable = Untransmittable (U = U) era. We longitudinally assessed temporal trends in self-reported experienced stigma and the association of experienced stigma with ART adherence and viral suppression among PLWH enrolled in the African Cohort Study (AFRICOS). AFRICOS is an ongoing cohort study enrolling PLWH in Uganda, Kenya, Tanzania, and Nigeria. As of 1 March 2020, 2937 PLWH enrolled in AFRICOS and had available data. In 2013, 22% of participants reported stigma at the enrollment visit and by 2018 the prevalence decreased to 1% overall and was below 2% for all countries. However, there was not a statistically significant change in stigma prevalence in our longitudinal models. In adjusted models, experiencing stigma was associated with a 0.67 decreased odds of ART Adherence (95% confidence interval (CI): 0.56–0.80) and a 0.64 decreased odds of viral suppression (95% CI: 0.73–0.99). HIV-associated stigma was associated with poor self-reported ART adherence and unsuppressed viral load. [ABSTRACT FROM AUTHOR]

People living with HIV/AIDS anticipate HIV-related stigma and fear disclosure to intimate partners. Yet, disclosure is critical to reducing HIV transmission and improving care engagement. This qualitative study characterized HIV disclosure experiences and normative beliefs among couples in communities participating in an HIV test-and-treat trial in Kenya and Uganda (Sustainable East Africa Research in Community Health, NCT#01864603). In-depth interviews were conducted with care providers (n = 50), leaders (n = 32) and members (n = 112) of eight communities. Data were analyzed using grounded theoretical approaches and Atlas.ti software. Findings confirmed gender differences in barriers to disclosure: while both men and women feared blame and accusation, women also feared violence and abandonment ("I did not tell my husband because [what if] I tell him and he abandons me at the last moment when I am in labor?"). Positive consequences included partner support for increased care-seeking and adherence ("My husband keeps on reminding me 'have you taken those drugs?'") Yet negative consequences included partnership dissolution, blame, and reports of violence ("some men beat their wives just because of that [bringing HIV medications home]"). Among HIV-infected individuals in discordant relationships, men more often reported supportive spouses ("we normally share [HIV-risk-reduction strategies] since I have been infected and she is HIV negative"), than did women ("my husband refused to use condoms and even threatened to marry another wife"). Care providers lent support for HIV-positive women who wanted to engage partners in testing but feared negative consequences: "They engaged the two of us in a session and asked him if we could all test." Findings demonstrate differing experiences and support needs of women and men living with HIV in eastern Africa, with HIV-positive women in discordant couples particularly vulnerable to negative consequences of disclosure. Efforts to strengthen capacity in health systems for gender-sensitive clinician- or counselor-assisted disclosure should be accelerated within test-and-treat efforts.

Expectations about future health and longevity are important determinants of individuals' decisions to invest in physical and human capital. Few population-level studies have measured subjective expectations and examined how they are affected by scale-up of antiretroviral therapy (ART). We assessed these expectations in communities receiving annual HIV testing and universal ART. Longitudinal data on expectations were collected at baseline and one year later in 16 intervention communities participating in the Sustainable East Africa Research in Community Health (SEARCH) trial of the test and treat strategy in Kenya and Uganda (NCT01864603). A random sample of households with and without an HIV-positive adult was selected after baseline HIV testing. Individuals' expectations about survival to 50, 60, 70, and 80 years of age, as well as future health status and economic well-being, were measured using a Likert scale. Primary outcomes were binary variables indicating participants who reported being very likely or almost certain to survive to advanced ages. Logistic regression analyses were used to examine trends in expectations as well as associations with HIV status and viral load for HIV-positive individuals. Data were obtained from 3126 adults at baseline and 3977 adults in year 1, with 2926 adults participating in both waves. HIV-negative adults were more likely to have favorable expectations about survival to 60 years than HIV-positive adults with detectable viral load (adjusted odds ratio [AOR] 1.87, 95% CI 1.53-2.30), as were HIV-positive adults with undetectable viral load (AOR 1.41, 95% CI 1.13-1.77). Favorable expectations about survival to 60 years were more likely for all groups in year 1 compared to baseline (AOR 1.53, 95% CI 1.31-1.77). These findings are consistent with the hypothesis that universal ART leads to improved population-level expectations about future health and well-being. Future research from the SEARCH trial will help determine whether these changes are causally driven by the provision of universal ART.

Men's uptake of HIV testing is critical to the success of "test and treat" strategies in generalized epidemics. This study sought to identify cultural factors and community processes that influence men's HIV testing uptake in the baseline year of an ongoing test-and-treat trial among 334,479 persons in eastern Africa (SEARCH, NCT#01864603). Data were collected using participant observation at mobile community health campaigns (CHCs) (n = 28); focus group discussions (n = 8 groups) with CHC participants; and in-depth interviews with care providers (n = 50), leaders (n = 32), and members (n = 112) of eight communities in Kenya and Uganda. An 8-person research team defined analytical codes and iteratively refined them during data collection using grounded theoretical approaches, and textual data were coded using Atlas.ti software. Structural and cultural barriers, including men's mobility and gender norms valorizing risk-taking and discouraging health-seeking behavior, were observed, and contributed to men's lower participation in HIV testing relative to women. Men's labor opportunities often require extended absences from households: during planting season, men guarded fields from monkeys from dawn until nightfall; lake fishermen traveled long distances and circulated between beaches. Men often tested "by proxy", believing their wives' HIV test results to be their status. Debates about HIV risks were vigorous, with many men questioning "traditional" masculine gender norms that enhanced risks. The promise of antiretroviral therapy (ART) to prolong health was a motivating factor for many men to participate in testing. Flexibility in operating hours of HIV testing including late evening and weekend times along with multiple convenient locations that moved were cited as facilitating factors enhancing male participating in HIV testing. Mobile testing reduced but did not eliminate barriers to men's participation in a large-scale "test & treat" effort. However, transformations in gender norms related to HIV testing and care-seeking are underway in eastern Africa and should be supported.

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

This study explored the efficacy of a lay health worker (LHW)-led physical activity (PA) counselling program for inactive patients with HIV/AIDS and mental health problems living in a Ugandan farming community. In total 49 (35 women) community patients (40.0 ± 11.2 years) followed an 8-week once weekly LHW-led PA counselling program based on a self-determination theory and motivational interviewing framework. Participants completed the Simple Physical Activity Questionnaire, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, HIV/AIDS Stress Scale and World Health Organization Disability Assessment Schedule 2 (WHODAS 2) pre- and immediately post-intervention. Small, significant (P < 0.05) effect sizes were found for reductions in HIV/AIDS-related stress (Cohen's d = 0.26) and in global disability (Cohen's d = 0.46). Large effect sizes were observed for reductions in time spent sedentary (Cohen's d = 1.97) and reductions in depressive (Cohen's d = 2.04) and anxiety (Cohen's d = 1.47) symptoms and increases in time spent active (Cohen's d = 1.98). Greater decrease in sedentary time was associated with greater anxiety symptoms reduction (r = 0.32, P = 0.021). In physically inactive patients with HIV/AIDS and mental health problems, an LHW-led PA counselling program reduced stress, anxiety, depression and disability. Randomized controlled trials are needed to confirm these preliminary positive findings. [ABSTRACT FROM AUTHOR]

HIV/AIDS prevalence among adults aged 15–49 is increasingly affecting elderly women as caregivers. This study explored the experiences of elderly women caring for people living with HIV/AIDS in Masindi District, Uganda. Employing qualitative methods, 24 participants (18 elderly women caregivers and 6 key informants) were purposively selected. Data was collected from in-depth face-to-face interviews and analysed thematically. Findings revealed that participants performed numerous roles, resulting in economic, psychological, social and physical challenges. Coping strategies employed are problem and emotion-focused. Elderly women caring for HIV/AIDS persons will benefit from direct intervention and support services. [ABSTRACT FROM AUTHOR]

Opportunistic infections (OIs) are the primary cause of HIV-related morbidity and mortality. To reduce the risk, the ART eligibility criteria were revised to start treatment before advanced disease onset. We evaluated the effect of 2014 HIV clinical guideline changes in Uganda on opportunistic infections and survival among Youth Living with HIV (YLWH). This retrospective cohort analysis used administrative data from the District Health Information System (DHIS2) and the national referral hospital, to compare YLWH, 15–24 years old, who started ART pre-guideline (January 2012–June 2014) and post-guideline (July 2014–December 2016). We assessed the effect using multivariable logistic and Cox Proportional Hazards regression models, respectively. Post-guideline youth had 18% and 30% lower adjusted odds of having an OI at 6 (aOR: 0.82, 95%CI: 0.67, 0.99), and 12 months (aOR: 0.70, 95%CI: 0.58, 0.85) after ART initiation, compared to pre-guideline youth. No significant differences were observed in survival probabilities (Z = 2.56, P-value = 0.11) and adjusted hazard ratios (aHR: 1.55, 95%CI: 0.46, 5.28). Early ART initiation reduced the risk of OIs among YLWH. However, given the existence of geographical and clinical variations in the endemicity, morbidity and mortality associated with different OIs, additional research is still needed. [ABSTRACT FROM AUTHOR]

HIV prevention needs among urban refugee and displaced youth engaged in transactional sex are understudied. We examined associations between transactional sex and the HIV prevention cascade among urban refugee/displaced youth in Kampala, Uganda. We conducted a cross-sectional survey with a peer-driven sample of refugee/displaced adolescent girls and young women (n = 324) and adolescent boys and young men (n = 88) aged 16–24 living in Kampala's informal settlements. We conducted gender-disaggregated multivariable linear and logistic regressions to examine associations between past 12-month transactional sex and: lifetime HIV testing, condom self-efficacy, and recent [past 3-month] consistent condom use. Among the 27% of young women reporting transactional sex, 63% reported HIV testing. In multivariable analyses with young women, transactional sex was associated with higher condom self-efficacy, increased consistent condom use, but not HIV testing. Among the 48% of young men reporting transactional sex, 50% reported HIV testing. In multivariable analyses with young men, transactional sex was associated with lower HIV testing but not with condom self-efficacy or consistent condom use. Young men were 68% less likely to report HIV testing if transactional sex engaged. Findings point to urgent HIV testing gaps among transactional sex engaged urban refugee/displaced youth and a need for gender-tailored HIV prevention strategies. [ABSTRACT FROM AUTHOR]

HIV disproportionately affect adolescent girls and young women in sub-Saharan Africa. In Uganda, the HIV prevalence is four times higher in adolescent girls compared to boys. This study examined gender, HIV general and clinical knowledge, and prevention attitudes among adolescents living with HIV in Uganda. Data from a cluster randomized clinical trial were analyzed. A total of 702 adolescents (average age of 12.4) were randomized to either a control arm receiving bolstered standard of care or the treatment arm receiving bolstered standard of care plus a family economic empowerment intervention to support medication adherence. Ordinary Least Squares models that adjust for clustering of adolescents within health clinics were conducted. No gender differences were observed in HIV knowledge and prevention attitudes at baseline. However, at 12-months follow-up, boys were more likely than girls to report correct HIV general knowledge (d = 0.21), clinical knowledge (d = 0.48), and favorable prevention attitudes (d = 0.27). The intervention was not associated with any of the outcomes. Given the high HIV prevalence among adolescents, specifically girls, there is need to develop and/or tailor existing programs and interventions that equip adolescent girls with comprehensive knowledge and prevention attitudes, that are culturally appropriate, to reduce HIV transmission and reinfection within this population. [ABSTRACT FROM AUTHOR]

Introduction: Discomfort with and reluctance to disclose HIV status can lead to depression, social isolation, and poor medication adherence; we examined relationships among these variables within a sample of adolescents living with HIV in Uganda. Methods: We used baseline data from the Suubi + Adherence study, which recruited a total of 702 adolescents (ages 10–16 years) living with HIV in southwestern Uganda. Structural equation models were conducted separately among in-school adolescents and out-of-school adolescents to assess associations between discomfort level with HIV status and depressive symptoms and if this association was mediated by hopelessness. Results: Out-of-school adolescents had significantly higher depression scores compared with those in-school youth (M = 6.24 vs. M = 5.03, p < 0.001). Although high discomfort level with HIV status was significantly associated with higher depression scores among both in-school adolescents and out-of-school adolescents, this association among out-of-school adolescents (B = 0.49, 95%CI: 0.19, 0.79), was more substantial than for in-school adolescents (B = 0.10, 95%CI: 0.03, 0.17). Discussion: One's discomfort with their HIV status and the extent to which they are hopeful about the future can contribute to the development of depressive symptoms and these factors need to be considered in the development of assessments and interventions for the treatment of depression among adolescents living with HIV. [ABSTRACT FROM AUTHOR]

Current tools for measuring medication adherence have significant limitations, especially among pediatric populations. We conducted a prospective observational study to assess the use of antiretroviral (ARV) drug levels in hair for evaluating antiretroviral therapy (ART) adherence among HIV-infected children in rural Uganda. Three-day caregiver recall, 30-day visual analog scale (VAS), Medication Event Monitoring System (MEMS), and unannounced pill counts and liquid formulation weights (UPC) were collected monthly over a one-year period. Hair samples were collected quarterly and analyzed for nevirapine (NVP) levels, and plasma HIV RNA levels were collected every six months. Among children with at least one hair sample collected, we used univariable random intercept linear regression models to compare log transformed NVP concentrations with each adherence measure, and the child's age, sex, and CD4 count percentage (CD4%). One hundred and twenty-one children aged 2-10 years were enrolled in the study; 74 (61%) provided at least one hair sample, and the mean number of hair samples collected per child was 1.9 (standard deviation [SD] 1.0). Three-day caregiver recall, VAS, and MEMS were found to be positively associated with increasing NVP concentration in hair, although associations were not statistically significant. UPC was found to have a nonsignificant negative association with increasing hair NVP concentration. In conclusion, NVP drug concentrations in hair were found to have nonsignificant, although generally positive, associations with other adherence measures in a cohort of HIV-infected children in Uganda. Hair collection in this population proved challenging, suggesting the need for community education and buy-in with the introduction of novel methodologies.

High prevalence of depression among people living with HIV (PLHIV) impedes antiretroviral therapy (ART) adherence and viral suppression. We estimate the effectiveness and cost-effectiveness of strategies to treat depression among PLHIV in Sub-Saharan Africa (SSA). We developed a microsimulation model of HIV disease and care in Uganda which captured individuals' depression status and the relationship between depression and HIV behaviors. We consider a strategy of screening for depression and providing antidepressant therapy with fluoxetine at ART initiation or re-initiation (if a patient has dropped out). We estimate that over 10 years this strategy would reduce prevalence of depression among PLHIV by 16.0% [95% uncertainty bounds 15.8%, 16.1%] from a baseline prevalence of 28%, increase adherence to ART by 1.0% [1.0%, 1.0%], and decrease rates of loss to followup by 3.7% [3.4%, 4.1%]. This would decrease first-line ART failure rates by 2.5% [2.3%, 2.8%] and increase viral suppression rates by 1.0% [1.0%, 1.0%]. This strategy costs $15/QALY compared to the status quo, and was highly cost-effective over a broad range of sensitivity analyses. We conclude that screening for and treating depression among PLHIV in SSA with fluoxetine would be effective in improving HIV treatment outcomes and would be highly cost-effective. [ABSTRACT FROM AUTHOR]

Growing demand for use of Health Facility (HF) HIV testing data, in addition to other testing data to obtain district level HIV prevalence requires understanding the comparability of these various sources. We analysed the 2011 Uganda AIDS indicator survey data to assess: the proportion of people tested for HIV across Uganda by venue of testing; HIV prevalence ratio for those tested in a HF compared to those tested in community setting; [Katz, D., Baptista, J., Azen, S. P., & Pike, M. C. (1978). Obtaining confidence intervals for the risk ratio in cohort studies. International Biometric Society, 34(3), 469–474. https://doi.org/10.2307/2530610] and factors associated with HIV positivity in each subgroup. Of the 11,685 individuals, 8978 (77.1%) had ever tested for HIV in a HF. Fifty nine per cent tested in a HF in the 12 months preceding the survey (female: 5507, 72.7% versus male: 1413, 34.9%). HIV prevalence ratio was 1.8 times among those tested in a HF compared to those tested at community setting (10.9% [95% CI: 10.0–11.7] versus 6.2% [95% CI: 5.4–7.0]). Among HF testers, older age group, previously married and having no sexual partner was associated with significantly higher HIV prevalence. Using facility testing data for planning and decisions should take into consideration the elevated and varying HIV prevalence among individuals accessing HIV testing services at HFs as well as differences in their social-demographic characteristics. [ABSTRACT FROM AUTHOR]

This article sets out to investigate alcohol and substance use (ASU) among adolescents living with HIV (ALWH) in the sub-Saharan African setting of Uganda. A cross-sectional analysis of the records of 479 adolescents (aged between 12and 17 years) attending the study, "Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)" was undertaken. ASU was assessed through both youth self-report and caregiver report using the Diagnostic and Statistical Manual of Mental Disorders-5 referenced instruments, the Youth Inventory-4R and the Child and Adolescent Symptom Inventory-5 (CASI-5). Rates and association with potential risk and outcome factors were investigated using logistic regression models. The rate of ASU was 29/484 (5.9%) with the most frequently reported ASU being alcohol 22/484 (4.3%) and marijuana 10/484 (2.1%). Functional impairment secondary to ASU was reported by 10/484 (2.1%) of the youth. ASU was significantly associated with urban residence, caregiver psychological distress and the psychiatric diagnosis of post-traumatic stress disorder. On associations with negative outcomes, ASU was significantly associated with only "ever had sex". Health care for ALWH in sub-Saharan Africa should include ASU prevention and management strategies. [ABSTRACT FROM AUTHOR]

Open-Label Extension (OLE) studies are important in the drug development process and are used to further support the licensing applications and regulatory approvals of products. We aimed to understand why women chose to join the HOPE OLE study - where women were offered the dapivirine vaginal ring after two pivotal trials were completed - through data collected from individual in-depth interviews. Ten women at each of the six HOPE research sites in Lilongwe, Malawi; Durban (2 sites) and Johannesburg, South Africa; Kampala, Uganda; and Chitungwiza, Zimbabwe, were enrolled ( n  = 60). Access to an effective user-initiated HIV prevention product was one of the main reasons women joined HOPE. Although many participants worried that their male partners might expose them to HIV, they chose to remain in their relationships and avoid conflict or confrontation with their partners by discreetly using the ring to protect themselves. Other reasons for joining were quality healthcare, reimbursement and altruism. Researchers should better understand social and personal motivators behind research participation in order to recognize community sociocultural norms and its influences on product acceptability and adherence challenges.

Attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) are important mental health concerns among children and adolescents living with HIV (CA-HIV). This study examines clinical correlates and adverse outcomes associated with ADHD, ODD/CD and ADHD + ODD/CD among (N = 1,336) CA-HIV living in Uganda. Being male, higher socio-economic status, emotional disorder, greater caregiver distress and youth-caregiver conflict were associated with a greater risk of behavioral disorders, particularly ADHD + ODD/CD. This group was also five-times more likely to have engaged in sex than their peers and report greater disciplinary problems at school than those without a behavioral disorder. These findings highlight the distinct clinical presentation and adverse outcomes associated with ADHD + ODD/CD among CA-HIV. As more CA-HIV are surviving into adulthood, screening and treatment of mental disorders is needed to ensure they are given the chance to thrive. In addition to youth, interventions should target caregivers due to their impact on youth outcomes. [ABSTRACT FROM AUTHOR]

We aimed to evaluate differences in socio-economic variables in a Ugandan cohort of children with perinatally acquired HIV (PHIVs), HIV exposed uninfected (HEU) and HIV unexposed uninfected (HIV-) children and their associations with markers of inflammation and intestinal integrity. This is a cross-sectional study in 57 PHIV, 59 HEU and 56 HIV – children aged 2–10 years old enrolled in Uganda. Mean age of all participants was 7 years and 55% were girls. Compared to HEU and HIV – children, PHIVs were more likely to have parents that only completed a primary education, live in a household without electricity and live in poverty (p≤0.034). PHIVs living in poverty had higher IL-6 (p=0.006), those with lack of electricity had higher hsCRP, IL6, sTNFRII and d-dimer (p≤0.048) and PHIVs with an unprotected water source had higher IL6 and d-dimer (p≤0.016). After adjusting for demographic and HIV variables, IL-6 and d-dimer remained associated with lack of electricity and having an unprotected water source only in PHIVs (p<0.019). Our findings suggest that addressing economic insecurity may mitigate the persistent low-level inflammation in HIV that lead to many end organ disease. Longitudinal studies are needed to better understand the impact of socioeconomic factors on HIV inflammation and comorbidities. [ABSTRACT FROM AUTHOR]

We conducted a cross-sectional study to describe routine physical function assessment for HIV-infected adults aged ≥60 years attending a large urban HIV clinic in Kampala, Uganda. Assessed demographic and clinical factors associated with low physical function in the population, generalized linear regression model was used to estimate factors associated with low physical function. Of the 93 elderly patients that underwent the Short Physical Performance Battery (SPPB) assessment, 43/93 (44.1%) scored 1–8 points at the SPPB evaluation and were categorized as low function, 45/93 (48.4%) scored 9–11 points and were categorized as moderate function and 7/93 (7.5%) scored 12 points and were categorized as high (normal) function. Women (adjusted risk ratio (ARR) 2.57; 95% confidence interval (CI): 1.54–4.29, p = 0.000) had increased risk of low physical function compared to men. A one-year increase in age (ARR = 1.09; CI: 1.03–1.15, p = 0.004) and being overweight (BMI > 25.0, ARR = 1.96; CI: 1.89–3.24, p = 0.008) also carried an increased risk of low physical function status. A higher number 13/41(32%) of falls was recorded in female than among male 3/53(5.8%) patients (p = 0.001). The SPPB assessment is a starting point for clinicians to comprehensively evaluate and consider the management of physical function limitation among older HIV-positive patients. [ABSTRACT FROM AUTHOR]

This study examined factors associated with alcohol related condom-less sex (ARCS) among youth living in Kampala, Uganda. Analyses are based on 2014 cross-sectional survey data of urban service-seeking youth participating in a Uganda Youth Development Link (UYDEL) drop-in center. The analytic sample consisted of only youth reporting alcohol use (n = 347). Logistic regression analyses were computed to determine the factors associated with ARCS. In the bivariable analysis, ARCS was associated with being female (OR: 1.86; 95% CI: 1.21, 2.85), age of first drinking being between ages 13–16 (OR: 2.63; 95% CI: 1.42,4.86), age of first time drunk being between ages 13–16 (OR: 2.88; 95% CI: 1.47, 5.67), binge drinking (OR: 3.64; 95% CI: 2.21, 5.98), rape (OR: 2.69; 95% CI: 1.64, 4.41), sex work (OR: 5.91; 95% CI: 3.09, 11.29), and being able to refuse sex when intoxicated (OR: 1.69; 95% CI: 1.10, 2.61). In the multivariable analysis, ARCS was associated with binge drinking (AOR: 2.97; 95% CI: 1.71, 5.17) and sex work (AOR: 3.48; 95% CI: 1.62, 7.49). These findings emphasize unmet needs of this population. Strategies seeking to prevent teenage alcohol use, particularly delaying initial alcohol use, may be beneficial for reducing ARCS in this population. [ABSTRACT FROM AUTHOR]

Adherence to antiretroviral therapy (ART) is critical in order to achieve viral suppression. We designed an intervention, Mobile Antiretroviral Therapy and HIV care (MAP-HC) in rural southwestern Uganda aimed to reduce travel distance and hypothesized that MAP-HC would improve ART adherence and rates of viral load suppression. The study was conducted at two district hospitals, among patients who lived >5 km from the hospital. For each hospital, we identified 4 health centers in the catchment area to serve as site for the mobile pharmacy. Each site was visited once a month to provide ART refills and adherence counseling. We measured patient waiting time, adherence and viral load suppression before and after the intervention. The proportion of patients who missed an ART dose in the last 30 days dropped from 20% to 8.5% at 12 months post-intervention (p = 0.009) and those with detectable viral load dropped from 19.9% to 7.4% (p = 0.001), however, mean waiting time increased from 4.48 to 4.76 h (p = 0.13). Mobile pharmacy intervention in rural Uganda is feasible and resulted in improvement in adherence and viral load suppression. Although it did not reduce patient waiting time at the clinic, we recommend scale-up in rural areas where patients face transportation challenges. [ABSTRACT FROM AUTHOR]

Uganda adopted voluntary medical male circumcision (VMMC) in 2010, but uptake remains disproportionately low in the Northern region despite implementing several demand creation strategies. This study explored the socio-cultural and structural enhancers and barriers to uptake of VMMC services in Gulu, a district in Northern Uganda where uptake is lowest. In September 2016, we conducted 19 focus group discussions, 9 in-depth interviews, and 11 key informant interviews with 149 total participants. Data were collected and analyzed thematically using both inductive and deductive approaches, then framed in four levels of the social ecological model. Enhancers included adequate knowledge about VMMC services, being young and single, partner involvement, peer influence, perceived increased libido after circumcision, and availability of free and high-quality VMMC services. Barriers included sexual abstinence during wound healing, penile appearance after circumcision, religion, culture, and misconceptions. Optimizing enhancers and addressing barriers could increase VMMC service uptake in northern Uganda. [ABSTRACT FROM AUTHOR]

Antiretroviral treatment (ART) diversion from prescribed to non-prescribed users (i.e., sharing or selling) is an understudied dimension of HIV treatment adherence. We sought to explore ART diversion patterns in high-prevalence fishing communities on Lake Victoria, Uganda. We implemented a qualitative study in two fishing communities on Lake Victoria in south-central Uganda to identify facilitators of and pathways to ART diversion. We conducted 25 semi-structured interviews with HIV-positive fishermen (n = 25) and female sex workers (n = 10) covering personal and community experiences with ART selling/sharing, reasons for medication diversion, and potential solutions to reduce diversion. Data were analyzed using an adapted framework analysis approach. Participants reported frequent ART sharing within occupational networks, but no selling. Mobility was the principal driver of ART sharing and was associated with other barriers to treatment access including stigma, fear of negative health provider interactions, and transportation. ART sharing appears to emerge in response to short-term treatment interruptions in this setting. Future studies should explore characteristics and drivers of ART diversion in other high-burden settings and identify how these practices are correlated with key health outcomes like virologic failure and drug resistance. [ABSTRACT FROM AUTHOR]

This study explored the efficacy of physical activity (PA) counseling in inactive patients with HIV/AIDS and a co-morbid mental health disorder living in a Ugandan fishing community. We investigated associations between changes in PA, sedentary behavior, mental health burden and quality of life (QoL) following an 8-week once per week PA counseling program using the self-determination theory and motivational interviewing framework. In total 41 (33 women) patients (39.8 ± 10.9years) completed the Simple Physical Activity Questionnaire, Patient Health Questionnaire, Alcohol Use Disorder Identification Test and World Health Organization Quality of Life Questionnaire pre- and post-intervention. Large effect sizes were found for reductions in time spent sedentary (Cohen's d = 2.85) and reductions in depressive symptoms (Cohen's d = 1.47). We also found large effect sizes for increases in time spent walking (Cohen's d = 1.38), in incidental PA such as household chores (Cohen's d = 1.69), and physical health (Cohen's d = 1.38), psychological health (Cohen's d = 0.95), and social relationships. (Cohen's d = 1.39). The more time spent sedentary decreased, the more the psychological health increased (r = −0.33, P = 0.037). In sedentary patients with HIV/AIDS and a co-morbid mental disorder, the mental health burden reduces and QoL improves following PA counseling. Controlled studies are however needed to confirm our findings. [ABSTRACT FROM AUTHOR]

Evidence suggests that simple text messaging interventions may not suffice to improve ART adherence among youth in low-resource settings. To address this shortcoming, we developed an intervention that shared weekly real-time adherence feedback to youth in Uganda using short message services (SMS), based on information tracked by an electronic device (Wisepill). We present results from 7 formative and 6 exit focus groups (FGs) in Mulago and Entebbe, Uganda with youth ages 15–24, providers, and Community Advisory Board members. Participants consistently conveyed positive impressions of Wisepill, noting that it helped store their medications, facilitated travel, served as a reminder, and motivated adherence. Participants raised phone-related issues before the study; most were addressed but some remained (e.g., limited network access, electricity for powering phones). Further, they highlighted the importance of carefully crafting text messages (e.g., use slang rather than potentially stigmatizing words) and viewed personalizing messages favorably but were divided on the desirability of including their name in study-related texts. Exit FGs confirmed that sharing group adherence levels with participants tapped into the competitive spirit common among youth. Our results suggest future mobile technology-based interventions can be improved by providing messages that go beyond simple reminders to provide individual and group-level adherence feedback. [ABSTRACT FROM AUTHOR]

Depressive symptoms among HIV-positive (HIV+) women may negatively impact their health and possibly that of their young children through risk of compromised caregiving. We evaluated how depression symptoms in predominantly (97%) female caregivers relate to neurodevelopmental outcomes in their HIV affected children. Data come from the IMPAACT P1104s Study, an observational cohort across six sites in four countries: Zimbabwe, South Africa, Uganda and Malawi. Participants (n = 611) were 5–11-year-old children with HIV (HIV), HIV exposed uninfected (HEU), or HIV unexposed uninfected (HUU). Primary caregivers were assessed for depression with the Hopkins Symptom Checklist (HSCL) and children with Behavior Rating Inventory for Executive Function (BRIEF) parent-report, Kauffman Assessment Battery for Children II (KABC), Bruininks-Oseretsky Test of Motor Proficiency 2nd Ed. (BOT-2), Test of Variables of Attention (TOVA), Multiple Indicators Cluster Survey, Child Disability and Development scales (MICS-4). Caregivers with higher depression scores (>1.75 mean HSCL score) reported more executive function problems in their children, regardless of HIV status. All executive function scores were significantly (p < 0.001) associated with depressive symptomatology at baseline and across time. Caregiver depressive symptomatology was not associated with other assessed neurocognitive outcomes. These results highlight the potential impact of caregiver depression on child behavioral outcomes. [ABSTRACT FROM AUTHOR]

Adolescents living with HIV (ALHIV) are prone to depression, which can have detrimental effects including disease progression, poor treatment adherence and mortality. We aimed to determine the prevalence of depressive symptoms and their associated factors among ALHIV in Uganda. We conducted a cross-sectional survey among ALHIV (10–19 years) attending urban and rural clinics in Mbarara, Uganda between March and May 2017. Presence of depressive symptoms was assessed using the Centre for Epidemiological Studies' Depression scale. We interviewed 336 adolescents with a median age of 13 years, 62% of whom were female. A third (37%) had disclosed their HIV/AIDS status and 13% were sexually active. Overall, 154 (∼46%, [95% CI: 40.5–51.2]) had depressive symptoms. On bivariate analysis, the odds of having depressive symptoms were higher among adolescents who were ≥ 15 years, had disclosed HIV status, traveled >30 min for routine care and had risky sexual practices. On multiple variable analysis, only travel time to the clinic of >30 min was independently associated with depressive symptoms (AOR = 1.6 [95% CI: 1.02–2.7]). With the high prevalence of depressive symptoms among ALHIV in Uganda, screening and prompt treatment of depression should be incorporated within their routine care. [ABSTRACT FROM AUTHOR]

Assessment of an individual's functional status, as measured by activities of daily living (ADL), is an essential element in the diagnosis of HIV-associated neurocognitive disorders (HAND) but individuals with cognitive impairment may not accurately report ADL. We assessed agreement between self- and caregiver-reported ADL in HIV-positive persons. Antiretroviral therapy (ART)-naïve HIV-positive persons (n = 321) and HIV-negative controls (n = 134) in Rakai, Uganda, completed neurocognitive tests and an ADL questionnaire. Co-resident relatives ("caregivers") were independently administered the ADL questionnaire to determine their perception of the participant's ADL. The relationship between neurocognitive impairment and participant-caregiver agreement was assessed using kappa statistics. Regression was used to estimate adjusted prevalence ratios (AdjPR) of participant-caregiver agreement on disability scores. Relative to HIV-negative adults, HIV-positive participants scoring at least 1 standard deviation (SD) below the norm on 2 or more neurocognitive tests were classified as having mild neurocognitive impairment and those scoring at least 2 SD below the norm on 2 or more neurocognitive tests were classified as having moderate-to-severe. Mean age was 36 years (SD 8.9), and 53% of participants were male. The rate of ADL agreement between participants and caregivers was 77% for HIV-positive and 87% for HIV-negative participants (AdjPR = 0.89, 95% CI 0.81–0.97, p =.01). Among HIV-positive participants, 41% had moderate neurocognitive impairment, 15% had severe neurocognitive impairment, and 44% were normal. For moderate neurocognitive impairment, the rate of ADL agreement was 69% and for severe neurocognitive impairment, it was 66%. Compared to non-impaired HIV-positive participants (86% ADL agreement), ADL agreement was lower with moderate impairment (AdjPR = 0.89, 95%CI 0.81–0.98, p =.023) and severe impairment (AdjPR = 0.77, 95%CI 0.63–0.95, p =.014). Gender, education and CD4 count were not associated with ADL agreement. HIV-positive persons with neurocognitive impairment have lower agreement with caregivers' reports of ADL than HIV-positive persons without cognitive impairment. [ABSTRACT FROM AUTHOR]

We investigated changes in cognitive function and physical health and behavioural outcomes (HIV disease progression, health-seeking behaviour, adherence to HIV medications and risky sexual behaviour) at baseline and 12 months later among 1126 Ugandan adults living with HIV. Overall, cognitive function improved from baseline to follow-up, except for gait speed, which was slower at follow-up compared to baseline. There were improvements in physical health and behavioural outcomes by follow-up, with greater improvements among individuals on ART compared to those not on ART. Change in gait speed over time significantly predicted risky sexual behaviours at follow-up. This is the first study to investigate the longitudinal relationships between cognitive function and health outcomes among Ugandan adults living with HIV and provide insights into the possible links between cognitive function and negative clinical and behavioural health outcomes in people living with HIV. [ABSTRACT FROM AUTHOR]

Novel monitoring technologies in HIV research, such as electronic adherence monitors (EAMs), have changed the nature of researcher-participant interactions. Yet little is known about how EAMs and the resulting interaction between researchers and participants affect research participation and the data gathered. We interviewed participants and research assistants (RAs) in an observational cohort study involving EAMs for HIV antiretroviral therapy (ART) in Uganda. We qualitatively explored interviewees' views about ethical issues surrounding EAMs and assessed data with conventional and directed content analysis. Participants valued their relationships with RAs and were preoccupied with RAs' perceptions of them. Participants were pleased when the EAM revealed regular adherence, and annoyed when it revealed non-adherence that contradicted self-reported pill-taking behavior. For many, the desire to maintain a good impression incentivized adherence. But some sought to creatively conceal non-adherence, or refused to use the EAM to avoid revealing non-adherence to RAs. These findings show that participants' perceptions of the study staff's perceptions of them affected the experience of being monitored, study participation, and ultimately the data gathered in the study. Investigators in monitoring-based research should be aware that social interactions between participants and study staff could affect both the practical and ethical conduct of that research. [ABSTRACT FROM AUTHOR]